by Diana Korte and Roberta
Scaer
Eight years ago, when the first edition of this book
was published, we told you that the two trends in
childbirth were moving in opposing directions. They
still are. One trend is the growing number of hospitals
providing homelike accommodations, including Jacuzzis
and microwaves, plus the more than 140 out-of-hospital
birth centers (with more than 40 in the works), which
numbered in the dozens only a few years ago.
The other trend is high-tech childbirth. We've had
routine IVs, labor induction, and cesareans for years.
Now there's a growing emphasis on tests and procedures
of all kinds. It starts early in many parts of the
country, with pregnant women of all ages being
encouraged to undergo prenatal testing. It continues
with the use of the electronic fetal monitor (EFM)
during labor for 75 percent of women (and before labor
for some), as well as the ubiquitous ultrasound offered
routinely in at least three ways (scans, Dopplers, and
external EFMs).
And in the last eight years, the cesarean rate has
increased from one in five births to nearly one in four.
However, the good news about cesareans is that the rate
has begun to drop, due primarily to the increase in the
number of vaginal births after previous cesareans
(VBAC).
What about homebirths, the defenders of all-natural,
no-interference pregnancies? They have shrunk even more
in the last eight years from 2 to 3 percent of all
births to less than one percent today, according to a
1991 report from the National Center for Health
Statistics. However, high tech is present in some
homebirths, too, with the use of the Doppler instead of
the traditional low-tech fetoscope. (Both are hand-held
devices used to listen to the fetal heart tones, but the
fetoscope doesn't use ultrasound.)
Which trend is growing the fastest? No doubt about it:
Despite the leveling off of our cesarean rate and the
upswing in the number of VBACs, high tech continues to
dominate childbirth. If you're like most pregnant women,
it's as much a part of your pregnancy and birth today as
is your big belly. For most of you, your decision making
about high tech is likely to be when and for how long
you will use which of these pregnancy and birth tools,
not whether you'll use them at all. The issue now is to
use birth technology wisely and not be seduced by it.
Though there are more choices in the United States for
birth attendant and place of birth than probably
anywhere else on this planet, women mostly give birth
one way here--with a doctor in a hospital. And over the
last eight years, despite the availability of these
choices and with the exception of an increase in the use
of midwives and VBACs, options in the birth process have
become less--not more--flexible.
Birth plans, for instance, with their list of mothers'
preferences during labor, birth, and hospital stay, were
designed to help women get what they want. But today
birth plans often carry little punch except for those
women whose requests match their physicians' usual
obstetrical routine. And the change in insurance
coverage for those of you who have prepaid plans (with
their limited choice of health-care providers and
hospitals) can curtail your options even more--unless
you're willing to pay additional cash out of pocket.
Each nation's culture is reflected in how women
experience birth, and that' s true here as well. Most
American women expect labor to be painful and anticipate
using a variety of drugs. And both expectations are met.
However, women always vary widely--no matter where they
live--about the "normal" amount of pain they experience,
just as the "normal" length of labor and the "normal"
number of days vary widely in pregnancies.
A 1988 study comparing labor pain experienced by women
in teaching hospitals in the Netherlands and the United
States found that the Dutch women did not expect to
experience as much pain and used far fewer drugs for
pain relief than American women. "There is in Dutch
birth participants a deep-seated conviction that the
woman's body knows best and that, given enough time,
nature will take its course, whereas birth in America
was characterized as much more of a 'medical event,"
noted one of the study's authors. In the Netherlands
most women are cared for by midwives, which suggests
that women are helped and encouraged in a variety of
nondrug pain relief methods; 35 percent of Dutch births
still occur at home. As old-fashioned and unscientific
as that sounds to many of you, nearly twice as many
Dutch babies survive per capita (even after allowing for
racial differences) than in the United States.
But we don't live in the Netherlands; we live in
medically oriented North America, where birth conjures
up much fear and anxiety. And too many laboring women
have been going to give you Pitocin (or a cesarean),"
which can increase their discomfort and pain, sometimes
leading to panic and a body's total shutdown of labor.
Due no doubt in part to stories like this, we found that
many of the original 2,000 survey mothers weren't
satisfied with their birth experiences. According to the
questionnaire responses we've received from readers,
most women giving birth in traditional hospitals with
obstetricians today still aren't satisfied. (See Chapter
3 for an entirely different reaction from those women
who gave birth elsewhere with midwives.)
Although most of you used a variety of tests and
procedures during your pregnancy and birth, many also
worry about the effects some of these interventions can
have on your infant. And the older your child gets, the
more critical some of you become. For those of you who
had been looking forward to an unmedicated birth, some
now feel guilty or defensive about erroneously believing
that you "flunked" childbirth because you used drugs for
pain relief.
Your comments came from forty-three states, seven
Canadian provinces, and seven other countries; from as
far as Malaysia and as near as the next block. One or
both of us have replied to your letters (though some of
you moved and our notes were returned). We thank all of
you, and invite you once again to tell us what you think
by sending us your questionnaire response. And though
we've added more of your comments in this third edition,
we apologize for not being able to add them all.
A few of you have bought many copies of this book to
give to friends, and others have enjoyed passing around
the same dogeared copy. Many childbirth educators, La
Leche League leaders, midwives, nurses, and doctors keep
copies in their libraries. In addition, A Good Birth, A
Safe Birth is offered in a number of mail-order catalogs
and has been placed on many recommended reading lists.
Several dozen of you wrote early on to say that you were
interested in organizing surveys or consumer groups.
More often than not, those plans changed, and some of
you decided to train as childbirth educators or midwives
instead.
Perhaps the biggest trend we've seen in reader replies,
particularly over the last few years, is the interest in
and use of the doula, a woman who offers comfort and
support during labor. And if you didn't have one of
these compassionate women at your last birth, you plan
to the next time.
Your stories have told us that for most of your births
hospital routines are remarkably similar in the United
States, from California to Maine. We noticed, however,
that questionnaire responses show a big jump in the use
of midwives in the last few years, and the births they
attend are often more individualized. Your letters have
also made it clear that your birth preferences can vary
from pregnancy to pregnancy.
I had two very different experiences with childbirth. My
son (number-one child) was a twenty-seven-week preemie.
I am still grateful that the interventions used were
available. I feel all were necessary, and I have nothing
but praise for the hospital, nurses, doctors, and
technologists who contributed to saving our son. Three
years later I gave birth to a healthy, full-term baby
girl. Same doctors, hospital, nurses, etcetera. Also
some interventions. It was a nightmare. I felt so
helpless. I checked myself and my daughter out of the
hospital against medical advice thirty-six hours after
her birth because of all the interferences. --Manitoba,
Canada
Just as one woman's Dr. Right is another woman's Dr.
Wrong, one woman's good birth experience is another
woman's misery.
I was amazed how my body took control. With the first
push or two, my water broke (I even got to do that
myself!) while I squatted. A couple more pushes and I
could see her head in the mirror. I reached down to
touch my baby! Minutes later, she was nursing at my
breast. The feelings of joy and awe at the experience of
a natural delivery are hard to describe. But I can tell
you that it was worth all the months of preparations,
discussions with the doctors, and two days of
contractions. --Ohio (third birth, following two
previous cesareans)
The information on anesthesia was extremely one-sided.
You've pointed out only the negative aspects of it
without giving examples of times when it is beneficial.
I know from experience that an epidural can be a sanity
saver, and turn what would otherwise be a nightmare of
prolonged, unbearable, uncontrollable pain into a calm,
happy, positive birth. --Connecticut
Though you were satisfied overall, nearly all of you had
suggestions for more information you wish had been
offered. Many of those suggestions had to do with
information about pain relief ("realistic discussion of
pain, not fairy tale") or discovering what options were
really available ("not just what doctors want us to
hear"). Many readers were especially critical of
hospital-based classes, and thought that instructors
"pushed drugs" and "didn't tell us about risks versus
benefits of anything."
Reminiscent of our comments in previous editions, most
of you found the best advice about breastfeeding came
from friends, La Leche League, childbirth educators,
midwives, and books. Now you also can get the help of
more than 1,000 lactation consultants. (See
"International Lactation Consultants Association" in
Appendix D.) Family members still tend to give advice
that falls either in the "really helpful" or the "really
terrible" categories. Hospital nurses, obstetricians,
and pediatricians fared the worst in the advice category
overall, though there were some exceptions, and family
practice doctors tended to be rated more helpful than
not.
Nearly every chapter has new research confirming the
conclusion we made in the first edition about a good
birth being also a safe birth. We provide information
about options that women want, including new data from
reader questionnaires, and about the seldom discussed
sexual pleasures of pregnancy, birth, and breastfeeding.
Types of birth attendants (midwife and doctor) and of
places of birth (hospital, birth center, and home) are
compared. We present a demystified view of doctors and
nurses so that you can understand why they do what they
do. From cesareans to circumcision, from prolonged
pregnancy to newborn jaundice phototherapy, the risks
and benefits of modern American childbirth interventions
are described.
We encourage you to appreciate your pregnant and
new-mother feelings. As your best guarantee of having a
normal vaginal birth once you're in the hospital, we
suggest that you plan in advance to have helpers--mate,
doula, and perhaps a monitrice (your personal ob
nurse)--with you. And as "husband" doesn't compute for
the 27 percent of you who are single when you give
birth, unless the research specifically mentions
husbands, we've used the words mate or partner.
Most of you who read this book will be working outside
the home throughout your entire pregnancy and returning
to your job within three to six months. Some of our
suggestions may seem to be too much bother for the
amount of time that you have, especially when you're
interested in making your pregnancy and birth as easy as
possible, not more complicated. We think the issue
remains choice, not what you pick. Do what works for
you, take what you want from this book, and ignore the
rest. I believe the best environment in which to deliver
a baby would be within the ob wing, but in a more
casual, homelike setting. I think a new mother should be
allowed to have as much interaction with family members
as she feels up to--including other children, parents,
spouse.... The new baby should be allowed in the
patient's room during these family gatherings if the
parents so wish. I would also encourage as much
mother-infant interaction as possible during the stay,
interaction hopefully commencing immediately after
delivery. I also feel "standing orders" for medication
prior to and following delivery should be replaced with
individualized recommendations.... Congratulations for
caring enough to conduct this important survey.
--Survey*
As health-care users, we have the right to have a big
say in those services that affect our welfare so
critically and cost us so dearly. But instead of finding
out what people want and need in their health care,
doctors and other health-care providers too often tell
us what we'll be getting. So far, that's worked because
hospitals and doctors have had a monopoly in their
business. But in at least one area of health
care--childbirth--doctors and hospital administrators
now are trying to respond to what women want.
Today more and more women know what they want to have
happen in their childbirth experience. Really, they've
known all along, but for years no one ever asked them
what they wanted.
In the late 1970s, three unique studies responded to
this over
*All quotes from women throughout the book are from the
three maternity preference surveys cited or from our
readers, who are identified by state or province.
More than 2,000 women were asked to rate hospital
maternity options in three different cities. They
represented the Northwest (Wenatchee, Washington), the
Mountain States (M.O.M. Survey, Boulder, Colorado), and
the East Coast (C.O.M.A. Survey, Baltimore, Maryland)--a
cross-section of the nation.
- Women of very diverse educational and economic
backgrounds agreed on what's important in maternity
care.
- They want their partner or the baby's father to
be present for the labor, delivery,
and recovery, and to have unrestricted visiting
rights.
- They want a lot of contact with their babies,
immediately after birth and
throughout their entire hospital stay.
- Women who breastfeed want effective help from
nurses and doctors.
- They want their other children to visit them and
to see and hold the new baby.
- They want cooperation and assistance from the
hospital staff--doctors and
nurses--in using prepared childbirth techniques.
The hundreds of women who sent in the questionnaire
in the back of the book or phoned or spoke to us in
person strongly agree with the first four of the five
most important needs from the survey results: the
partner's presence, baby contact, breastfeeding help,
and seeing their other children. Women continue to see
childbirth as a social event in the broadest sense: It
either unites the family unit or pulls it apart. They
want the time around the baby's birth to be one that
strengthens relationships and welcomes the new baby.
Women have changed their view of the fifth need
identified in the surveys. Our readers are turning to
doulas to get the help they need in the hospital.
Eight years ago, when the first edition of this book was
published, we told you that the two trends in childbirth
were moving in opposing directions. They still are. One
trend is the growing number of hospitals providing
homelike accommodations, including Jacuzzis and
microwaves, plus the more than 140 out-of-hospital birth
centers (with more than 40 in the works), which numbered
in the dozens only a few years ago.
The other trend is high-tech childbirth. We've had
routine IVs, labor induction, and cesareans for years.
Now there's a growing emphasis on tests and procedures
of all kinds. It starts early in many parts of the
country, with pregnant women of all ages being
encouraged to undergo prenatal testing. It continues
with the use of the electronic fetal monitor (EFM)
during labor for 75 percent of women (and before labor
for some), as well as the ubiquitous ultrasound offered
routinely in at least three ways (scans, Dopplers, and
external EFMs).
And in the last eight years, the cesarean rate has
increased from one in five births to nearly one in four.
However, the good news about cesareans is that the rate
has begun to drop, due primarily to the increase in the
number of vaginal births after previous cesareans
(VBAC).
What about homebirths, the defenders of all-natural,
no-interference pregnancies? They have shrunk even more
in the last eight years from 2 to 3 percent of all
births to less than one percent today, according to a
1991 report from the National Center for Health
Statistics. However, high tech is present in some
homebirths, too, with the use of the Doppler instead of
the traditional low-tech fetoscope. (Both are hand-held
devices used to listen to the fetal heart tones, but the
fetoscope doesn't use ultrasound.)
Which trend is growing the fastest? No doubt about it:
Despite the leveling off of our cesarean rate and the
upswing in the number of VBACs, high tech continues to
dominate childbirth. If you're like most pregnant women,
it's as much a part of your pregnancy and birth today as
is your big belly. For most of you, your decision making
about high tech is likely to be when and for how long
you will use which of these pregnancy and birth tools,
not whether.
Excerpt reprinted with permission from
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