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Have we learned anything about birth?

This article appeared in the International Journal of Childbirth Education, Vol. 7, No. 3, Fall 1992.

Like many ICEA teachers, I have been a childbirth educator for close to two decades. I first trained with a CEA group in Los Angeles and have been a loyal member since 1974. My purpose in writing this is to challenge those of us who have been around for a while to ask ourselves, "What have we learned about birth in the intervening years?" and to share our answers with those who are newer in the field.

"Back then" we were clear about the dangers for the baby of spinal and epidural anesthesia and how they detracted from the mother's experience of giving birth, but we were less certain about IVs, shaves, episiotomies and giving birth at home. As a pregnant parent having my first baby at home in 1973, I can remember seriously researching whether it would be all right to have a baby without a shave and an enema. Was it humanly possible? Would it be safe?

Twenty years ago we could question the necessity of the myriad interventions which were an integral part of the American way of birth, but we still maintained the illusion that there must be some scientific basis for them, Now we know that virtually all of the procedures of "standard hospital birth" are unnecessary for the " standard pregnant woman": the shave, the "high, hot and heavy" enema, the IV drip, the continuous electronic fetal monitor, the breaking of the waters for a routine internal monitor, the stirrups, the episiotomy, the manual exploration of the uterus after the placenta and the "visualization of the cervix" for tears. Yet I observed every one of these standard procedures at a normal birth in a Detroit area hospital in 1989, including pulling the woman's cervix out with three-ring forceps to look at it (on an unanesthetized woman with a normal delivery). At a birth in a different hospital in 1991, they only visualized the cervix with a metal retractor--how much more humane!

How can we know that these standard procedures have no scientific basis? A Guide to Effective Care in Pregnancy and Childbirth by Enkin, Keirse and Chalmers reviewed thousands of studies in the English language and showed that most of our birthing practices are "forms of care that should be abandoned in the light of available evidence" or that they, at best, "require further evaluation" to prove their efficacy. The word from the scientific community is in, and is today easily accessible to childbirth educators and the public alike.

We have also learned about what is and is not necessary by observing births and midwives in hospitals, birth centers and at home. The fact that births within the same institutions are conducted in such radically different manners has not escaped everyone's notice. Whether a woman is a clinic or private patient, whether she elects the midwives or doctor x, whether she chooses the birthing room or the delivery room determine how her labor and delivery are "managed," not physiology or scientific principles.

Perhaps models and statistics from European countries like Holland and treatises like The Cultural Warping of Childbirth by Doris Haire seemed somehow too far removed from ordinary American birth. But now the statistics are in from our own birth centers and homebirth practices: mortality and morbidity are not increased when standard procedures and their accompanying iatrogenic problems are avoided. The experience, procedures and skill of the attendant are the determining factors for outcome, not the place of birth.

Births with midwives (and ICEA has issued two position papers supporting both midwifery and birth at home) have provided models which are slowly revolutionizing hospital birth. These institutions are finally having to open labor/ delivery/recovery/postpartum (LDRP) rooms as the incongruity between what was/is going on in the birthing rooms and their standard delivery rooms finally becomes too great to bear.

I've learned something about birth in the past twenty years and I suspect that since you also read this journal and are conscientious childbirth educators, you have, too. But what are we teaching? "Freedom of choice based on knowledge of alternatives." Don't get me wrong, I support that motto wholeheartedly, but I also know our job can no longer be "to present all alternatives in as complete and unbiased a light as possible." For example, I have been told that our teaching about episiotomies needs to be balanced by the fact that "some women want an episiotomy. " If that is true, it is because they have been fed misinformation: their doctor has told them that their pelvic floor will hang down around their knees or he has told them in second stage that it would take forever without an episitomy and wouldn't they rather have the baby right now? Women are always free, and will make their own decisions. Right now, they are making them based on a cultural norm that is male dominated rather than women-centered.

The question should not be are we presenting (in a fair and unbiased manner) hospital procedures which violate women (and all of them do). Rather, the question is have we become agents for changes or agents for the maintenance of the status quo? We can know from history that changes gradually become incorporated into the status quo and activists gradually become co-opted into working to maintain that (new and improved) status quo.

As far as I'm concerned, none of us is telling the truth strongly enough to balance and counteract the forces that control birth in our society. The exception is Nancy Wainer Cohen. In her new book Open Season: A Survival Guide for Natural Childbirth and VBAC in the '90s, she doesn't mince words. The book fairly sizzles in your hands and will hopefully become the wake-up cry and rallying point for a whole new wave of birthing women, just as Immaculate Deception was for women giving birth in the '70s. There are many reasons why we don't tell the truth about birth, tell what is really necessary, what is really needed, or tell how women can really regain confidence in themselves and their ability to give birth. First, it's not polite (no one likes uppity women); the doctors and hospitals won't like it; the women themselves don't want to hear it. All three of these are as true now as they were twenty five years ago. As far as the women go, the Yuppie phenomenon and the epidural epidemic won't last forever. Something new is arising, a new consciousness is coming in again, re-enlivening us and our work. We can see signs of it in the publication of Open Season, in the acceptance of non-nurse midwifery by the ACNM and the renewed interest in homebirth and midwifery that is firing the nation.

We need to rally our forces, to be courageous again, not be afraid to say what we know is true. As far as I'm concerned, we can't present the truth of what we know strongly enough. For example, episiotomy is almost completely unnecessary, has been foisted upon women starting with Dr. Joseph DeLee in the 1920s and--even though it is done with the best intentions--is in fact genital mutilation. Even though those are strong words, you don't have to be a radical feminist to recognize they are true. Women are starting to refuse episiotomies in a very different way from "trying to avoid one" five years ago. It's like "the hundredth monkey": when enough of us know something, suddenly everyone is able to know it more easily and things have to change as a result. What can we know about birth? It is not a medical event, but a creative expression of a woman's health and wholeness. Women have always been attended by women and accepting someone who doesn't even have a vagina as the authority on birth is symptomatic of the problem, not the solution. The procedures of standard hospital birth hinder rather than help the process of birth and have proven ineffective in lowering infant mortality statistics. If you really don't want an unnecessary cesarean, don't give birth where they are done. The list goes on and on. How would we teach these things in childbirth classes? Wouldn't we all be out of jobs? Wouldn't we be unfair to women who "have to" give birth with a certain doctor if we said these things? Each instructor must find her own answers, but first she must ask herself what has she really learned about birth? What is important? What do women really need to know? Then she will find new ways to share that knowledge which will empower women rather than sacrifice them to maintain the existence of obstetricians or healthcare institutions, whose fiscal and spiritual bankruptcy is becoming more apparent every day.

Robbie Davis-Floyd, an anthropologist who has spoken at many ICEA conventions, has shown how the medical model of birth supports the dominant values of our culture. It is time that women, led once again by the childbirth educators. awake from their slumber and declare that those values are not our values. We can no longer afford the luxury of being silent. The very existence of life on our planet depends on it.
COPYRIGHT 1992 Association of Labor Assistants & Childbirth Educators
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Copyright 1992, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Title Annotation:Childbirth Education
Author:Baldwin, Rahima
Publication:Special Delivery
Date:Dec 22, 1992
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