Childbirth

When I began this project I decided I was going to write about the controversy over the cesarean rate in the United States. I have heard nurses and friends talk about the trend of rising rates in cesareans, and from the conversation I’ve realized it’s a very controversial topic. I am interested in women’s health, so I started asking my health care providers what they thought of the c-section rate in the U.S., and I started seeing a trend that people’s view on c-sections often has do with a more general outlook on obstetrics. Many of the people who I came across that didn’t approve in the increasing rate of c-sections had other complaints about how obstetric units are run. People who disproved of the c-section rate often felt that medicine practiced in hospitals is too ‘interventionalist’ and treats birth like there is going to be an abnormality, when in general births are normal. Of the people that told me they didn’t think there was something wrong with the c-section rate, they often had the outlook that giving birth outside of a hospital puts the mother and baby at unnecessary risk of being without a physician.  After talking about birth and doing a bit of research I decided I wanted to not only do my paper on c-sections, but also on births in hospitals versus non-hospital births. I interviewed two ob/gyn’s and two certified midwives to try and get their opinions on the matter.

I interviewed these health professionals so I could try and see how they got into medicine and how they developed their beliefs regarding birth. I had a set of questions for both the midwives and ob/gyn’s and the interviews were loosely based on them. First I interviewed Kathleen Dalke, a practicing ob/gyn on the west coast of the U.S.. From a young age Kathleen knew she wanted to go into medicine. She grew up in a rural town and prior to medical school thought she wanted to go into family medicine. When she was 16 she worked as a ward cleck in an emergency unit with only an LPN. Kathleen found it extremely stressful when she needed to wait for physicians to arrive in cases where the LPN didn’t have the necessary skills. She didn’t like not having the skills to help people in critical condition. Although she knew she wanted to go into medicine she didn’t know she wanted to go into women’s health until she was in medical school. Kathleen thinks giving birth in a hospital versus outside a hospital is advantageous because a hospital is safer. She had a postpartum hemorrhage with her second child, which resulted in losing half of her blood. If she hadn’t been in a hospital she would have died. Kathleen sees mothers and babies that come in that are in critical condition and should have received care much earlier; in some cases they die. When I asked her if she thought home births were safe she said that they put the mother and baby at unnecessary risk because they cannot get the fastest medical attention if it’s needed.

I said “it’s been commented that hospitals as institutions try and get patients in and out as quickly as possible to be efficient, so can this rush pregnancy?” Kathleen replied that no, there is no rush with hospital policy. She takes as much time as the labor needs, and if an intervention is necessary for the mother of child’s health she performs it. Kathleen works with midwives every night, and if the pregnancy isn’t high risk the midwives deliver. There are two kinds of midwives, one is certified which means they have gone to nursing school and received their masters in midwifery, and the other is non-certified which has no set definition. Only certified midwives can work in the hospital, and she said that it is a west coast trend for midwives to even assist c-sections. Midwives work with Kathleen during the night and residents work during the day, but at all times Kathleen has assistance.

I’ve heard midwives and women who have given non-hospitalized births say that giving birth in a familiar environment can make the woman more relaxed, so I asked Kathleen if she thinks there is a benefit of having a more familiar environment to give birth in. She said no, because when you have an un-medicated birth, even in a hospital, you go into a zone, so it doesn’t matter where you are (she was speaking from personal experience). I’ve also heard that giving at home can make a woman more comfortable, which relaxes her muscles and can result in a smoother delivery. Kathleen responded saying that she doesn’t agree with this statement because “giving birth isn’t going to be relaxing or pleasant regardless of where you are”.

Kathleen works with high-risk patients. Of all the births she does, about 15-20% end in c-sections, which is low considering her clientele. Kathleen’s average is lower then the national average of c-sections, which was 32.8% in 2011 (1 ). I asked Kathleen why the U.S.’s c-section rates have been increasing and she said that this increase in c-sections occurs for multiple reasons, like more gestational diabetes is leading to bigger babies, so they are harder to vaginally deliver. When everyone did vaginal deliveries there were more ruptured uteruses, so there is a risk when one refuses to have a c-section. Some women demand elective c-sections where they don’t consider vaginal birth as an option, but she doesn’t do this policy. Some patients are against vaginal birth for aesthetic reasons, for example the c-section rates in certain parts of Brazil are approximately 90%. For Kathleen the c-section rate is not a concern, because she only performs them when necessary. She doesn’t think that there is a serious problem with the U.S.’s rate of c-sections because they are performed to benefit the mother and child. When I asked her if she thought there are any big downsides to giving birth in a hospital she said no.

Then I asked some questions about being an ob/gyn to try and look at the job outside of just delivering babies. I’ve also heard claims that physicians in general do not spend enough time with their patients (whereas nurse practitioners and midwives do), so I was curious what she would say. Kathleen said she is happy with the time she spends with patients. She can spend as much time as she wants, although she doesn’t get paid as much if she doesn’t see as many patients. She feels that she has enough time to get to know her patients, for example she was talking to a patient and discovered that the patient’s old ob/gyn went to medical school with Kathleen. Next I asked her what she likes most about being an ob/gyn. Kathleen feels that because she has an m.d. she gets a lot of respect and is a role model to her patients. For example, she was seeing a single mother of two children and the woman went on to get her masters degree because Kathleen encouraged her. She also likes how she becomes part of families and has long-term relationships with her patients. She just performed a hysterectomy on a patient who she delivered 19 years ago. Midwives can get very close with patients, but she often sees women from multiple generations of a family. Kathleen feels that being an ob/gyn is really hard work. A fair amount of the time you have to go into work in the middle of the night. To be an ob/gyn you have to work hard and enjoy what you do.

I interviewed another ob/gyn, Cynthia Silber. In college Cynthia was interested in biology and was encouraged by her parents to go to medical school. Cynthia hadn’t thought about women’s health until she got to medical school, but she was always interested in women’s lives, so it felt natural to become an ob/gyn. I started out with the same question that I asked Kathleen, which is ‘what do you consider the most important reason to give birth in a hospital’ and like Kathleen, Cynthia said giving birth in a hospital is safer. She said, “when labor goes wrong, it goes wrong really fast and really wrong. It goes downhill fast and badly”. Although Cynthia thinks hospitals are safest she also thinks birthing centers like University of Pennsylvania’s that are connected to hospitals are a legitimate option (U Penn’s hospital has birthing center that is connected by a tunnel to the hospital). She understands that women can want the familiarity of home for giving birth, but she doesn’t think it outweighs the risk of not being with a physician. Also she has had women who bring in their own pillows, blankets, photographs, and furniture into the birthing rooms at the hospital she worked at to make it more comfortable.

I asked Cynthia what she thought about the claim that hospitals have regulations such as limiting food and liquid intake that can in the end be unhealthy and uncomfortable for the mother, but she said hospitals are loosening up with these policies. I also asked her about a concern midwives have voiced with hospitals have the policy of having constant monitors of the mothers, which limits their movement (which can lead to abnormal deliveries). Cynthia replied that when she was working the mothers only needed to be monitored every 30 minutes to an hour, so they we able to walk around in between. Cynthia is skeptical of whether there is validity to claims that hospitals speed up births to be efficient. She understand doctors are people, so yes they may want to get home for dinner and have as many deliveries as possible while working to make the most money; but at the same time they most likely became doctors to help people, so they presumably want what’s best for the patient.

When I started asking Cynthia about c-sections it was clear that she isn’t a fan – she thinks they can definitely be necessary, but doesn’t think they should be a regular course of action. When she was practicing she did a fairly low number of c-sections; she didn’t like to do them and thought a lot of women could deliver vaginally. She was very confident and good at using forceps and vacuums to help assist vaginal births. She tried to do vaginal births because c-sections are a major surgery and can have very serious side effects like blood clotting in the lungs, damaging other organs, and wound infection. Like Kathleen, Cynthia doesn’t approve of elective c-sections (where you schedule a c-section and don’t consider a vaginal birth), so she didn’t take patients who insisted on them.

Cynthia thinks that there are high rates of c-sections in the U.S. because doctors are afraid of being sued and if a doctor performs a c-section they are less likely to be found responsible because surgery shows that the doctor went to great measures. Another reason she thinks c-sections are so common is because women are afraid of the side effects of vaginal deliveries, which include damage to the pelvic floor (can the feeling and appearance the vagina), and urinary and fecal incontinence. She doesn’t condemn people for wanting to have c-sections because both vaginal deliveries and c-sections have risks. Cynthia knows that c-sections are very controversial between both help care providers and patients, so she thinks it comes down to what risks you can deal with. She personally thinks vaginal birth should be attempted because the risks associated with it are less severe and unlikely to occur.

Cynthia said working as on ob/gyn was an extremely demanding but rewarding job. I asked her if the amount of time she had with patients during office hours was an issue and she said no, as long as you know how to make the time count. She does things like sit down with patients instead of standing up because it seems like you’re more focused on them, and leaves the patient happier. One problem she encountered was the incredibly high rates of malpractice insurance. Kathleen’s situation is different because she works for Keiser, which is a self-insured HMO, so she doesn’t have to pay for malpractice insurance.

Next I interviewed Sally Heiman, a nurse practitioner gyn who works at the Bryn Mawr College Health Center and used to be a practicing midwife. When Sally was growing up she was interested in nursing and when she got to Bryn Mawr College for her undergrad she was pre-med. After a year Sally dropped being pre-med and majored in German. She sparked an interest in women’s health because while at Bryn Mawr she volunteered at the birth center and the only non-fiction she liked to read was about birth. She took a year off working as a nurse’s aid and then went to school to become a nurse practitioner. After she got her bachelors she worked for a year as a nurse then got a masters in midwifery. Sally thinks that in certain ways being a midwife is harder then being a doctor because its not really well accepted it has a stigma.

When I asked Sally why she thought giving birth outside of a hospital is advantageous she said that it’s because of a mindset that birth is a natural process, and in general going to the hospital signifies that you have an abnormality (but that isn’t the case for most pregnancies). She said that the vast majority of women don’t need intervention and should be treated like they are normal because if women are correctly monitored up to labor then you most likely will know if it’s a normal pregnancy. She thinks that it’s very important to have a certified midwife who knows how to do the proper screenings, so she wouldn’t necessarily recommend lay midwives because they don’t have required certifications.

Sally thinks that hospitals have to be practical, which involves getting women in and out of the delivery rooms because time is money. She says that health professionals need to be patient and give women time in their labor, but the health care system doesn’t pay for time. With our current health care system the more procedures a doctor can squish into an amount of time the better they will do financially. She doesn’t think this approach has do with an ob/gyn in particular, but a general pressure of running a hospital to economically efficient, which is really hard with obstetrics. In the past 5 years 15 obstetric units in hospitals in Philadelphia have closed because they can’t afford to stay open. Sally says Philadelphia is one of the worst parts of the country for midwives because there are so many medical schools, so there is a general outlook that midwifery isn’t very legitimate. It is different in rural places where there aren’t as many doctors and high tech options available – in those situations midwives receive more respect. In the Netherlands it is much more popular, in fact almost all women go to midwives unless their pregnancy becomes high risk. Sally thinks the U.S. should be the same way, because she agrees with the outlook that only abnormal births need to be delivered in hospitals. Although Sally advocates for out of hospital births she thinks that births can be improved in hospitals when midwives are present. Sally says that there is a smaller use to pitocin (which speeds up the delivery), less breaking waters, and other interventions when midwives are present.

Sally worked at University of Pennsylvania Hospital birthing suite, which is just across the street from the main hospital building (which is where women go who need to have birthing interventions). The birthing suite has a jacuzzi, regular looking big bed, and spacious rooms where women are encouraged to walk around during labor. The biggest difference between the birthing center and the regular obstetrics unit in the hospital is that there isn’t constant monitoring in birthing suite. Sally says there is no evidence that a low risk birth needs continuous monitoring, and actually by constantly monitoring the mother and child it limits movement, which can increase health risks and lead to over diagnosing abnormalities.

Sally also thinks home births can be a good option as long as: the home is close to a hospital, the midwife has proper skills to monitor the pregnancy, and has an active agreement with an ob/gyn in a nearby hospital.

Sally said that the reason the c-section rate is so high in the U.S. is a combination between doctors and patients wanting c-sections. Doctors perform c-sections out of fear of lawsuits. Having a c-section “gives you the ultimate control of getting the baby out so you can get your hands on the baby and fix it if anything is wrong”. She thinks doctors also perform c-sections as a way to save time. Women also want c-sections because you can schedule them – this is something that Cynthia said as well, that people like scheduling things so they know when they will occur. Sally thinks it’s a societal outlook where women have a different view of the process and have come to have certain expectations that are opposite of what is normal because nothing about natural pregnancies can be ‘planned’.

Margot Bradley was the last person I interviewed and she is also a nurse practitioner gyn at the Bryn Mawr College Health Center. She used to work as a midwife at the Bryn Mawr Birthing Center. Margot was always interested in nursing and she worked at a children’s hospital in British Columbia when she was a kid. When she was twenty she got pregnant and during her pregnancy she read an article about midwifery in Temple University’s newspaper. The article got her interested in midwifery and she gave birth with midwives, then decided she wanted to become one. She went to nursing school, and then got a masters in midwifery because she wanted every license possible. Margot never thought about going to medical school because she doesn’t like sickness, she likes dealing with the normal.

Margot sees childbirth through a feminist lens where the midwifery approach to birth is an empowering choice because women have the opportunity to give birth without intervention. She thinks that the standard approach to childbirth in an obstetric unit is to listen to your doctor, “here’s your epidural, don’t scream out in pain”. Margot thinks the midwife approach is sisterly because she will help the mother but she doesn’t dominate. She isn’t anti c-section or anti-epidural, but she thinks that women if have the chance to deliver naturally it’s extremely empowering. She respects that interventions can be necessary, but thinks that should be a last resort.

Margot thinks birthing centers are an ideal situation for labor because in places like the Bryn Mawr Birth Center where she worked the midwives had a collaborating agreement with Physicians across the street at the Bryn Mawr hospital so the patients can receive fast assistance. Margot says a physician should be available 12% of time for consultation, and 5-9% of the time mother will needs direct care (1 ), so it is important to be close to a hospital. She thinks with both home births and births in birthing centers it is key to have a “seamless system for transfer” if necessary. It is also very important for the midwife and mother to be comfortable with the medical equipment, possible outcomes, and knowledge of relationship with the hospital.

Margot thinks that hospitals are a less preferable choice for birth for many of the same reasons as Sally, which mainly center on the intervention rate. The hospital of Philadelphia (h.o.p.) did an academic study on c-sections and found that they supported low c-sections and intervention rates and support natural childbirth from an academic standpoint.

An issue with hospitals is that it is so difficult to run an obstetrics unit. A reason hospitals have constant monitoring is because it’s easier just to look at monitor instead of being in the room and dealing with helping comfort the patient. It’s not an efficient model of care to give lots of personal care to the mother. Margot told me that studies show that a huge number of babies now are born around 6, 7, 8pm, which is an attempt of doctors to manage labors into a work week. Of course naturally there should be an even distribution of birth times. Another argument Margot made against hospitals was that only after obstetric anesthesia became a profession did anesthesiologists go around asking women if they wanted epidurals- especially when in mid labor. Margot’s issue is that there are tons of side effects to epidurals, like infection and bleeding (2 ). When Margot spoke about epidurals I understood why she would be weary of the side effects, but why would doctors recommend epidurals if the benefits didn’t outweigh the risks? At the same time I understand that she places a lot of value in the ability of the body to naturally delivery, so I think it just has to do with her values of natural birth being empowering.

After doing the interviews I decided to do a bit of research to see what the actual statistics for interventions were. The following statistics come from a study done in 2005 with women across America who met the Healthy People 2010 criteria for low-risk laboring women (1 ). The study compares low risk women with usual health care to low risk women with midwives. The rates of intervention are between 2 and 16 times higher with the usual health care compared to the midwifery care.

After doing all of these interviews and trying to process what the women said, I felt extremely confused. From looking at the data above it is clear that midwives do have lower intervention rates, but why is this the case when the midwives and ob/gyn’s I talked to had the same goal in mind? There were two main trains of thought that I understood, one was that it’s better to give birth outside a hospital because the birth is done completely on the women’s time table and interventions are only used as a last resort. The rational behind this thinking is that interventions like epidurals, Pitocin, and c-sections expose the mother and baby to unnecessary health risks. The midwives main claim for why hospitals do these interventions is to save time, and in cases of epidurals is to minimize pain. When hearing the midwives describe this outlook I was confused, because it’s hard for me to image the medical community as a whole approving of these ‘interventional’ practices when they aren’t in the mother and child’s best interest. Another thing that confuses me is if midwives are claiming doctors speed up deliveries for economic gain, then why wouldn’t midwives as well? What makes them different?

I think the difference in outlooks comes down to just having different values – for Margot a big part of being an advocate for natural birth comes from being a feminist. Margot thinks that having a natural birth, being capable of delivering without intervention is one of the most empowering things a human can do. There must be other rationales like Margot’s that value the experience of giving birth with the medicine or surgery. People also think that the health risks of speeding up labor are not worth the gains.

I realized that I cannot make general claims about people’s opinions on health care based on whether they advocate for hospital or out of hospital births. Both Kathleen and Cynthia, two ob/gyn’s think hospital births are a better choice, but at the same time they don’t agree with elective c-sections and think women should always try for vaginal births. When Cynthia practiced she wouldn’t take patients with elective c-sections because she didn’t approve of that method, but she still respects patients having the choice. C-sections are a big debate in the medical community, and even among physicians there is much controversy over when they should be used. Cynthia thinks that as long as patients are educated they should have the ability to make their own decisions, especially when it is one that is backed by parts of the medical community.

The main reason that the ob/gyn’s and other people support hospital births is because of safety. People think that the risk of a pregnancy going wrong isn’t worth the advantage of being outside of a hospital. Not everyone who supports hospital births feel 100% confident in the policies because Cynthia said she isn’t sure if births in hospitals are sped up for reasons other than the mothers health. She could possibly for see other reasons being doctors wants, such as not wanting to stay at work all night. Some people like Cynthia are supportive of hospitals and birthing centers that are attached to hospitals because both have physicians near by.

Another thing I realize that was flawed with my approach to this paper was my thinking that I could interview these health professionals and that answers would fit into certain categories. My original thought was just c-sections, then I changed to hospital versus non-hospital birth, but that is complicated because there are multiple ways to give birth outside of a hospital. The interviews didn’t always go in the same direction, which can make the information feel a bit disorganized, but I think that’s representative of my findings – that although there are general trends, people think differently on specific issues and constant debating can change people’s opinions. I’m still unsure of what I think I’d want to do if I have children.

From interviewing all four women it’s obvious that they are all passionate about their jobs and care deeply about their patients, yet they still have different outlooks on birth. All the women want what’s best for their patients and agree that procedures shouldn’t be done unless necessary, but there is a difference in how often labor is intervened when in the care of a midwife versus a doctor. But really it is hard to tell, because doctors like Kathleen are dealing with the abnormal so it would be expected that she would need to intervene in the delivery. The main argument from the midwives was that births in hospitals tend to treat birth like an ‘abnormality’ so intervention occurs more frequently; but both the ob/gyn’s I talked to said that of course they only intervene when it is necessary. I guess what it comes down to is drawing the line of ‘what is necessary’, and as being raised to value education I would assume that an m.d. would be most informed about this decision. That still doesn’t mean that I’m saying I chose someone’s ‘side’ because there aren’t really ‘sides’ on this issue – hospital versus non-hospital have so many issues within those categories, so I cannot make a blanket statement. As for trying to approach this issue from a feminist point of view, I would say the best thing to do is to have the most autonomy over your body, which to me would be choosing to give birth outside of a hospital with a midwife. I think that there are multiple ways you could frame a feminist point of view on these issues, but I would agree with Margot’s feeling that a woman giving birth on her own without intervention is  very empowering and feminist .

Bibliography

(1)  "Childbirth Connection: Helping Women and Families Make Decisions for Pregnancy, Childbirth, Labor Pain Relief, the Postpartum Period, and Other Maternity Care Issues." Childbirth Connection: Helping Women and Families Make Decisions for Pregnancy, Childbirth, Labor Pain Relief, the Postpartum Period, and Other Maternity Care Issues. Web. 10 May 2012. <http://childbirthconnection.org/>.

(2)  "Epidural Steroid Injections: Risks and Side Effects." Spine-health. Web. 11 May 2012. <http://www.spine-health.com/treatment/injections/epidural-steroid-injections-risks-and-side-effects>.