Questions from Our Readers

Abstract

In response to Lamaze International's latest position paper, “Lamaze in the 21st Century,” the author discusses the concept of normal birth and identifies the need for an advocacy effort in support of normal birth as the standard procedure.

Lamaze International's latest position paper, “Lamaze in the 21st Century” (see pp. x–xii), provides a framework for insuring that Lamaze classes truly reflect a deep trust in the normal, natural process of birth. The position paper documents the evolution of Lamaze, beginning with the method known for giving birth. It continues on to the development of the Lamaze Philosophy as the recognized preparation for birth that helps women to understand and trust the normal, natural process of birth and to develop confidence in their inherent ability to give birth. This idea was a dramatic shift in thinking that reflects all that has been learned about normal birth in the past 40 years.

The first thing that strikes me when reading the position paper is the strong stand Lamaze takes in support of “normal” birth. The word normal creates confusion and concern in a world where medically managed birth is the standard. What is “normal” birth? The dictionary defines normal as “usual,” “natural,” and “occurring naturally” (Webster, 1998). Equating “natural” birth with not using medication during labor does not help our understanding and contributes to confusion. It's time to get back to basics. We know a great deal now about “what occurs naturally” during labor and birth. We know about cervical and hormonal changes in the weeks before labor begins, the physiology of cervical effacement and dilation, the cardinal movements of rotation and descent, and the role of hormones (the relationship between pain, oxytocin levels, and endorphin release) in maintaining strong, effective contractions of the uterus. We also know how both the movement throughout labor and the upright position for birth change pelvic diameters and facilitate rotation and descent of the baby. Nature has designed reproduction, including birth, as beautifully as our other body systems.

[K]eeping normal birth normal is a challenge in the world of medical birth.

Digestion provides a useful analogy. Our bodies competently digest food without knowing anything about the science of nutrition and without reading books or attending classes. We experience hunger when our bodies need nourishment and satiety when we have had enough to satisfy our nutritional needs. Evidence also shows that, under ideal conditions, we crave foods that provide the specific nutrients our bodies need at any point in time. The process of digestion is complex, happens without us paying much attention to it, and works beautifully most of the time. Occasionally, problems arise and medical management helps. Vomiting can lead to dehydration and intravenous fluids are required. In some instances, tube feedings are necessary. Diabetes requires dietary changes and often insulin. Still, the standard is the normal, natural physiologic process of digestion.

Normal birth, then, is birth that takes place the way nature physiologically designed it to happen. Like digestion, problems may occur and intervention may be required. Sometimes, we overeat and develop indigestion. Sometimes, we eat something that does not agree with us and we vomit. Sometimes, a baby is too big to fit through the pelvis and we require a cesarean birth. Sometimes, labor is very long and very hard and we need the time-out that epidural anesthesia can provide. The possibility of complications does not change the standard—the underlying normal, natural process—be it digestion or birth. And yet, we remain reluctant to embrace normal birth as the standard.

We also know a great deal about how to facilitate normal birth. In spite of all that we know, keeping normal birth normal is a challenge in the world of medical birth. In an ongoing effort to evaluate effective care in normal labor and birth, the World Health Organization has identified five care practices that are proposed to reflect effective management of normal labor. These practices (1) allow labor to start on its own, (2) allow freedom of movement, (3) provide continuous emotional and physical support, (4) allow the upright position for birth, and (5) keep mothers and babies together from the moment of birth (Chalmers & Porter, 2001). The Lamaze position paper addresses each of these practices, along with one more: avoid routine interventions. Women who attend today's Lamaze classes are encouraged to allow labor to start on its own, plan for continuous, emotional, and physical support, actively work with their labors, find comfort in a variety of ways, avoid routine interventions, and keep their babies with them.

After reading “Lamaze in the 21st Century,” one thing seems clear: If normal birth is to become the standard, a huge advocacy effort is needed. Teaching and supporting one woman at a time in our Lamaze classes will eventually create change. I think we need to do more. It's time to join the World Health Organization and collaborate with other committed, concerned organizations. It's time to work together to make normal birth the standard, once again. We must also insure that, wherever birth takes place, care is provided that helps keep normal birth normal. The publication of this position paper is an important first step.