Birth in America

There is something really wrong with birth in America. Oh, sure, plenty of women are still giving birth. However, if you ask women themselves about their birth experiences, you will get a wide range of opinions. Most troubling is the fact that there is a significant proportion of women who are extremely dissatisfied with their birth experience. These women are in fact so dissatisfied with their children's births that there is a significant movement in the United States today to have home births, use midwives, and push back against the hospital culture in general.

Unfortunately, I have become a better educated woman with each of my three children's births, and I have learned that the standard hospital birth is usually not the best. Where other similar countries have managed to reduce their infant mortality rates, we are just treading water and remaining the same. We have the worst or nearly the worst infant mortality rates of any comparable industrialized country (i.e. eliminating very small countries with less than 100,000 births). Worse still is the fact that the USA's maternal morbidity has actually risen between 2000 to 2005 when compared to the declines registered by other similar first-world (i.e. industrialized) countries. How the heck is this possible? I thought the U.S. is supposed to have the world's best health care!

The problem is that the U.S. has a very high rate of cesarean section--about 33% as of 2007. This is a much higher rate than most other industrialized countries. When the c-section rate was first measured in the USA, it was 4.5% (1965). There has been a slow but steady climb in the c-section rate, but the problem is that the fetal and maternal morbidity statistics show no improvement in conjunction with this massive increase in cesarean sections. A c-section is supposed to be a life-saving procedure for moms and babies. So if this is the case, and all c-sections performed in the USA were really necessary to save the life of the mother and/or baby, shouldn't we see a corresponding decrease in fetal and maternal morbidity from childbirth? Instead, we see an increase in maternal morbidity and zero improvement in fetal morbidity--this when our rates of each are already among the highest of comparable industrialized nations! This is a TRAVESTY!! I am utterly flabbergasted that this is not a BIG, HAIRY DEAL in the current discussions about health care reform in the USA, because, again, studies show that this poor rate of morbidity for moms and babies is NOT the result of poor prenatal care for moms, or confined to one subgroup such as immigrants or low income mothers. So if this is not something that can be attributed to some missing healthcare for poor moms or recent immigrants, it logically must involve a systemic problem in maternal and fetal healthcare in the United States!

The glaring difference for the USA is cesarean section, and also the incredibly short hospital stays for new mothers. Most other industrialized countries provide postpartum support in the form of mandatory home health visits by trained nurses, or keep their mothers and babies in the hospital for longer. In this way, the healthcare system can spot postpartum complications for moms and babies, and get them corrected sooner. Here we are shoved out of the hospital within 1-2 days for a vaginal birth, 2-3 for a cesarean (if that is where we choose to give birth) and are asked to bring the baby in for a check-up within a few days, then they don't see the baby again for two months! Mom is treated to a visit with the obstetrician/gynecologist at SIX WEEKS postpartum--far, far too long for moms that experience complications. Further, the US does not provide a great deal of education to new mothers regarding what they can expect post-partum, and ways to diagnose what is normal or abnormal with regard to their lochia, cramping, etc. Most "postpartum education" in this vein involves giving the mom a printed sheet of information at worst, and at best a labor & delivery nurse reeling through the list with the mom as she completes a blizzard of discharge paperwork.

But back to the cesarean section rate. One of the new factors contributing to this increase is the tendency for doctors to practice defensive medicine, and opt to counsel patients with suspected macrosomic babies (i.e. babies weighing in excess of 4000 g, or 8.8 lbs) to have a scheduled c-section rather than attempt a trial of labor. This is a widely known practice--so widely used that there are multiple websites and tales of woe concerning this and how to avoid it. Why do doctors do this? Well, they claim to be worried about shoulder dystocia, despite its extremely low incidence rates, and damage to the mother's bladder, urethra, and vagina (prolapsed bladder, urinary incontinence), despite the fact that these types of injuries occur with a percentage of all vaginal deliveries. (As a side note, there is a reason that many older women are candidates for the "bow" repair to their bladders/urethras, and it's because pushing out a baby regardless of the baby's size is gonna have an impact on the adjacent organs and their placement/function!) My own obstetrician frankly admitted in her discussions with me concerning her repeat cesarean recommendation that she was concerned about her malpractice insurance and her license when I was planning a VBAC (vaginal birth after cesarean) with my third child. So certainly defensive medicine has a large part to play.

Now a lot of people say, "Well, as long you have a healthy baby and healthy mom, that's all that matters." And our culture says that a doctor (most often, an obstetrician) and a hospital setting are a proven formula and the safest way to give birth. It's the modern way! Most of us have the assumption that if a woman chooses to give birth at home or even a birthing center, she is endangering her baby and herself. In fact, that is not true. Given the inherent risks associated with a cesarean, and the fact that a third of all women giving birth in the U.S. end up having one, there is a lot to be said for a prospective mother preparing in advance to avoid a cesarean if she chooses to labor in the hospital, or to labor at home or in a birthing center with a trained midwife. Further the maternal and fetal morbidity statistics would argue strongly AGAINST our hospitals currently being the safest place to give birth.

And, there is a hidden cost to the prominent form of labor management, where the doctor and hospital staff believe that their usual modus operandi is always best. The question now being asked: do doctors deliberately manipulate the drugs available to induce labor to deliberately cause fetal distress and precipitate a c-section? The number of women reporting trauma and abuse from doctors and hospital staff over their births is astounding--so much so that one woman is suing her attending obstetrician for abuse, a woman has won a lawsuit for an unnecessary cesarean, and millions of women find it necessary to attend counseling and support groups. There is also an active and vocal movement, prominently visualized by Ricki Lake and her documentary, "The Business of Being Born," which is seeking to change the status quo and actually improve our maternity care here in the U.S. Yet you rarely hear about any of this on the news, and it's certainly not being debated as part of the discussion of healthcare reform.

So, when a well-meaning person says, "At least you have a healthy baby," they don't know how right they are. At least, and we could (and should) be doing much, much better to give our moms and babies the best possible care and start to life.