Perspectives on Normal Birth.

I recently returned from a three-month internship at one of the birthing centers that doubles as a training center for direct-entry midwives. It was an experience that opened my eyes to the great need for increasing the rates of normal, natural birthing.

I had already studied a basic course in midwifery academics and apprenticed briefly as a labor coach and midwife assistant, but it had become clear that hands-on experience would come very slowly as an apprentice.

The requirements for both national certification as a Certified Professional Midwife and licensure in California include at least twenty births in which I act as primary attendant under supervision. Unfortunately, it might take several years to get that experience in a standard homebirth apprenticeship.

Because I was nearly forty years-old and didn't want to add an extra couple of years to my training time, I gathered information about various intensive midwifery training programs and finally selected one that was likely to offer the kind of experience I needed. Although there were sacrifices in terms of tuition money, rigorous conditions, and three months spent away from home, I expected to get a lot of experience, including twenty catches.

Fortunately, my sacrifices were amply rewarded with an amazing amount of valuable education and experience, including a new perspective on how cesarean rates of 20-30 percent are outrageously unnecessary.

During my time at the birthing center, there were 116 laboring women who came into the center. Of those, only three were transported--one for pitocin augmentation, one for possible fetal distress, and one for suspected CPD (cephalopelvic disproportion). Only this last case ended in a cesarean delivery. Although most babies were routinely suctioned, a small percentage needed oxygen or more serious resuscitation. So, during those three months, of the 116 women who came to the center, only one labor ended with a cesarean. That's a cesarean rate of less than 1 percent; or a 3 percent combined transport and cesarean rate.

I've given a lot of thought as to why this might be so low. Certainly it was not because of the population. If anything, it was a population at risk--many of the clientele struggled to afford the low birth fees and had limited ability to purchase recommended supplements, although they did manage to grow healthy babies nonetheless. There were a number of women with characteristics of android or platypelloid pelves--not considered ideally suited to giving birth. A lot of the "young women" were really girls, many younger than 18. And, as in any population, there were women with family situations or past traumas that made giving birth a trying emotional ordeal.

Some women were not entirely trusting of natural childbirth and were apprehensive about our lack of drugs to dull the sensations. Some had had unsatisfactory previous birth experiences--they came with episiotomy scars, and a few even came with cesarean scars. So, yes, there were VBACs (vaginal birth after cesarean) and borderline cases of PIH (pregnancy induced hypertension), or polyhydramnios, and there were lots of first-time moms; there was even one planned breech birth. A lot of women were "induced" with castor oil after 41 weeks so that their care wouldn't have to be transferred out of the birth center at 42 weeks, which no one wanted.

Hardly an ideal clientele. And yet, a cesarean rate of less than 1 percent.

How was this possible? How could it be that this birthing center had such a tremendous success rate, and all without any drugs for pain relief? How could they do this with no electronic fetal monitoring and no pitocin IVS? Well, that's probably half the answer right there. Recent studies have shown that active management (i.e. pitocin augmentation) and continuous electronic fetal monitoring do not improve outcomes for moms and babies; in fact, they only seem to increase the cesarean rate. So maybe the "shortcomings" of an out-of-hospital birth were a great part of the secret to success.

But still not enough.

Perhaps it was the built-in labor assistant system. Although most laboring women did not have continuous labor support from birthing center staff, they were individually observed each fifteen minutes or so when the responsible intern checked the baby's heart rate. Each of these visits was an opportunity to observe the mother's condition, her progress, her response to contractions.

We did a lot of the standard labor assistant work--recommending changes in position, making sure they're eating and drinking enough to keep up their strength, suggesting a shower when they got to some of the transition points. And sometimes, for a mom without family to support her, we did stay with her continuously if she was having a hard time. But mostly it was family staying with them.

So, could it have been the labor support that made the difference? Maybe, but the doula studies only show a 50 percent reduction in cesareans, not anything so dramatic as down to 1 percent.

So, I kept thinking. What was different about the situation at the birthing center? What was the single ingredient there that you didn't get anywhere else?

And then it came to me. These women were getting the kind of care that money cannot buy. Each of these laboring women had a dedicated caregiver who had or knew how to access the necessary expertise to do whatever it took to help each woman have a vaginal delivery; and that caregiver desperately wanted this labor to end in a vaginal delivery.

I'd like to be able to say that our dedication to the desired result was because of our unrelenting support of natural childbirth, our dedication to the clients, etc. But, in reality, operating on severe sleep deprivation, working every day of the week, 75 hours per week, sometimes with clients we had never met before, our motivation was not entirely pure. We needed that birth to be a normal, spontaneous vaginal delivery because nothing else would count as a catch for the intern. And we needed that birth to be as easy as possible for the mom so she would progress well and give birth on our shift, or else it would count as a catch for some other intern.

Averaging out the tuition money and time I spent at the birthing center, each baby that I caught cost me over $100 and half-a-week away from home. These were not opportunities that I was going to let slip easily from my grasp, and certainly not to end in a cesarean.

Really and truly, I wasn't thinking about all the economics of this. I only knew that I had waited for nine long months for the opportunity to catch babies, and I desperately wanted to catch as many as possible. I worried when I didn't seem to be catching as many as other interns. I was willing to stay for hours after my shift ended if it meant an opportunity to catch a baby that looked like it might come soon, as was permitted by policy. Even though I would then also be required to provide another couple of hours of postpartum care, I was eager to work a 16-hour shift if it meant more experience--another catch.

So, basically, the laboring woman was in the care of someone who happened to have an unusually strong commonality of interest--an efficient, easy vaginal delivery.

It didn't always work out that way. There were first-time moms who needed one-on-one labor support for the better part of my twelve-hour shift and then didn't deliver until six hours into the next shift. I feel very lucky to have been at a place where I could still share in her triumph, as we had the opportunity to observe every birth, even when not on our shift. (No, please, don't ask when we slept; it makes my body wince to think about it.)

But mostly, my intense focus on keeping this woman's labor "easy" and efficient was rewarded. I learned how to keep an eagle eye on heart rate--to notice the first little beginnings of a troublesome pattern and to keep trying things until we figured out what was causing it (almost always the woman's position). Sometimes we saw early decels that made me a little nervous, but then we knew the baby was at the ischial spines and it might be a rough road through. No problem. I learned a lot about taking advantage of the relative relationship between the baby's head and the mom's pelvis. I knew that it was almost certain that this baby could fit through this pelvis--it was just a matter of figuring out how.

And mostly it took a lot of time, patience, and hard work. There were some marvelous teachers there, and I saw babies birthed in just about every position in between upright and a full squat. I learned how to reshape a pelvis by applying pressure to this bone or that bone at the critical moment to help the head get through.

I learned the beauty of real midwifery, being with the woman, advising, but not controlling. I saw some amazing examples of women knowing exactly what her body needed to do to get this baby out. Sometimes I would suggest a particular change of position, and she would start to assume that position but somehow end up in another position that I could never have imagined. Then, fifteen minutes later, she was ready to push the baby out. I learned a profound respect for instinct.

I learned to take pleasure and pride in minimizing the interventions--trying to help the mom deliver nice and slowly, assuming the baby's heart rate wasn't at all worrisome. The slower the better--the baby was better oxygenated at birth and the moms didn't tear. The rate of tears that needed suturing was about 15 percent while I was there, even with small mothers and big babies. I saw nine- and ten-pound babies born with no tears.

So, will I be able to duplicate this level of success in my own midwifery practice? Sad to say, probably not. I'll probably need to transfer care earlier for women with borderline conditions, mostly due to legal restrictions. I, personally, won't deliver breeches until I have a lot more experience, but I do know an excellent homebirth midwife who is more than qualified to attend breech or twin births. And I'll probably never feel the same passion about really, really wanting the woman to deliver under my care. This is probably a good thing and will keep me from making decisions that might not be appropriate for a homebirth, even when they are appropriate for the birthing center, where there are lots of experienced hands around.

However, I will strive with every ounce of ingenuity to see that I match the overall statistics. I hope to be able to say that of all the women who entered my care, less than 1 percent had cesareans, even though my transport rate may be more like 10 percent.

I hear myself say this and I hear the voices of doubt saying, "But even the midwifery advocate Marsden Wagner says that cesarean rates less than 5 percent tip the balance towards losing moms and babies unnecessarily."

But I know that this is only the case where you're getting care that money can buy. That's the type of care that isn't passionate about preparing each and every mom mentally and physically for a vaginal birth.

That's the type of care that doesn't even believe in the concept of "setting a mom up for success" through prenatal education, visualization, and appropriate herbs. That's the type of care that knows they "can always do a cesarean." That's the type of care that doesn't give you much information on "how to turn a breech baby" other than to schedule an external version, knowing they can do a cesarean if things go wrong or it doesn't work.

That's the type of care that thinks it's "easier" to have a mom with an epidural than a mom who's up and about, changing position, and eating and drinking to meet her needs. That's the type of care that ignores those early warning signals of a funky heart rate and ends up doing an "emergency" cesarean for a situation that could have been prevented--but only by the kind of care that money cannot buy.

I feel confident in saying that if any individual woman offered a skilled caregiver a million dollars if she had a vaginal birth, that woman would have a vaginal birth 99 percent of the time.

Why? Because then it would be economically feasible to spend an hour with her at each prenatal and address issues of presentation and position at every appointment. Then it would make economic sense to anticipate the physical, social, emotional, and psychological issues that might become a problem for this particular woman, and to advise strategies for coping with them.

Then it would make infinite sense to visit the woman early in labor to make sure the baby's position is favorable, before it's too late to change it easily. Then it would be extremely cost effective to hire the best help necessary to provide non-pharmacological support during labor--massage, chiropractics, hypnotherapy, a birthing tub, a TENS (transcutaneous electrical nerve stimulation) unit, all in her own home, where she can labor most easily and effectively.

Then it would obviously make sense to attend the woman full-time once she's in active labor, to make sure that everything continues to go well. Then there would be no rush to hurry the pushing phase, or the crowning, or the cutting of the cord, or the bathing and separation of the baby.

In short, it would be a completely different experience. Unfortunately, it is an experience that reasonable sums of money cannot buy.

But sometimes that which cannot be had for money can be had for love; love of the triumph of the human spirit in each birth; love of the strength of women as they labor to bring forth life; love of facilitating the easiest, gentlest, quietest birth possible; love of life and love itself.

So, if you want to improve your odds of having a normal, spontaneous vaginal delivery and a triumphant birth experience, I recommend selecting a caregiver who does it for the love of the work above all else.

--This article was originally published in the November, 1996, issue of The Clarion (Vol. 11, No. 3), the journal of the International Cesarean Awareness Network (ICAN). Ronnie Falcao, LM, MS, is a homebirth midwife, licensed in California. She also practices as a labor coach and prenatal hypnotherapist, based in Mountain View, near San Jose, California. This article was written in September of 1996 after a three-month residential internship at a birth center in El Paso, Texas. Email can be sent to [e-mail].