Read Our Bodies, Ourselves Online
Authors: Boston Women's Health Book Collective
Our Bodies, Ourselves (80 page)
When my contractions had not kicked in . . . twelve hours after my water broke and the usual time they give before they start to induce, we said we wanted to wait a bit. We walked, delaying the Pitocin, but [later] . . . negotiated half the normal dosage. . . . By that time, my husband looked at the monitor and noticed the contractions were getting stronger and more frequent without being induced. Despite the suggestion to continue as planned, we decided to go natural, asserting our right. The doula arrived, and after four hours of intense labor. . . . I reached a point where I said that I couldn't go on. She said to me, “No, you are there. Let's get ready to start pushing!”
Like a set change in a play, there was a whole new team, the bed changed position, and we started to push. Our incredible nurse-midwife was on her knees for the entire two hours while I pushed, holding a warm compress to my perineum so I wouldn't tearâwhich I didn't. At 5:40
P.M
., Sadie was born. It was the single most incredible moment of my life. We feel very blessed to have had the seemingly elusive wonderful, natural hospital birth
.
For many of us, pregnancy is our first serious contact with the medical system. Whether you have a healthy pregnancy or experience complications, with excellent information, care, and support, you can emerge from your maternity care experiences as an empowered, savvy health care consumer, better prepared to take control of your own health and that of your children.
I started my pregnancy with so much fear and mistrust of doctors and hospitals and decided on a home birth to avoid even having to deal with them. Well, best laid plans . . . at thirty-three weeks, I developed severe preeclampsia and HELLP syndrome. I had to accept that we needed doctors and hospitals to do this safely, but I wanted to be involved in making decisions about my care and not just accept every medical intervention just because I had a complicated pregnancy
.
I was induced at thirty-four weeks, and even though I was on magnesium sulfate, which made me feel woozy and sick, and Pitocin, which strengthens contractions, had electronic fetal monitors, couldn't eat, and had to stay in bed, I was able to labor on my termsâwith my husband and doula by my side. Against what seemed like all odds, I delivered my healthy daughter vaginally with no pain medication and was able to hold her skin to skin after birth. She did end up going to the NICU for a couple of days, but I think the fact that I held her right away made breastfeeding easier and helped me cope with the separation. I thought I'd feel traumatized by a “medicalized” birth, but I felt ecstatic and like I could take on whatever life throws my way. I think the experience prepared me for the intensity of motherhood, and I would even say it strengthened my marriage
.
Unfortunately, too often the opposite is true. The maternity care system frequently offers fragmented, impersonal care that does not reflect what research has shown for decades produces the best health outcomes for mothers and babies. Maternity care in the United States is characterized by several problems:
Too few women get adequate prenatal care.
In the past decade or so, care optionsâsuch as testing for pregnancy complications or pain relief options in laborâhave become much more complex. Fewer women are taking prenatal education classes and more women are experiencing high-risk or complicated pregnancies. Yet the time a woman spends in prenatal visits has been reduced. The typical woman may have as little as two hours of total interaction with her doctor or midwife during her entire pregnancy.
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Many women also enter prenatal care late, especially low-income women who have Medicaid insurance.
Too many women are exposed to the risks of high-tech procedures, even when they are healthy and unlikely to benefit from them.
The most visible example of this is the U.S. cesarean section rate: one in every three women gives birth by C-section. Cesarean sections can be lifesaving and health-enhancing in emergency situations, but unnecessary cesareans expose more mothers and babies to the risks of major surgery, without any clear gains for maternal and infant health overall.
Too many women are subjected to these potentially harmful procedures without giving informed consent.
In Childbirth Connection's national survey of women who had given birth in U.S. hospitals, Listening to Mothers II, participants overwhelmingly agreed that women should know the potential harmful effects of procedures. Yet far fewer than half of women were able to correctly answer basic questions about the risks of labor induction or cesarean surgery, even if they had experienced these interventions themselves.
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In addition, nearly three-quarters of women who had episiotomies (a surgical cut to make the vaginal opening bigger during birthâa painful procedure associated with known harms when used routinely) did not give consent.
U.S. MATERNITY CARE: ROADBLOCKS TO CHANGE
Why are some medical interventions still being overused in the United States today, despite the evidence against them? And why aren't approaches that are known to be helpful offered to all women? Advocates for improving maternity care point to the following roadblocks to change.
Obstetrical training and the medical system.
Obstetricians provide care for the vast majority of pregnant women in the United States. Obstetricians' training emphasizes identifying and managing the complications of pregnancy and childbirth. They generally receive much less instruction in the natural progression of childbirth or in low-technology techniques that minimize problems. While doctors trained years ago learned to safely deliver breech and twin babies vaginally, newer doctors have not learned these skills, as the standard of care has shifted to require cesarean for such births.
Economic incentives.
Surgical interventions can save doctors time and money. Many payment systems offer a single or fixed fee to doctors, regardless of whether a baby is born vaginally or by cesarean, and others offer a larger fee for a cesarean. Therefore, doctors who patiently support natural labor, which starts at unpredictable hours and generally requires more time, are penalized financially. Scheduled inductions and cesarean sections help hospitals make nursing staff schedules more predictable and shift more of health care providers' work to convenient weekday hours. Nondrug methods of pain relief and the one-on-one nursing care that enables natural labor are not billable to insurance, while epidurals and other anesthesia services are major sources of revenue for hospitals.
Fear of lawsuits.
If something goes wrong, doctors may be blamed for not doing something, but rarely are they blamed for doing something that is not necessary. For example, malpractice lawsuits for not performing a cesarean section are much more common than lawsuits for doing one when it wasn't necessary. To avoid litigation, many doctors and some midwives report that they feel compelled to do “too much” rather than be accused of doing “too little.”
A rushed, risk-averse society.
The desire to eliminate pain and control outcomes may cause both health care providers and expectant parents to embrace unneeded and potentially harmful procedures. Healthy women with low-risk pregnancies receive treatments that were designed for use by women with high-risk pregnancies. The widespread use of epidurals also has transformed childbirth in the United States. Though epidurals are in most cases a very effective form of pain relief during labor, they sometimes have adverse effects and require the proactive use of other interventions to keep mothers and babies safe and labor progressing.
The language of “choice.
” Labor and birth approaches are sometimes presented as equivalent “choices” without full, accurate information about their potential consequences. Choices that are perceived as risky for the fetus are more likely to be restricted than choices that are clearly shown to be risky to women. For example, vaginal birth after cesarean (VBAC) and planned home birth, though both are supported by research, are seen as unreasonable and made inaccessible to many women, while elective cesareans (cesarean sections done without a medical need) are increasingly presented by the media and some doctors in a misleading fashion as a reasonable option for healthy pregnant women.
Too few women have the benefit of low-tech supportive care practices that help them safely cope with the demands of pregnancy, labor, and birth.
In the Listening to Mothers II survey, most women said they were not allowed to drink or eat food, were confined to bed once admitted to the hospital and in “active” labor, and gave birth lying on their backs (a position that is more painful than upright positions and poses challenges for giving birth). Only 2 percent of women experienced a set of five supportive care practices that research shows benefit mothers and babies.
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Too many women end up with physical and emotional health problems after giving birth.
In a follow-up survey of Listening to Mothers participants, many women experienced pain, physical exhaustion, and sexual problems lasting months after birth, as well as shorter-term problems such as infection and rehospitalization. Most had some symptoms of postpartum depression in the two weeks prior to the survey, and 9 percent of mothers appeared to be suffering from childbirth-related post-traumatic stress disorder.
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Prenatal care consists of three interrelated elements: regular visits with your midwife or doctor; the care you give yourself; and the care you receive from friends, family, and other support people. This section focuses on prenatal visits with a care provider.
Prenatal care by your midwife or doctor will encompass regular health assessments, coordination of care with other providers or services, and establishing a plan of care for labor, birth, and your postpartum recovery and adjustment to motherhood.
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These practices are: labor begins on its own; the woman has the freedom to move and change positions; the woman has continuous labor support from a partner, family member, or doula; the woman does not give birth on her back; and the mother and baby are not separated after birth.
RIGHTS OF WOMEN DURING PREGNANCY AND BIRTH
No matter what situations you face when you are pregnant and in labor, understanding your rights is key to making good decisions and being better able to act on them. The statement below is excerpted and adapted from Childbirth Connection (childbirthconnection.org), a nonprofit group that works to improve maternity care for all U.S. women and families.
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The statement outlines a set of basic rights for childbearing women, applying widely accepted human rights to the specific situation of maternity care. Most of these rights are granted to women in the United States by law, yet they are not always honored. In addition, the wider social, political, and economic organization of health care, parenting, and the workplace makes it difficult or impossible to consistently exercise these individual rights.
Every Woman Has the Right to:
Choose her birth setting
from the full range of safe options available in her community, on the basis of complete, objective information about the benefits, harms, and costs of these options.
Receive information
about the professional identity and qualifications of those involved in her care and know when any are trainees.
Communicate with caregivers
and receive all care in privacy (which may involve excluding nonessential personnel) and have all personal information treated according to standards of confidentiality.
Receive maternity care
that is appropriate to her cultural and religious background and receive information in a language she clearly understands.
Leave her maternity caregiver
and select another if she becomes dissatisfied with the care.
Receive full advance information
about harms and benefits of all reasonably available methods for relieving pain during labor and birth, including methods that do not require the use of drugs.
Accept or refuse procedures
, drugs, tests, and treatments. She has the right to have her choices honored and to change her mind at any time.
Enjoy freedom of movement
during labor, unencumbered by tubes, wires, or other apparatus. She also has the right to give birth in the position of her choice.
Be informed
if her caregivers wish to enroll her or her infant in a research study. She should receive full information about all known and possible benefits and harms of participation, and she has the right to decide whether to participate, free from coercion and without negative consequences.
Have unrestricted access
to all available records about her pregnancy, her labor, and her infant; obtain full copies of all records; and receive help in understanding them, if necessary.
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For the full text of this statement, see Childbirth Connection's “The rights of Childbearing Women” at childbirthconnection.org/rights.
A woman who had planned a home birth but discovered late in pregnancy that her baby was breech describes how she exercised her rights in a hospital setting:
Through all our research, we found out that there were several doctors at this hospital who were experienced in delivering breech and that while hospital staff would try to pressure me into having a C-section, it was my right to decline a cesarean. We showed up at the hospital the next day to try a version [where doctors try to manually turn the baby] with a letter that specified that we were not giving consent to a C-section unless mine and/or the baby's lives were at risk. The version didn't work, and the doctors tried to convince us to have a C-section. The biggest reason they could give us was that it would be challenging to schedule staff who were experienced at delivering breech to be available when I went into labor. That did not seem like a good enough reason to cut me open.
Once the doctors realized that we were not going to consent to a C-section, a very nice female doctor offered to be on call for me. She spent over an hour talking with me, trying to get me comfortable with delivering in a hospital. As I became more comfortable, my labor kicked into high gear. My third daughter was born less than four hours later. It was the easiest and quickest labor I have had. We were back home less than three hours after giving birth.
