By: Leila Muse
The results are out from the MANA stats!! And they are even more encouraging than we had originally hoped. Currently only the abstract is available online, but The Journal of Midwifery and Women’s Health is planning to release the entire study for Free soon. We are very excited to read it and to hear reactions from the birthing community! To check out the abstract, click here.
By: Leila Muse
Birth has a fascinating undercurrent: Death. I might venture to say that life is always followed by death,
and humans have a long history of both struggling to prevent death, to extend life and also a tendency
to tempt death. The life-giving process of pregnancy and birth is no exception. A mother connected to
the life inside of her is aware that life is delicate and her own life may be on the line. A mother’s
instincts are to protect her child, even at the cost of her own life. The choice of where to and what birth
attendant to have present at the birth of her child sometimes affects this risk of death.
In our modern world, women lean on obstetricians to take the risk of death for their babies and
themselves away. Has this worked? Not really. Moms still die. Babies still die. At alarming rates in our
country. In fact, the “United States doesn’t even rank in the top tier of countries in terms of maternal
health,” as Suzi Parrasch describes in her article on the United Nations Trends in Maternal Mortality
1990-2010 report.1 The UNFPA states that “in all countries that have achieved dramatic improvements
in maternal mortality, professionally trained midwives have been a key to success.2” So, where is the U.S. going wrong? Is it mothers choosing homebirth with midwives or is it the highly medicalized care with little to no access to trained midwives?
More moms are hurt and more babies are hurt than should happen. Hurt, however, we can rationalize. The rationale usually begins with, “She would have died if she had not been in the hospital…” When mom or baby does die in the hospital, there is a sad shake of the head knowing everything humanly possible was done. When mom or baby dies during a homebirth, the assumption is the homebirth, or the midwife, caused the death.
For moms choosing out of hospital birth- and I distinguish this from the unprepared mothers who have
quick labors without making it to the hospital on time and the moms who simply do not have access to
or the willingness to find prenatal and labor help- it is the stories of the almost dead moms and babies
who were saved by heroic obstetricians that become the mantra of those who try to convince these
mothers they are choosing poorly. “She would have died had she not been in the hospital, so how could
you possibly choose to not be in the hospital and therefore risk your baby?” How does a mother
choosing a homebirth with a midwife understand the risk of injury or death to herself or her baby?
There is a medical term: iatrogenic. Iatrogenic comes from the Greek for physician, iatros, and to
produce, gen. Iatrogenic simply means doctor caused. During a typical hospital birth, there are many
standard interventions a laboring mother undergoes. All of these interventions have risks and benefits.
Physicians and medical staff are okay with the risks. They have been trained on how to intervene when
risks show up. Mothers who choose hospital birth trust that their labor team can and will handle any
issues that show up. Hospital birth mothers rarely wonder if the hospital policies might actually be
causing the risks. Homebirth mothers do worry about policies and procedures that might cause risk.
There is a birth phrase: the cascade of interventions. This phrase describes the almost inevitable process
of more interventions happening due to the risks caused by the first original intervention, and
compounded by the risks of every other intervention done after. Interventions can be necessary. Some
mothers leave the risks and benefit assessment to their care team, others prefer to be more fully
informed on which interventions are truly necessary and which are more about the convenience and
training of their care providers.Mothers choosing out of hospital births with midwives understand that the interventions used in a
highly medicalized hospital birth can and do lead to complications. Most of the time, those
complications are managed by more interventions, but the medical team can often keep mom and baby
from serious injury or death. Sometimes those complications can be devastating, and nothing the
medical team can do helps. The vast majority of these interventions do not happen in a normal birth
outside of the hospital. Homebirthers are choosing to avoid unecessary complications.
Mothers choosing out of hospital births also assume more responsibility for prevention of
complications, their own education on pregnancy and birth, and assessing their willingness to get
medical help if that help is necessary. Mothers who live in a state, like Maryland, that is hostile to the
homebirth choice, often need to weigh the risks of difficulties with transfer of care to a hospital if
something goes wrong. The risks often have more to do with the hospital’s response to the reason for
transfer than with the actual reason for transfer.
The fact is, the majority of births in the United States happen in hospitals. The majority of maternal
deaths happen in hospitals, despite the medical technology and expertise, and is not related to out of
hospital birth. According to the CDC’s vital statistics report for 2010, “98.8 percent of all U.S. Births
occurred in hospitals. Among the 1.2 percent out-of-hospital births, 67.0 percent were in a residence
(home) and 28.0 percent were in a freestanding birthing center.3 ” There were 3,999,386 births in the U.S. In 2010. 47,028 were out of hospital and 282 were listed as unknown location.4 In the CIA WorldFact Book, the US is listed with a maternal mortality rate of 21 per 100,000 live births in 2010. The countries that are doing better than the U.S. Include: Kuwait, 14 per 100,000; United Arab Emirates and Serbia, 12 per 100,000; Switzerland, 8 per 100,000; Germany and Quatar, 7 per 100,000; Netherlands and Slovakia, 6 per 100,000; Japan and Finland, 5 per 100,000; and the best country is Estonia, 2 per 100,000.5
Obstetricians are trained to manage labor and birth. Obstetricians rarely attend births where little to not
intervention is used. Midwives are trained to watch and wait. Obstetricians treat high risk pregnancies,
and often look at low risk pregnancies as potential disasters. Midwives assist low risk pregnancies.
Even the CDC agrees that homebirth has a low risk profile6. Obstetricians are simply not trained in low
risk, but they are vital for high risk.
Birth has an element of risk. No matter where a mother chooses to give birth, there is a risk. Moms and
babies will sometimes die. If we followed what is known about safety during pregnancy and birth, we
would use more midwives and obstetricians would be able to focus their skills where they are truly
1. Parrasch S. UN Report Shows Dramatic Drop in Maternal Mortality, But Is It Enough?
http://www.takepart.com/article/2012/05/18/un-report-shows-dramatic-drop-maternal-mortalityit-enough on Mar 3, 2013.
2. Midwives. UNFPA.
C757E74C96C827E77C2C.jahia02 on Mar 3, 2013.
3. Martin, JA, Hamilton BE, Ventura SJ, et al. Births: Final data for 2010. National vital statistics
reports; vol 61, no 1. Hyattsville, MD: National Center for Health Statistics. 2012.
4. US DHHS, CDC, NCHS, Division of Vital Statistics, Natality public-use data, 2007-2010, on
CDC Wonder Online Database, Dec 2012, http://wonder.cdc.gov/natality-current.html on Mar
By Leila Muse
A month before my paternal grandmother died, I spent treasured time with her just talking. She was an
amazing lady. Memories of early childhood are filled with the comfort I always felt around her. During
our conversation about the past and present and future, she spoke to me about how my father was born.
Sixty years after her birth experience, the memory was strong for her.
I never had the chance to tell my grandmother I was pregnant. I did not know until shortly after our
final conversation. I did talk to her about the first human birth I witnessed in person, a woman attended
by a midwife at a birthing center, and how that birth left me in awe of birthing women and the creation
of a family. My grandmother’s birth story came after my story. She had not felt awesome like the
mother I had recently assisted. She was afraid of her body. My grandmother’s body was dysfunctional.
My grandmother was a small, slight woman. My grandfather was a large, impressive man. They were
an adorable couple throughout their lives. Their love for each other was evident and inspirational. She
told me my father was born by cesarean surgery. Cesarean surgery had earned greater popularity by the
1940′s1, as physicians had learned greater skill, and effective antibiotics became readily available.
Cesarean surgery was a ready fix for a tiny, frail woman having what would be her only baby.
Through the years, I have spoken to many women about their birth experiences, from new mothers to
octegenarians. Some have allowed me the privilage of being with them as their doula during their
births. There is a helplessness many mothers express; their births just happened, their bodies were
simply there and these mothers relied on someone else, usually their physician, to make the birth
happen. These women say, “I can’t!” Some mothers feel more powerful; they made decisions, worked
with their bodies’ urges. They birthed their babies, with the loving support of someone else watchfully
waiting to assist if needed. These women say, “I can!” Some women start out with “I can’t,” and learn
to say “I can!”
Every mother is affected by the births of her children2. No matter how birth happens, the experience is
deeply moving and profoundly important to the mother. She remembers her births when she plays with
her great grandchildren. Her birth experience can shape her psyche, her mothering, her relationships.
The resounding theme- how confident a mother is in her self and in her mothering- revolves around her
feelings about the care she received during her pregnancies and the births of her children. Mothers who
are supported on all levels- emotionally, physically, and medically if necessary- have a more positive
experience regardless of how the birth happens. Mothers tend to find this whole-woman care through
midwives, not the standard obstetric care.
There are two basic models of care in pregnancy and childbirth: medical and midwifery3. Midwifery is
the centuries old women-centered way of caring for a pregnant mother and supporting her through birth
and postpartum. The medical model started gestating over three-hundred years ago, when men started
learning midwifery. By the twentieth century, the medical model birthed into a seemingly better, safer
care that relieved women of responsibilty. Interestingly, death rates were not dropping with increased
Physicians had the better answers by the mid-twentieth century, much to the relief of mothers. Use
heavy anesthesia to knock a mother out. Save her from the agony of childbirth. More birth
interventions were necessary- drugs to force labor contractions, episiotomies, forceps, surgery- because
mothers became passive, uninvolved, and immobile during the birth process. Newborns kept far away
from their mothers, partly because mom was too drugged to be safe around her baby and partly to save
her from the tiring responsibility of mothering.
Now, more women are questioning the medical model and seeking a return to the ancient midwifery
practices. The United States’ maternity care statistics are not improving under medical management.5, 6
Some mothers are questioning handing over their bodies and their babies to an impersonal professional.
Out of hospital births have increased in the United States7. Many hospital based practices recognize
women want the more personal touch and have added midwives to their staff.
The most ideal care involves collaboration between midwives and physicians. When physicians refuse
to work with midwifery, mothers have difficult choices: have their babies in a hospital under medical
management- risk of unnecessary interventions; have their babies with a midwife who does not have
back-up- risk of complications if a transfer is needed; or birthing unassisted- risk of not being aware of
or able to do something about a life-threatening complication.
When I look at my extended family tree, I can see this midwifery to obstetrics and back to midwifery
phenomenom. My mother had hospital births with physicians. My mother’s father was born at home.
My grand-aunt and namesake, Lela, had her children on her farm. Their family physician acted more as
a midwife than what is seen in our modern days. One of Lela’s children was premature and she writes
about that child’s birth and loving care that helped her baby survive and thrive:
…1916, we were surprised with a visit from the stork with a 2 months premature baby…
The tiny baby arrived ahead of the doctor and weighed in at 2-1/2 lbs. For the next 2
months (it) was a nightmare but with the help of mother Nedrow and Dr. Hargis, she lived…
We carried Forence on a pillow until she was three months old8.
My daughter’s father and siblings were all born through cesarean surgery. My daughter’s paternal
grandfather was one of thirteen born at home. Twentieth century mothers had fewer children. Before
1900, families were full of children. In my extensive family tree, there have been few perinatal deaths.
Those that I have found in the history seem to be related to outbreaks of disease, a teenage mother,
potential genetic disorders in one family line, and a case of maternal disease.
A mere two generations ago, most of my relatives birthed at home. Now, most of my family have their
babies in a hospital under the medical model of care. My sisters and I began to change that pattern. My
older sister had a hospital birth followed by a homebirth. I used a homebirth midwife and experienced a
supportive transfer to hospital birth during labor. My younger sister had a highly medicalized hospital
birth followed by a hospital birth under the care of midwives.
Sometimes, I think about my grandmother and what our conversation might be today.
1. Melissa Jeffries. C-Section Overview. 03 January 2008. HowStuffWorks.com
13 Feb 2013
2. Sarah Barre Clark. Why the Birth Experience Matters. Midwife International 13 Feb 2013
3. Choosing a Caregiver. Options: Midwives for Maternity Care. 17 January 2008. Childbirth
Connection < http://www.childbirthconnection.org/article.asp?ck=10163> 16 February 2013
4. Drife, J. The start of life: a history of obstetrics. 6 February 2002. Postgrad Med J 2002; 78:311-
315 <http://pmj.bmj.com/content/78/919/311.full> 16 Feb 2013
5. United States Maternity Care Facts and Figures. Transforming Maternity Care.
<http://transform.childbirthconnection.org/resources/datacenter/factsandfigures/> 16 Feb 2013
6. Deadly Delivery: The Maternal Health Care Crisis in the USA. Amnesty International, London:2010
7. MacDorman MF, Mathews TJ, Declerq E. Home births in the United States, 1990-2009. NCHS data
brief, no 84. Hyattsville, MD: National Center for Health Statistics. 2012
8. Nedrow, Lela Waugh. Covered Wagons to Jets: The Life History of Lela Waugh Nedrow of Ashton,
Idaho. First Edition, December 1983
What an amazing day we had today! We got to meet a bunch of awesome moms, dads, kids, grandmas and grandpas who love birth and love midwives! The rain held off, we even saw the sun shine. It was exciting to see so many supportive friends in one place. And we got some wonderful pictures. Thanks to all the people who made today happen, especially Maryland Families for Safe Birth! On to the hearing on March 5. We plan to attend and take notes. So, expect an update very soon. We will also be introducing our new blogger to you in March, so look for that as well!
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