Abstract
Childbirth educators and doulas express frustration that the vast majority of women choose standard obstetric care for labor and birth, even though the evidence shows that this care increases the likelihood that they will experience unnecessary intervention and morbidity. Women are preparing for childbirth by reading and taking classes, but they are unprepared for this reality. What responsibility do doulas and childbirth educators have in alerting women of the risk?
Keywords: childbirth education, doulas, preparing for childbirth, optimal experience, “pushed birth”, women's choice, place of birth, birth attendant, cesarean rate, rate of out-of-hospital birth, access to care
A good midwife can tell by a woman's voice alone how far along she is in labor. In much the same way, the voices of doulas and childbirth educators are dead giveaways when you learn what to listen for. After all, they too are engaged in a labor of sorts, and I've noticed that at a certain point in their career—let's call it “transition”—a certain tightness grabs hold of the vocal chords. What was once perhaps an energized, hopeful, generous voice turns into one that is tired. You might even say bitter.
There they are, trying to make birth better for women, and there are the numbers—the cesarean rate, the induction rate, the maternal mortality rate—each getting worse. The minority of women choosing out-of-hospital birth, 1%, hasn't budged for a generation (Martin et al., 2006).
Doulas and childbirth educators have been my predominant audiences at readings and book-signings this past summer. And they've kept the conversation going hours after we've put the book down. They're frustrated. Confused. They ask me—the room, the universe—why 99% of women haven't come to the same conclusion they have: that birth is normal, that it functions best when allowed to progress without interference, that taking it outside of the hospital is perfectly logical and something more women should be doing. The information is available, they say. The research is solid. Why aren't women making better choices? Women could be voting with their feet; why aren't they?
A noted author and women's health guru, sounding particularly bitter, recently offered an opinion on this. To paraphrase, she said that women don't care enough, that they spend more time choosing which designer purse to buy than what kind of birth they want. In other words, women don't want the vote.
I've been tossing this one around in my head all summer. I've heard the sentiment verbalized in various ways by others in the field and have admittedly thought it to myself at times. True, social change happens from the bottom up. And at the end of the day, if women wanted a better system, we'd have one. Take the Women's Movement, arguably the most profound, radical, breathtakingly swift social change of the 20th century. Women decided they wanted equal rights, and they had a nonviolent revolution.
Perhaps the biggest problem with the maternity-care system is that women don't believe it's broken. As the Listening to Mothers II survey shows, 85% of women think the care they're getting is just fine—and that's after they've given birth on their backs (Declercq, Sakala, Corry, & Applebaum, 2006).
The survey also showed that women aren't getting enough information, the kind they need if they are going to demand better care. Though a majority of first-time mothers took childbirth education classes, read books, and consulted Web sites, most couldn't identify the risks of labor interventions they had experienced. Some didn't even realize that they had the right to refuse them. It's not that they were out shopping instead of caring about their births. They prepared. But they were not prepared for the reality of childbirth care. Is that their fault? Or was the information not given to them?
Women are not being told that the care they are likely to receive isn't good for them. I've talked to many who didn't know that they would be immobilized by a fetal monitor after they got to the hospital. Or that their provider would very likely want to induce. Most important, they were not told that these common practices are not in their best interest. Women are not being prepared for what I've taken to calling a “pushed birth”—one that's induced or hurried along with drugs and instruments, immobilized by wires and tubes, and very likely to cause unnecessary morbidity. This is the kind of birth the majority of U.S. women are experiencing. Are we afraid to tell them so?
I am of course approaching this from a journalistic perspective, as a seeker and purveyor of information. And after exhaustively researching the literature and talking to women and providers for my book, Pushed (Block, 2007), the information I think pregnant women need most is (a) there is such a thing as optimal maternity care, and (b) they're not likely to have it in this country unless they work hard to find the right provider or start demanding better practices from the ones they've got.
This is a tough conversation, to be sure. And what I hear from doulas and childbirth educators is that they don't want to have it. They don't think it's appropriate. They're worried it will alienate clients, infantilize them, and disempower them. The thinking has been that pregnant women are adults, they make their choices, and they hire doulas and childbirth educators to support them, not to scare them. Furthermore, they feel they are kept from giving any “medical advice.” Telling a woman that she's likely to be pushed by her provider or hospital is certainly incompatible with the standby disclaimer to “check with your provider.”
Perhaps it's time to take off the kid gloves and tell women the truth, or what I've been calling the “painful truth”: Just by virtue of being standard maternity patients, women are at risk of winding up with any number of suboptimal outcomes—stitches in their vagina; a scar on their uterus; a baby in the neonatal intensive care unit; a long, painful recovery; trouble breastfeeding; or complications with the next pregnancy. This is not opinion; this is epidemiology.
For my part, I decided to launch a Web site and blog (www.pushedbirth.com) as an information tool, a place where that tough conversation can begin. Because I don't think this is about women not caring or not wanting to know. On the whole, women want what's best for themselves and their babies. I think that to say otherwise sounds like the same kind of victim-blaming that happens when a high cesarean rate is blamed on “maternal request,” or a high induction rate on “consumer demand,” or a date rape on a miniskirt. Women, I keep hearing, are asking for it.
Information aside, there are many other reasons why women aren't voting with their feet. One is the lack of access to care. I recently met a woman in Philadelphia, nearing term, who told me she'd read all the right books, taken all the right prenatal classes, and knew that her best chance of having a normal birth was to give birth with a midwife outside of the hospital. “That's all well and good,” she said, “but I'm on Medicaid.”
It's important to remember the millions on public assistance, the scarcity of midwives in some communities, and the fact that even private insurers refuse to cover “alternative” providers. Many women, insured or not, are making do with the care they've got. Here's to making that care better.
Footnotes
Lamaze members can view the entire report of the Listening to Mothers II survey by logging in to the Lamaze Web site (www.lamaze.org). Others can purchase the full report from the Childbirth Connection Web site (www.childbirthconnection.org), where the Executive Summary of the report is also available to the public.
Read a review of Jennifer Block's book, Pushed: The Painful Truth about Childbirth and Modern Maternity Care (Da Capo Press, 2007), on pages 75–76 of this journal issue.
Visit Jennifer Block's Web site and blog at www.pushedbirth.com
REFERENCES
- Block J. 2007. Pushed: The painful truth about childbirth and modern maternity care. Cambridge, MA: Da Capo Press. [Google Scholar]
- Declercq E. R, Sakala C, Corry M. P, Applebaum S. 2006. Listening to mothers II: Report of the second national U.S. survey of women's childbearing experiences. New York: Childbirth Connection. [Google Scholar]
- Martin J. A, Hamilton B. E, Sutton P. D, Ventura S. J, Menacker F, Kirmeyer S. Births: Final data for 2004. National Vital Statistics Reports. 2006;55(1) Hyattsville, MD: National Center for Health Statistics. [PubMed] [Google Scholar]