Maslow’s Hierarchy of Needs

In watching the clip of The View, where Ricki Lake talks about The Business of Being Born (below), there is a comment by Barbara Walters that interested me. Lake is explaining how having a natural birth at home with midwives empowered her; Walters is confused by that.

This started me thinking about how many women do (or don’t) take childbirth classes and why that might be. Of course, partially that is because I’ve had this poll on the blog asking people if they took classes and why or why not. At the time of this writing, 52% did not take a class, and most respondents who didn’t take class said it was because they didn’t need one.

Of course, you know I’m going to ask ‘why’ next, right? Did they feel they didn’t need one because they figured they’d blindly trust whatever their OB told them? Did they not understand the purpose of a childbirth class? (Hint, it has nothing to do with ‘breathing’…you must know how to breathe already or you’d be dead and I hate to say it, but there is no magic breath that gets babies out.) Did they have a midwife as a caregiver, and had everything explained to them (and had actually helpful books recommended to them so they could educate themselves) so that a childbirth class was redundant? Did the non-hospital childbirth classes not market themselves well?

It was this last question that was on my mind when Maslow’s Hierarchy of Needs came up in conversation. Now, this pyramid of needs has tickled the back of my brain several times in recent months, as it’s come up in regard to effective marketing and in sociology. This time, I realized why it kept bothering me.

First, here’s a visual of Maslow’s theory: (if you click on the image it will open up a full-sized image you can read)

The basic idea is that when we make a decision about something, these are the factors that will motivate us.

First, we are concerned with survival issues. If our basic needs are not being met, we don’t really care about the other stuff.

Next, we need to know we are safe and secure. We need some order in our life, some predictability and to be part of a larger whole. This is also about survival to a certain extent. Being part of the larger group is an evolutionary desire. We are tribal by nature. Solitary humans don’t do well, not just because we need others to be most effective at hunting, gathering, farming, etc., but we need social stimulation for the sake of our brains. If we don’t interact, we go a little bit nuts. Think of the movie Cast-a-way with Tom Hanks.

Beyond that even, we need to fit in with our family, peer and work groups. We have a need to feel appreciated and loved.

We can survive if the only the first two needs on the pyramid are met, but without the third, we probably would be slightly maladjusted.

Next, we have the need to feel special. We want to feel respected and to be able to feel pride in our accomplishments. Finally, we reach a state of enlightenment or our full realized potential. Some say not many of us get to that point, except maybe Oprah. J

Ok, so how does this relate to birth, childbirth classes and Barbara Walter’s bewilderment? Here’s my theory:

Most American women are still making decisions at the first two or three levels. They believe birth is a dangerous, excruciating medical event. They want to be able to predict exactly what will happen each step of the way, even if the security is an illusion. If they do what every body else does, not only can they have a plan, but its familiar because it’s what everyone they know has done. They are following a blueprint. Sadly, because they do what everyone else does, they get the experience everyone else got, which is likely the painful medical event. But that’s ok with them, because they all have the same war story to tell. They fit in. They also get admiration for ‘surviving’ such a harrowing event.

Those of us who make the decision to birth at home, or who take a class that advertises gentle and empowering birth, are doing so because we are not operating from a place of fear. Make no mistake I am NOT saying we are ‘better’ or ‘higher’. I’m saying because we are confident that we are safe, and our babies are safe, we are not operating from survival need. Because we know what the research says BIRTH is safe, we are not operating at security need. Hence OUR confusion when someone says, “You birthed at home? Oh, you are so brave! I could never do that!” We, of course, are thinking, “Sure you could.” We don’t consider ourselves brave at all. We are just doing what makes sense, personally and per the evidence.

We are working from the ‘esteem’ level, because if we can. We feel a need for a sense of accomplishment like anyone else. We feel a need to be respected by our spouse or our home-birthing friends and to feel unique. Now, we all have these needs, but what I’m saying is that we can make our birthing decisions from this level because we don’t have to worry about the first three needs. To try to empower a woman who is operating at a survival or security level will not work. She has other things to worry about. Not to mention, if she is in an unsafe environment, or doesn’t have access to nutritious food, or is in some way actually not healthy, she actually is at risk for complications, which means she’s operating at exactly the level at which she needs to be operating. This is why it is absurd when people say homebirth supporters are trying to ‘make people feel guilty’. Even the most strident homebirth advocates realize hospital birth is the only place to be for about 10-15% of women. Homebirth should be an option because it’s safe, not because it’s right for everyone.

Think about it like this: You feel education is important. You improve the schools, and you make attendance mandatory. But one kid just doesn’t seem to care. He is often truant, and when he is there he doesn’t make much of an effort. You try to tutor him. You try special classes. You try rewards and punishments, but nothing works. He just doesn’t seem to value education.

What if you found out the kid was homeless? What if he’s being beaten at home, or doesn’t get to eat every day? What if he was convinced he was worthless because he was told he was, every day? If you met the more basic needs, from the bottom up, he might be more interested, and able, to operate at a higher level on the needs hierarchy. Otherwise, he simply can’t. He has to meet his basic needs first.

So, when we talk to women about the empowerment of natural birthing, they are confused. Sometimes they’re angry, but they may not be sure why. I believe it is because there is cognitive dissonance because on some level they know that the fear they feel is disproportionate to the actual risk. Because there is someone who doesn’t feel that same fear, it makes them question why they have it. Not consciously, of course, but if they become aware that some women can birth with dignity, comfortably, maybe painlessly, even ecstatically, and still be safe, but they believe that they must sacrifice all that for safety, it suggests that their suffering was for nothing. That’s not a comforting idea. It would make me angry too.

This brings us to the question of how we can help them meet their needs so they can feel the ecstasy and empowerment we know is so transformative. Right now they don’t even care about that. You don’t know what you’re missing if you’ve never had it. You won’t even try for it if you don’t believe it’s really possible for you. Can you see how bubbling over with enthusiasm about your positively transformational birth experience comes across as lunacy to someone who is convinced they “would have died” if they’d done what you did? It doesn’t matter if it’s true or not, it’s what they believe.

It doesn’t matter if they had an epidural that caused a sudden drop in blood pressure, that caused fetal distress that required a cesarean that saved their life. The only part of that equation that is important is the last part. It doesn’t matter that the medical management of their birth lead to the problem in the first place. What matters is the medical management saved their life…and it did. It doesn’t matter that they almost died of hemorrhage due to an elective cesarean, what matters is that modern medicine saved their life. Undoubtedly it did. It doesn’t matter that their baby almost died from a cord prolapse that coincidently happened just after artificially rupturing the membranes. What matters is that modern medicine saved their baby from certain death. It did. And because they are operating at that place of survival, it makes sense that is what they would focus on, it’s what’s important. They aren’t even going to question it unless they are operating from the 4th level. If they are, they are going to wonder how things got so askew. Many do. These are the women who have a couple of horrible experiences and then come to a HypnoBirthing class. Or, the women who hire CNM for VBACs after questionable cesareans. Or, the woman who has seen several of her friends suffer from birth-related PTSD who decides to explore the option of homebirth. No one is right or wrong; they are just making decisions based on their where they are on the pyramid of needs.

What that means to childbirth educators, midwives, doulas, etc., is that we need to consider this in our marketing and in our interactions with others. No wonder we haven't reached a 'tipping point' yet. Maybe The Business of Being Born with be that tipping point that will allow more women to feel safe enough to work from a different need level?


What Makes Us Tick

From a sociological perspective, our cultural beliefs about birth and many early parenting issues are incredibly fascinating. We don’t often stop to consider that our culture shapes our decisions. We have this idea that we are choosing to do things a certain way of our own volition. Rarely is that the case.

Macionis, in Sociology: The Basics, says that the greater a person’s marginality, (meaning someone is not part of the dominant group) the greater the ability to see things other people don’t see, or using a sociological perspective. I guess I qualify as an outsider in many ways. He lists things like gender, age, sexual orientation, and disability as things that can marginalize a person. Other than the fact that I am a woman, I’m not marginalized by any of those things. I’m pretty typical. I’m married to a man, am able bodied and am of middle age. However, I belong to several ‘subcultures’; groups that are different from my dominant group, which for the purposes of this exploration would be an American Parent. Certainly I could be classified in many ways, but for simplicity, I’m picking this one.

Practically nothing I’ve done is in step with the dominant culture. Why? I have no clue. I question everything. My favorite quote is ‘Examine everything you’ve been told. Reject what insults your soul’ which is how I live. If something doesn’t make sense to me, I want to know why, and then I want to see if there is something that does make sense, and then I want to know if there is hard, verifiable evidence to support the alternative.

In most cases, I’m actually not very concerned about what someone else thinks of my choices. By the time I’ve made a choice, I’ve done enough research, from a global perspective, that I’m very sure I’m making the right choice for me and my family based on all of the evidence available to me. Some people won’t even consider information that doesn’t originate in the U.S. I think that’s a huge mistake. Other countries have much to teach us. It is arrogant to think otherwise, which is why so many people around the globe hate us. But I digress.

Back to my alternative choices, which include:



Selective Vaccination


And if I’d had a boy, I would have rejected circumcision

These choices put me in specific subcultures. These subcultures may not be easily recognizable through commonalities such as dress or ways that other subcultures are identified, yet they fit the definition of subculture because by questioning the status quo, they set themselves apart to a certain extent.

This is very threatening to the dominant culture. I’ve been called judgmental and told that I’m trying to ‘make people feel guilty’ because I made different choices and want to expose people to the idea that they can too. I’ve never said my choices are right for everyone. I can’t impose guilt on anyone. It’s an internal emotion, and I don’t try to shame anyone for making any decision they feel is right for them. I do use a lot of statistics that call into question why certain decisions have become the norm, but that doesn’t mean I really care about anyone else’s personal decisions. Sociologically though, suppose I’m looking for the general in the specific.

What I do care about is needless suffering, and many of the decisions made in the childbearing year cause problems that lead to suffering. So it baffles me when simply trying to educate people draws such an angry response sometimes. No one has to agree with me. No one needs to defend their choices to me. My opinion should mean nothing to anyone. Lots of people disagree, sometimes vehemently, with the choices I’ve made. I’m ok with that. I have no need to defend those choices because I have no regrets in having made them. No one can shame me for not making the choices they’ve made, because I take responsibility for my choices, and mine alone. I just wish everyone could feel that confidence. I wish that through informed consumerism, parents could really understand what their options are, and that a lot of what they think are parenting options are not really options at all, as well as why certain parenting decisions are influenced a lot more by culture than anything else. We tend to think that just because many, or most, people do things a certain way, it’s the “right” way. So much so we may not consider there are alternatives.

These are things that are important because they influence patterns of health and illness, both emotional and physical, in our society. For example, we have an epidemic of childhood obesity and diabetes currently, which will eventually lead to an adult population with serious health issues. The roots may well begin at birth with breastfeeding (or rather lack thereof), but if we can’t be open to questioning infant feeding choices (a parenting option), we can’t address it fully.

On 1/14/08, USA Today ran an article in the ‘Life’ section that listed the complications of the obesity and diabetes and gave parents some concrete ways to help children stay healthy. They included: limiting television, limiting junk food, making nutritious food available, and encouraging exercise; all excellent ideas. Yes, they will all lower the incidence of obesity and diabetes. However, not once was breastfeeding mentioned. Not once was it mentioned that one of the main ingredients in formula, besides cow’s milk, is sugar. There were no resources explaining to parents that this culturally induced idea that formula and mother’s milk perform exactly the same function isn’t based on science, but politics and social mores.

From a structural-functional sociological perspective, there is a consequence to this social pattern that disrupts society as a whole. This approach also explains why this is such a heated topic: bottle feeding is a social structure that serves many functions besides feeding a baby (the manifest function). It allows women to be in the work force (a latent function). To suggest it isn’t good for babies creates a conflict, because were it not available, there would be a disruption in the way society currently operates. But another latent function is illness, which also disrupts society.

Any of the counter-cultural parenting options I chose pose the same threat. It makes people uncomfortable to think there might not be a logical reason for the things we do as a culture. This discomfort creates social conflict between the different groups, but this is important and necessary. The presence of these countercultures is a good thing, because without them, change would not be possible. If no one is willing to speak out against the needless suffering of women and babies, why would it stop? The culture at large isn’t even aware the suffering exists. The suffering is considered ‘normal’.

However, many of the problems that new mothers encounter are not common natural occurrences; they are created by the choices made in birth and shortly thereafter, many without the women even knowing they’ve made a choice.

This creates issues, and mothers talk about these issues, and because they all have the same issues, it is considered ‘normal’. Thus, no one bothers to consider that they aren’t, or that there are predictable ways of behaving that will reduce or eliminate the issues. This is how we have 70% of women anguishing over the ‘fact’ that they ‘can’t’ breastfeed. They have constructed the reality through their interactions-according to the symbolic-interaction approach. It never occurs to them that the reason they suffered was because of birthing decisions, bad advice or simply the cultural acceptance of an inferior substitute to human milk.

Another example might be the idea that birth is supposed to be excruciatingly painful. Empirical evidence tells us this is so. Right? We see it. We hear about it. The idea is accepted as something ‘every body knows’, or just pain common sense.

So, what we talk about and study is why birth is painful and how we can anesthetize the pain. It never occurs to us to wonder if the pain must be present, and if not, why not.

So, we come to conclusions that birth is painful, and perhaps dangerous, because we have big brains. We dismiss any evidence that lots of people give birth painlessly without drugs, either by chance or by design. We attribute any danger encountered, not with the multitude of variables that could have played a part, but with birth itself. We form all sorts of scientific ideas about pain, we write papers or even books about it; we measure it and draft policy to deal with it. But all along, we are asking the wrong questions because the premise with which we began was flawed.

Surely, there is a correlation between birth and pain. But is birth the CAUSE of the pain? If it is, all women would experience pain in birth. They don’t. At least 30% of HypnoBirthing mothers don’t, and there are many others who naturally don’t. Then it can’t be the process of birth that causes the pain. If birth doesn’t have to be painful and dangerous, then a ‘big head’ has nothing to do with anything. What causes pain during birth is actually very predictable and often avoidable, even with 11 lb. babies with truly big heads! Why on earth do people resist this idea, even when they can see statistics and videos of painless births (or even orgasmic births)? Because it disrupts the way their world works. People don’t like change, and this idea, while it seems deeply personal, has a ripple effect on many systems in our non-material culture.

Our patriotism is called into question if we are confronted with the idea that we don’t have the best maternity care system. We don’t even come close to the best.

Our ideas of freedom are called in question if we learn we have rights and responsibilities as a pregnant patient, yet are denied those rights when we try to exert them. This also makes us question our ideas of a benevolent health care system that we’d like to think puts our best interests first. We have many cherished ideas about what to expect of babies and motherhood. People who make different choices make us question our own, and the ideas that preceded them. Our very values and beliefs are challenged and that is very threatening.

Sometimes cognitive dissonance occurs when a core cultural value contradicts a belief. For instance, we (as a culture) have come to believe that epidurals are safe and justified. So, when a woman has an epidural that slows down her labor, necessitating pitocin which causes fetal distress and leads to a cesarean, there will likely be no acknowledgment that the epidural was the cause of the surgery. Birth will be blamed, because a cultural core belief is that birth is dangerous. Volia! Cognitive dissonance gone, to be replaced with denial and perpetuation of a harmful practice. In this instance, two birds are killed with one stone, because we have a cultural belief that breastfeeding is difficult too. Epidurals create breastfeeding problems, which reinforces the belief.

There has been a cultural lag regarding this issue. We got to where we are through invention, though our ethics have not kept pace. Through discovery and much research we know how to bring balance. Much of the information required for women to have easier, more comfortable safer birth and smoother postpartum transitions can be found in this blog. Now we need to allow diffusion, the spreading of ideas from places where birth is safer to create change on a larger scale. This diffusion also must happen within our boundaries. I hope that Ricki Lake’s movie, The Business of Being Born (trailer on this blog) may be the impetus for that diffusion. Once women understand that their best and loving mothering intentions are being sabotaged before their babies are even born, there will be a revolution! When women realize they can have the healthy baby prize without sacrificing their body integrity, their sex lives or their dignity, man, will they be pissed!

Thus far they’ve been socialized by their mothers, sisters, friends, and media to accept what’s been done to them; to be good little girls and buck up. As long as we can fix what we break, don’t worry about us breaking it. We know best, dear. All of your friends are doing it this way. Your mother did it this way and it turned out just fine…unless of course we x-rayed her (and told her it was safe) or gave her DES (and told her it was safe) or gave her thalidomide (and told her it was safe), or use Cytotec on her (and told her it was safe), or gave her a routine episitomy (and told her it was necessary).

We say that we value mothers and babies above all else. We hold that as a cultural value, in fact. If we really mean it, we must offer safe alternatives in childbirth. We must demand evidence-based care. We must have people appointed/elected to government offices at all levels who will be committed to actually putting our efforts toward what we say our values are. We must support and protect the mother-baby nursing relationship. We must admit that what we are doing now isn’t working. We can’t fix the problem until we acknowledge it. Some orgs that are already doing so can be found here:





The Business of Being Born

I'm so excited! Finally The Business of Being Born is making the news! Here is the trailer:

I'm so grateful that Ricki Lake did this! One of the things I've been saying for a long time is that until we get the 'innovators' out there talking about their wonderful births, women won't believe that it's possible. If you go to You Tube, you will see that big stars who've had natural and or home/births are getting out there, and TV shows like The View are talking about this.

Please support this effort! Go see it if there is a screening in your area. Rent it from your local movie rental places or Netflix.

It really is worth the effort!


The Baby Fell Out

Ok, stories like the one below (titled the same as this one, but with an MSN video embedded) drive me nuts!
The guy who cut the 'umbiblilcal cord' (please note that it has nothing to do with anything biblical...it is UM-BIL-IC-AL cord) has determined that the second baby would have died in another 'two to three minutes' because somehow being breech deprived him of oxygen? It doesn't say there was a cord prolapse, placental abruption or anything. The baby was fine in the end. If there was oxygen deprivation on the way to the hospital, the baby would have had issues. Likely the second twin was surgically removed simply because he was a second twin and breech. There was no mention of turning him. Granted, they were little babies. Vaginal delivery of a tiny preemie (there are certain criteria in safe vaginal breech birth; not too little, not too big, not a first baby, etc.) is not risk free, but there is no mention of if the baby was a preemie or not, and the first baby 'just fell out'. Obviously she had an adequate pelvis! There is also no mention of what kind of breech the second baby was. Feet first? Butt first? Just because it was an hour between twins doesn't mean the other twin wasn't getting oxygen! There can be hours between twins! They each have their own O2 supply.
Would vaginal birth have been safer for baby than surgery? Who knows? But to suggest that there was "plenty to worry about" simply because her babies were falling out nearly painlessly and doing pretty darn well on the outside seems a bit alarmist to me.
This is the type of reporting that leaves women afraid of birth. Please notice also that the sister 'didn't know what to do'. This is because we do not teach women anything about the nature of birth! We leave it up to the 'experts'. The satirical Monty Python skit , 'The Miracle of Birth', (below... done in the 80s I believe, yet sadly just as relevant today) shows this quite well. The mother asks, 'what do I do' and the doctor tells her 'nothing dear, you're not qualified'.

This is why I've developed a syllabus for a series of college level courses (which could be adapted to high school) that would leave women confident, not afraid of the processes of their own bodies!

'The Baby Fell Out'


Birth: Medical Event or Natural Process?

Imagine if you will, a woman who has just discovered she’s pregnant. If she lives in the United States, one of her first thoughts will likely be that she has to make an appointment with her obstetrician.

From that first appointment the woman usually acquiesces to test after prenatal test throughout the pregnancy. She will likely accept a plethora of interventions throughout her labor and birth that in many cases are, at the very least, uncomfortable or stressful (or both), and in some cases painful. She may be facing a fear of the unknown with courage henceforth unknown to her. She does so for the sake of her baby. She sacrifices privacy, and in some cases dignity, because she believes it will keep her child safe and herself healthy.

What if the vast majority of women and babies are delivered safely because birth is a reasonably safe, healthy, physiological function of the mammalian body? In other words, what if the end result could be the same in a way that focused on the joy and wonder of the process of procreation…not on every possible thing that could, but is not likely to, go wrong?

In the U.S. today, most people assume that medically managing birth makes it safer. It is widely accepted that the interventions in pregnancy and birth serve a purpose…in effect, that they are safe and effective. Does the evidence support these beliefs?

To assess whether birth is safer medically managed as opposed to expectantly managed, I believe we must first examine how obstetricians became the primary caregiver for birthing women. As an experienced childbirth educator, I’ve discussed this with parents, and without exception, the belief has been that birth originally shifted from a midwife monitored event at home to a medically managed hospital occurrence due to safety reasons. That is an erroneous assumption.

According to The Official Plan to Eliminate the Midwife: 1900-1930 (Gibson, n.d.), at the time that birth moved to the hospital, there was little doubt that midwifery was the safer option. Through early professional journals such as Transactions for the Study and Prevention of Infant Mortality (1910 – 1915) we have a unique glimpse into history. She quotes Dr. Ira Wile as saying in 1911, "In NYC, the reported cases of death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives’"(as cited in Gibson, 2006, Part I), and she attributes the following to a Dr. Levy in 1917, "Of the babies attended by midwives, 25.1 per 1000 ... died before the age of one month; of those attended by physicians, 38.2 per 1000 .... died before the age of one month; and of those delivered in hospitals, 57.3 per 1000 died before the age of one month. These figures certainly refute the, which Gibson obtained through Stanford University Medical Library, charge of higher mortality among the infants whose mothers are attended by midwives, and instead present the unexpected problem of explaining the fact that the maternal and infant mortality for the cases attended by midwives is lower than those attended by physicians and hospitals" (ibid.). This, despite the fact that 80 years prior, Dr. Ignaz Philipp Semmelweis had admonished physicians for not washing their hands before attending women after handling cadavers, which he suspected was one reason for their high rate of childbed fever, and subsequently higher mortality rate (CDC, 2001). He was ridiculed.

Midwives would have had no idea their vocation was systematically being eliminated to provide “clinical material”…pregnant women…to obstetricians (as cited in Gibson, 2006, Part II). Even if they had known they couldn’t have done a thing about it. Women didn’t have the right to vote.

Since that time, there has never been a definitive study showing medically managed birth with obstetricians to be safer than expectantly managed birth with trained midwives, though there have been those that have tried (Pang, 2002). The conclusions and methodologies, however, have been called into question (MacCorkle, 2003; Vedham, 2003; Citizens for Midwifery, 2002; Gibson, 2006; Strong, 2000, pp. 222-223). In fact, Jock Doubleday (Doubleday, 2005) has been offering progressively larger amounts of money, with $50,000 being the last offered in December of 2005, for anyone who can provide such a study. The reward has stood unclaimed since he first offered it in 1998.

Childbirth is safer than it was 100 years ago (Johanson, Newburn, & Macfarlane, 2002). Undoubtedly, it is safer to give birth in the U.S. than it is in many places throughout the world. However, to assume that if obstetricians now attend birth, then improved outcomes must be due to that development alone is a fallacy that does not take into account improved nutrition, sanitation, disease control, birth control or any number of other variables. It is a spurious correlation. There are many contributing factors to improved health and well-being in the childbearing year (Wagner, 1994). In fact, countries that enjoy the modern advancements mentioned above in addition to midwifery care have the best outcomes in the world (Strong, 2000), and “…there is never a doctor in the room” (Wagner, 1994, pp.124). Where exactly does modern obstetrical management place the U.S. in comparison to the rest of the world? There are 42 countries with lower infant mortality rates (Central Intelligence Agency, 2006) and 29 countries where fewer mothers die (World Health Organization, 2004, pp.23).

While this may be surprising to some, certainly, it is not to suggest that the practice of obstetrics is unnecessary. We need surgeons and experts in pathology for a small number of cases that might be deemed high risk, such as mothers who have pre-existing medical conditions or mothers with addictions. The evidence suggests that number should be a very small percentage (Johnson & Daviss, 2005; Declercq, Skala, Corry, Applebaum, & Risher, 2002).

In essence, the system under which the U.S. currently operates might be like hiring a cardiologist as a personal trainer. Could heart attack deaths be reduced by having surgeons immediately available in the event that a normal, but strenuous, activity turned tragic? It’s very likely. However, would a game of tennis be imminently more difficult, if not impossible, if mobility were restricted by an assortment of electrodes and devices strapped to the player to assess every biological function and make the job of the cardiologist easier?

If this seems like an absurd analogy, consider this: the image that most of us have of birth is of a woman in bed, usually on her back, pushing out her baby, possibly with her feet in stirrups, or her legs being pulled toward her ears by herself, her partner or a nurse. Now, look at the following two pictures. The picture on top is the reproductive anatomy of an upright female. The picture on bottom has been turned as if the model were on her back.

Free clip art from http://www.arthursclipart.com/medical/reprobw.htm

The path the baby follows is called the ‘curve of Caras’. It becomes apparent in the second picture that, on the back, the mother would be pushing her baby uphill. Why? Is there some physiological reason that mothers are expected to lay on their backs? No. The reason mothers are restrained to bed is so that the monitors can be hooked up and so that the doctor can sit comfortably at the end of the bed.

Women are told throughout pregnancy to avoid laying on their backs because oxygenation to the uterus can be impeded by the weight of the baby resting on the vena cava (major blood vessel). Does the position suddenly become safe in labor? No. This position is detrimental to babies, and it creates pain for the mother because the weight of the baby rests on her tailbone (Lamaze, 2005). The position also makes the pelvic outlet considerably smaller by resting the mother’s weight on the tailbone, this flexing it inward. It makes the final stage of labor much harder than it needs to be. It almost guarantees the perineum (area between the vagina and anus) will tear (Walsworth & French, 1998). Therefore, episiotomies are done to prevent tears. This means healthy perineal tissue is cut to prevent tears that would be unlikely to occur if the mother were not in a position that creates conditions for tears. Does it work? Think about it. If you try to rip a piece of whole fabric, it remains strong. If you first cut the fabric a tiny bit, it rips easily. The same is true of the human flesh. Fourth degree lacerations (where the perineum rips through to the rectum) happen almost exclusively with episiotomies (Goer, 1995).

All of this so the baby could be continuously monitored, and for the convenience of the provider, without any regard for how it impedes the process of birth, the danger it introduces into the process, or the comfort of the mother. It is not supported by evidence as safe, is not backed by common sense or evidence as effective for, well, anything. Yet it is a nearly universal intervention.

At this point, it might be argued that by constantly monitoring the baby, we can avert a terrible tragedy by knowing moment by moment what the state of the baby is. Except that what the evidence says is that the routine use of continuous electronic fetal monitoring does nothing but increase the rate of surgical birth without any improvement in outcomes (Goer, 1995; Wagner, 1994).

The act of giving birth becomes more difficult, and in some cases impossible, due to the assortment of wires and devices meant to assess every biological function.

Each obstetrical intervention was created for a specific medical indication for which, when used appropriately for that indication, it is effective. Unfortunately, instead of being used selectively in exclusively pathological (abnormal) situations, many interventions are used routinely within a healthy population, in part due to the litigious environment in which physicians must operate (Carpenter, 2004).

The following graph (Wildner, 2006) illustrates some of these. It shows the percentage of women who will experience the selected interventions under different caregivers, with no substantial difference in outcomes.

If we can obtain virtually the same results without performing them, why are they being done? How many of these common procedures proven safe and are they effective?

Two interventions deserve special consideration. These are procedures deemed ‘elective’, which is a bit misleading, because a woman may ‘elect’ to have them, but should she ‘elect’ to refuse them, they may be performed under court order (Irwin & Jordon, 1987).

These two procedures, induction of labor and cesarean section, while they are extremely important life-saving measures when used for medical indication, are perfect examples of obstetrical technology gone awry when used for convenience.

The World Health Organization suggests that induction is medically indicated no more than 10% of the time (as cited by The Coalition for Improving Maternity Services, 2003). Yet, according to the Listening to Mothers survey, (
Declercq, et al, 2002) 55% of mothers were induced, even though there is acknowledgement that induction increases risk (Baxley, 2003; Rubin, 2006) and the chemical agents, such as Cytotec, used for elective induction are not approved by the FDA for such use (Haire, 2001; Physician’s Desk Reference, 2003). In fact, not only is Cytotec not approved for elective induction, it carries a serious warning not to use it for induction at all (U.S. Food and Drug Administration, 2005), which does not seem much of a deterrent to the American College of Obstetricians and Gynecologists (ACOG) or the American Academy of Family Physicians who “…supports the safety and effectiveness of vaginal misoprostol (Cytotec) for cervical ripening and labor induction” (Weaver, 2006) contrary to the scientific evidence.

The Centers for Disease Control, (CDC, 1993) and the World Heath Organization, (as cited by The International Cesarean Awareness Network, 2004) recommend rates of surgical birth not to exceed 12-15%. The U.S. is currently at 29.1% (Dress, 2005), meaning at least half of these surgeries are medically unjustified. Obstetricians contend (
Rubins, 2003) that the increase is due to ‘maternal request’ surgeries, to avoid such things as urinary incontinence later in life, or sometimes due to fear of pain, supposedly the case with Britney Spears. Yet, vaginal birth is not a factor in urinary incontinence (Albers, 2003; ACOG, 2005), despite what some doctors may suggest (Healy, 2006). If women are requesting surgery over natural birth, which some sources doubt (Lamaze International, 2006), then one would wonder if they are being apprised of the significant risks (Thornton, 2006). Risks that are perhaps worth taking if the life of mother or baby are compromised…but not worth introducing where none previously existed.

People often say that in the end, all that really matters is that the mother and baby are okay. Is that really all that matters?
What if the mother and baby could have been safe without adding insult to injury?

While some authors merely tell women they should expect care with no basis in science (
Murkoff, Eisenberg, & Hathaway, 2002) others defend over-treating in order “To be sure that not even one baby will be harmed during delivery” (Tuteur, 1994; Part III-Common Obstetrical Practices). Is that a realistic goal? Is it being realized? Not as evidence by the many people who have studied obstetrical management versus midwifery attended pregnancy and birth for the last 25 years or so (CIMS, 2003; Johnson & Daviss, 2005; Enkin, Marc, Keirse, Renfrew, & Neilson, 1995; Gibson, 2003; Goer, 1995, 2002; Wagner, 1994, 2003; Stewart, 1981; Keefe, 2001; Tillett, 2005). If success is measured by results, the U.S. obstetrical system could do better. In those 25 years, infant mortality has actually worsened, (Kristof, N., 2006) and maternal mortality has remained unchanged (CDC 1998; CDC, 2003).

While this may seem an indictment of an entire system it truly isn’t. It is a call for reformation. Obstetrics have at their disposal the most advanced technology in the world. However, when you have a hammer, everything looks like a nail. By transferring care of healthy women and babies to midwives, only the actual ‘nails’ reach the ‘hammers’ through a referral from midwives, guardians of normalcy. Obstetricians are then able to use their considerable skills to benefit the women who really need their help. Under this new paradigm that views birth as a natural process, health care costs would be reduced, (Druley, 1998) maternal satisfaction would increase, (Villagran, L., 2006) outcomes would improve and obstetricians would get the recognition and respect they deserve for doing the job they were trained to do. Everyone wins.


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