Put It Away
Six of my 10 children were born at home. Of the 6 home births, 4 were mid-wife assisted.
I found this paper I had written years ago on midwifery for an economic's class and thought I would share it. I also plan to share my birth stories as quickly as I can.
Just one note: Elizabeth, who weighed over 9 lbs at birth was one of my easiest births and I laid brick for a patio the day of her birth. The weight of a baby isn't as big a factor as the manner in which the birth is handled...
The whole community in its entirety needs to realize that a woman plays the central role in deciding the various procedures and care she is to receive while pregnant; that social, physical, psychological, developmental, and economic factors must be considered in choosing the type of birth she prefers: home birth, a birthing center, or a hospital birth.
The World Health Organization (WHO) has published several recommendations for use by those who are looking for an alternative birthing method. The following document has been written to inform parents that there is an alternative to hospital birthing that is considered by many to be superior and less expensive.
"The training of professional midwives or birth attendants should be promoted. Care during pregnancy and birth, and following birth should be the duty of this profession" (WHO 1). If more midwives were trained, women would be given the option to choose.
Most midwives that are currently trained are covering far too wide a region due to lack of qualified birth attendants. The state of Kansas currently has between six and ten practicing lay midwives. When compared to the fact that a midwife will spend up to thirty hours at a birth, assisting the woman during pregnancy, birth, and the weeks following the birth, and the average cost for a lay midwife providing all the services is $1,200.
An obstetrician typically speaks briefly with the woman about the procedure, delivers the baby, and leaves. Usually spending a grand total of two hours with the woman. The cost of the Doctor's fees alone amount to $2,600 and the hospital cost associated with an uncomplicated vaginal birth are around $3,500 (Kitzinger, 1991).
This shows two of the most common economic problems associated with childbirth; costs and access. Information about birth practices in hospitals (cases of cesarean section, etc.) should be given to the public served by the hospitals. The current rate of cesarean sections in the U.S. is nearly 21 percent. That is, twenty-one percent of all births in the United States involve a major operation- most of which are completely unnecessary with an additional cost of $3,000 to $4,000.
Doctors are trying to substitute technology for personalized care. Many managed care programs now reimburse the same for C-sections or vaginal birth with the reimbursement being at the low end. One private doctor in Dallas is reimbursed $2,600 for a vaginal birth, and $2,700 for a C-section. This move by the insurance companies is a sound one socially and economically as to deter the trend of nonessential C-sections.
Cesareans are not saving lives- we rank twenty-six in worldwide infant mortality rates (this includes third-world countries),(Meyers, 1992) and yet the U.S. has the highest percentage of cesareans. If those c-sections were saving lives, would the case not be that the United States would experience fewer infant deaths?
One would almost certainly be led to believe so. And yet, not only do those statistics, so closely related, not match up, the medical profession itself admits that hospitals are dangerous: "Avoiding hospitals is not just cheaper but may be better for the patient," states Prof. Phil Caper of Dartmouth Medical School. "They can be dangerous places if you don't need to be there, Says Massachusetts medical researcher Dr. Paul M. Gertman. His study of 815 patients at a leading teaching hospital showed 36 percent took on complications that they didn't come in with" (News).
This cost to society isn't even documented. However, the same profession that tells one to leave the hospital as quickly as possible turns around and demands that a healthy woman should not only expose herself, but also the newborn baby to those diseases and infections, often for periods longer than 48 hours. It is generally known that staph infections can be serious or even deadly, if not treated properly.
Eighteen percent of those who spend more than two nights in a hospital are likely to leave with staph or some similar disease (Quotes). Hospitals are for sick people, not for those who are simply bringing a new life into the world. One may say, "Just giving birth? Are you nuts?" No, for if one is informed and has studied the implications of home birth versus hospital births the educated finds that if the mother is healthy and has good prenatal care that “the results suggest that under certain circumstances, home birth attended by lay midwives can be accomplished as safely as, and with less intervention than, physician-attended hospital deliveries, (Duran, 1992, p.450).
The outcome of a study (Ford & Franklin, 1991) of the outcomes of planned home births in an inner city practice showed that birth at home is practical and safe for a self selected population of multiparous women, but nulliparous women are more likely to require transfer to the hospital, usually due to a delay in labor. Their conclusion was that close cooperation between the general practitioner and both community midwives and hospital obstetricians is important in minimizing the risks of trial of labor in the home.
According to Albers & Katz (1991) nontraditional birth settings present advantages for low-risk women as compared with traditional hospital settings: lower costs for maternity care, and lower use of childbirth procedures, with out significant differences in perinatal mortality.
The Dutch believe that alternative care is safer. Holland leads the industrial world in home birth, providing a system of midwifery and nursing that offers women the comfort of having babies in their own bedrooms. More than one-third of Dutch mothers give birth at home - about 60,000 a year, compared to five percent or fewer in other industrialized countries, according to the World Health Organization.
That reflects the strong commitment to women's rights in this social-welfare state of 14.6 million and has created a cross-border argument between the Dutch, whom are supported by WHO, and the German medical establishment. “Netherlands maternity care is an enormous thorn in the side of obstetricians all over the globe," Said Marsden G. Wagner, the U.N. health organization's Maternal and Child Health Officer for Europe. Wagner, based in Copenhagen, accuses the medical profession of trying to keep a monopoly on obstetrics by claiming home birth is dangerous.
This practice is known as Asymmetric Information. This is because health care services are so little used and yet are so technical, that the consumer is usually uninformed. Those who prefer midwife assisted birth, believe giving birth at home or in a birthing center is safer than giving birth in a hospital, and that the psychological advantages far outweigh any medical risk... "When a baby comes, it's not an illness; it's not essential to go to the hospital," says Dini, 34, whose four children were delivered by Astrid Limburg, a midwife in Amsterdam.
In Limburg's view, "People function better in their own surroundings. If somebody is healthy and has had a healthy pregnancy, to give birth at home is safer than to give birth in the hospital" (Idaho, 1991, p. B4). The 1,000 licensed midwives in Holland, who received three years of obstetrics training, are the key to the system. A midwife sees a woman about 12 times during her pregnancy, to monitor both mother and baby.
Also consider the fact that a midwife charges $25 per pre-natal visit while the doctors charge $65. Midwives also watch for complications that might necessitate a hospital delivery. In those cases, such as twins, or anticipated breach or Cesarean deliveries, the woman is referred to a specialist for prenatal care and hospital delivery. The economic and health benefits here are that the less expensive midwife attends healthy women, and only those who really need the more expensive services receive them.
After the delivery, the Netherlands employ a maternity assistant. This is someone who comes in and helps care for the mother and newborn. The costs for both the midwife and assistant are covered by the National health care system. Midwifery has been in the Netherlands since the 1800's and is a very respected profession.
The first training school opened in 1860. Home births declined in the next 100 years but have leveled off to about 35 percent since 1978. G.J. Kloosterman, a preeminent obstetric gynecologist in Holland is author of the standard obstetrics textbook "Human Reproduction". He also is an ardent supporter of home birth. Kloosterman has followed and studied both systems for many years and he has come to the conclusion that the home is a better psychological environment for birth.
He notes too, that many times, even when there have been no prenatal complications, the obstetricians’ end up using forceps, suction, or worse yet, Cesarean sections. Midwives are not authorized to use those procedures so they tend to manage the birth different. Dr. Kloosterman points out that part of the problem is the focus; all day long doctors are confronted with disease, they are pathology oriented, whereas midwives see pregnancy as the natural biological function that it is, and are constantly surrounded by healthy mothers.
Physician resistance to alternative birthing is publicly based on the issue of maternal and infant safety, however a study (Matthews & Zadak, 1991) shows that additional issues are that physicians fear economic competition and resist loss of control over obstetric practice. The authors also traced the historical antecedents and social factors leading to the alternative birth movement.
Many of the reasons for the trend had to do with parents seeking more opportunity to participate in
the birthing process, bond with their child, and eliminate “paternalistic and mechanistic medical obstetrical practices”. One of the most asked questions is, what if something goes wrong during a birth at home?, and yet, maybe the question should be, what happens when something goes wrong at the hospital and more importantly, why?
Does it get corrected, does the doctor take the time to repair the situation, or is a C-section promptly performed? The midwife does take the time, and if humanly possible, will try to reverse the situation. A descriptive analysis of two midwifery practices came to this conclusion.
Anderson and Greener (1991) examined outcome data from two nurse-midwifery operated home birth services in Texas. The population of the study was all clients who planned a home birth within the two services during 1987. The analysis revealed that the women choosing home birth were more frequently married, usually white, and more educated when compared to the overall U.S. childbearing population.
Analgesia, episiotomy, and cesarean delivery were all found at lower rates than is reported when births occur in a hospital setting. Complications were less too, when compared to national statistics. There is no scientific evidence that routine electronic fetal monitoring during labor has a positive effect on the outcome of the pregnancy (WHO 1).
In fact, there are so many discrepancies as to how to read the printouts, what to do and when, what constitutes a normal reading, and what is abnormal that it one begins to wonder how a whole group of people can be so confused and not even realize it. "When four experienced obstetricians studied the same fetal heart traces and were asked whether they would deliver immediately, they agreed in only one out of five cases.
Nearly two years later, these O.B.'s were shown the same traces again, and asked what they would do. In one out of five cases, they assessed them differently from the time before (Idaho 4). Many women are not aware that in order for a fetal monitor to stay attached to the infant's head, the node is encased within a screw that is literally inserted into the baby's skull, just as a carpenter would put a screw into a new crib.
Another economic factor comes to play in this situation. Because of the misinformation of the general public about technology, such as the fetal monitor, a doctor to protect himself against possible suing will use many nonessential tools. That way he can claim he used every means possible to have the desired outcome. This is known as defensive medicine.
Medical ethics or traditions also drive up the costs of birthing and lead to interventions that are ineffectual. A case in study is the annual statement of findings of the National Vital Statistics Reports. From the Centers for Disease Control and Prevention comes a ten-year comparison in trends in the attendant, place, timing, and use of obstetric interventions.
- The circumstances surrounding having a baby in the U.S. changed between 1989-1999. Key findings of the report were: 92 percent of the births were attended by physicians. This proportion has steadily declined as the number of midwife attended births has increased to about seven percent.
- Also, births attended by D.O’s have increased consistent with a decline in those births attended by M.D’s.
- About 99 percent of births were in hospitals, basically unchanged from 1989, but the percent of out-of-hospital births that were in residences increased while those in freestanding birthing centers declined.
- While births were more common on weekdays than on weekends in 1989, they have become even more concentrated on weekdays since 1989.
- Births delivered by repeat cesarean and vaginal births that were induced are especially likely to occur on weekdays. The single most popular day is Tuesday.
- The percentage of mothers receiving electronic fetal monitoring, ultrasound, induction, and stimulation all increased over the period with the most dramatic increase being the doubling of the use of induction of labor (from nine percent in 1989 to eighteen percent in 1997).
- Between 1989 and 1996, the rate of cesarean births dropped by nine percent (from 22.8 per 100 births to 20.7) while the rate of vaginal births after a previous cesarean (VBAC) increased by 50 percent (from 18.9 percent per 100 women who have not had a previous cesarean to 28.3). However, the trends appear to have changed between 1996 and 1997—the cesarean rate increased slightly while the VBAC rate declined by three percent. The highest cesarean rate in 1997 was in Mississippi (26.7) while the lowest was in Colorado (15.3).
- The percent of births that were delivered by forceps consistently declined during the period, from 5.5 to 2.8 percent of births, whereas the use of vacuum extraction consistently increased, from 3.5 to 6.2 percent (Curtin & Park, 1999).
While there are several trends that are for the better, the report demonstrates that certain medical traditions are still in place that lead to the use of intervention. Electronic fetal monitoring, induction, and stimulation all increased. These procedures plus others not studied tend to increase the use of cesarean sections.
he timing of births which result in artificial labor also tend to increase the need for cesareans. The social implications are that the convenience of the mother or doctor are outweighing the safety and consideration of the infant; a tradition that midwifery and home birth hopes to change.
There is no need for pubic shavings or pre-delivery enemas (WHO 1). Both of these procedures are done solely for the convenience of the doctors, and both have negative effects on the mother.
Pregnant women should not be put in a lithotomy, that is, flat on the back during delivery and labor (WHO 1). Each woman should be encouraged to walk and move about freely. Further, each woman should decide for herself what position to adopt during delivery. Each woman is different, and what will be perfectly comfortable for one will cause discomfort to another (Wainer & Estner, 1983).
Penny Armstrong is a midwife who began practicing in Scotland and has since practiced in Maine, St. Louis, Philadelphia, in hospitals, and is now practicing home birth in Amish areas.
The following is an excerpt from her book, A Midwife's Story that tells of her first home birth in an Amish farmhouse. It is a good example of how someone who has been brought up to believe that home birth is good and natural handles herself... Katie, the woman in the story, shows what seems to many to be an incredible presence of mind, but as the book later demonstrates, is quite the usual thing in her area.
"I was overwhelmed with the responsibility. I'd delivered a lot of babies by then; that is, enough to know that things go wrong. That was my job - knowing about things that went wrong. As a midwife, I could help a good healthy birth be a relatively comfortable and probably a richer experience for the mother, but by and large, she could do it herself with her husband or friend.
What she needed me for was to anticipate problems and to handle emergencies. By the number of them I'd seen, I had no trouble justifying my presence at a birth. At Booth (a hospital), I had backup: not only fetal monitors, intrauterine pressure monitors, X-ray machines, ultrasound scans, suction, oxygen, drugs, IVs, Blood transfusions, but also anesthesiologist, obstetricians, surgeons, neonatologists, and skilled nurses, not to mention a scrub basin and a sterile trolley.
But what do you do about emergencies when you're standing in somebody's bedroom in a farmhouse in the middle of a cornfield, in a place where the fanciest technology is hot and cold running water and your medical team is comprised of a farmer who-at best-had delivered his own calves.
Take flat babies. They have poor color-that is, they are blue or gray and their bodies are limp; they show very little or no enthusiasm about breathing. It was my clear impression that most babies were flat. In the hospital you automatically cleaned out air passages with a suction tube that's piped right into the room; then without breaking rhythm, you leaned in the other direction and grabbed an oxygen mask so you could, if necessary, "bag" the baby, that is, pump oxygen into its lungs. You could stimulate its heart. You could turn to the neonatologist and have him or her take the problem off your hands, especially if the mother was having difficulty.
Suppose Stephen, (the backup Dr.) was late for a delivery, baby was flat, and the mother started to hemorrhage? How would I resuscitate the baby, keep the father from fainting, get the emergency team on the road, and stop the hemorrhaging all at the same time? And how long does it really take for one of these country emergency teams to respond to a call?
Women die in childbirth, for heaven's sake. If the placenta breaks away from the uterine wall just the right place at just the right time, a women can loose enough blood in fifteen minutes to die.
And I was off to deliver babies where there might not be any electricity and the nearest phone was either in the chicken coop or across the pasture.
My first delivery was in an Amish cottage, fenced in with an honest-to-goodness white picket fence. I turned into the drive just as Enos, the father, was tucking his two-year-old onto the seat of an open buggy. Enos-with dark wavy black hair, a square jaw, eyes the color of a mountain stream, six feet tall and broad-shouldered; in other words, a picture-book husband- waved, grinned, and said he'd be right back.
He prompted his horse and pulled off down the gravel drive to take little Johnny, the two-year-old, to his aunt's house. Thinking I would find Katie stretched out in her bed, I turned to go up the back porch steps.
Just then she popped out the back door. She had a paintbrush in her hand. "Oh," she said, "Hi. Oh, my goodness, I'm not quite ready. I was putting the final coat of lacquer on this rocking chair when I started to have stronger contractions. I just wanted so much for it to be done, so I could rock the baby in it.
Then I decided that I'd better call Enos. He works at the machine shop, so I went to the neighbor's phone, and I didn't want to call you because they'd know, but I just called Enos and said I thought he ought to come home."
She'd cleaned the brush and now laid it down on some neatly folded newspapers spread out on a corner of the porch. Not only did the rocker look freshly lacquered, but it also appeared that the porch floor had been scrubbed and waxed not long ago.
She stopped talking for a moment when she stood up, put her hands on her hips, and stretched out her back.
"Is that a contraction?" I asked.
"Yes it is."
"Is it pretty strong?"
"Yes I believe it is, and I haven't put that plastic thing on the bed yet."
We walked through an immaculate kitchen and a spotless living room. She'd gotten her husband off to work, got her toddler up, washed, fed, and dressed, cleaned up the breakfast dishes, straightened up the living room, and painted a rocking chair. I think it was about 8:30 in the morning.
I had a small bag in my hand. "Before we make the bed, let's see how dilated you are."
I was thinking that this woman couldn't be too far along since she was running around like she was getting ready for her first date. Wrong. Nine centimeters.
"Where's that plastic sheet?" I said. "Looks to me like you're about to have a baby."
She chattered her way to the linen closet and back.
"Oh, I'm so excited," she said. " I can hardly wait. Every night when I go to bed, I say to Enos, `Maybe tonight I'll have the baby. Maybe by tomorrow morning it will be lying right here between us.' And then in the morning when I wake up, I'm so disappointed because it didn't happen and I've been thinking I would have to wait all the way until the next night before there was a chance again. I never even thought I could have it during the day. Enos keeps telling me not to be so impatient. He says he has to remind me that he believes that the baby really will be born."
She stopped again for another contraction, and as soon as it had passed she went back to spreading out the plastic sheet over the mattress cover. I was supposed to be helping, but I was having trouble concentrating. I kept staring. The woman was nine centimeters dilated and she was bustling about furiously. We finished making up the bed, then she thought maybe she'd like to change from her dress into a dressing gown.
Next thing I knew, she's hopped onto the bed. Her face was flushed and she was ready to push. Stephen's office was only a quarter of a mile away. I'd put in a call to him on my radio as soon as I checked Katie that first time, and he pulled in just as she was getting serious about pushing her baby out. Enos followed right behind him. He went to Katie's side and grabbed her hand. The three of us attended quietly.
A couple of times Katie said it hurt and she called her husband's name, and he got closer to her and held her so she could push more easily.The baby, a boy, popped out as if he were on his way to the outfield to catch a long fly.
I put him on the bed at Katie's side, and she curled herself around him."Oh," she said, "look at him. Look at our new baby. Oh I wonder what Johnny will think."
Enos stroked her head and said, "So now you have your new baby."
And she said, "Oh my, look how beautiful he is. Just look. Oh, Enos, I love him already."
I checked Katie to see if there were any tears in her perineum. There weren't."
The systematic use of episiotomy (incision to enlarge the vaginal opening) is not justified (WHO 1).
If you will note, from Penny's story, an episiotomy was not performed and the perineum stretched to accommodate the baby without the aid of instruments or drugs.
The rest of the Penny's book contained story after story of how these women birthed without help, how there were few flat babies, and how there are almost never any complications.
Birth should not be induced for convenience, and the induction of labor should be reversed for specific medical indications. No geographic region should have rates of induced labor over ten percent (WHO 1). The use of drugs and puncture of the membranes are two technologies that are routinely used that create further complications that can in turn lead to a cesarean.
The healthy newborn must remain with the mother, whenever both of their conditions permit it. No process of observation of the healthy newborn justifies a separation from the mother (WHO 1).
These procedures too, add to the cost of a hospital delivery, and as they are not used at most home or birthing center births, the cost to society at large, and the unmeasured costs of pain, senseless intervention, higher infection, and loss of dignity, should be considered.
When a baby has been delivered, a midwife will place the baby on the mother before the cord has even stopped pulsating. The midwife will not even cut the cord until it has stopped pulsating- an indication that the baby 's blood has a higher oxygen content.
During this time, the mother inspects her new arrival. The baby likewise looks at his mother, whom he has just spent the last nine months within (Gaskin, 1977).
Bonding and the importance of breast-feeding are something that scientists are just now finding out that mothers and midwives have known for centuries - the first ten to fifteen minutes after the birth will make a major difference in the first days and weeks together. The babies respond better, are happier, and mothers "tune" in to the babies faster (Kitzinger, 1980).
According to Davis (1994), the dominant mythology of a culture is often displayed in the rituals with which it surrounds birth. In contemporary western society, that mythology—the mythology of the technocracy—is enacted through obstetrical procedures, the rituals of hospital birth.
Davis explores the links between our culture’s mythological technocratic model of birth and the body images, individual belief and value systems, and birth choices of forty middle-class women—32 professional women who accept the technocratic paradigm, and eight homebirthers who reject it.
The conceptual separation of mother and child is the Cartesian mind-body separation that has been fundamental to the development of both industrial society and post-industrial technocracy.
The professional’s body images and lifestyles express these principles of separation, while the holistic ideology of the homebirthers stresses mind-body and parent-child integration. In conclusion, the home birth thought process allows and provides for the bonding of infant to parents.
Breast-feeding is also an important factor to the development of the relationship between mother and infant, physically as well psychologically.
Lucy Waletzky, M.D., a psychiatrist who breastfed her children, explains: The more intimate bodily communication inherent in the breastfeeding situation leads to a feeling of psychological ‘oneness’ with the child, which allows the mother to satisfy her own dependency needs (needs to be cared for and loved) at the same time she meets the baby’s dependency needs.
A mother’s dependency needs may be accentuated postpartum by pain, fatigue, and the psychological stress of adjusting to new motherhood. When her dependency needs are thus met, her resentment of the child’s dependency (often a very difficult problem) is alleviated, and the positive maternal feelings can flourish unencumbered (LaLeche League, 1985, p. 48).
Home birth in particular is very encouraging of breast-feeding. Outcomes of several studies (Tyson, 1991; LaLeche League, 1985; Davis, 1994; King & Shiell, 1993) show a direct correlation between ease of birth, postnatal care, the education of the mother, and breast feeding.
Home births, which are inclined to contain these features, promote the nurture of the infant. Tyson’s (1991) study of 1001 midwife-attended home births reviewed clients records to provide data on maternal age, socio-economic status, gestation, ruptured membranes, length of labor, episiotomies and perineal lacerations, transfer to the hospital of mother or baby or both, infant resuscitation, and breastfeeding. The proportion of mothers breastfeeding without supplement at 28 days postpartum was 98.6 percent.
Encouragement of breast-feeding is also an economic factor. The mother who breast feeds will save in money, the equivalent of the cost of a major appliance, during the first year of a baby's life, over the mother who uses formula (Kitzinger, 1987).
WIC, a government sponsored program for low-income mothers of infants and small children, now gives incentives to mothers who breast-feed. Prenatal services that have critical attitudes towards technology and that have adopted an attitude of respect for the woman and child are the services that appear to have the greatest benefit for mother and child. These are also the most enduring services.
Even with all of today's technology, midwifery still persists as a major alternative in many industrialized countries. This point helps to explain why other nations spend less on health care, and yet have better health and lower infant and maternal mortality rates. Prevention versus rectification, one way of thinking and acting versus another.Too often in American hospitals today, the process of labor and delivery is treated like an illness, not as a natural, if life-altering, event.
Women are dehumanized by artificially established “labor curves” and confined by often-unnecessary machinery, their personal needs, even their privacy, subsumed under the rules of system. Fear of malpractice has added to the rigidity of the system- but so has a lack of true caring and a fondness for expediency (Diamond, 1996, inside front flap).
Midwives are trained to prevent complications from ever occurring. Whereas doctors' mindless use of technology produces an environment where complications arise and then the damage must be rectified. This sets up the stage for the now common use of cesareans because they have no other alternatives.
Midwives are trained with the complete focus on the woman and her sense of security. When all costs are considered; developmental, social, physical, psychological, and economic. Midwife assisted birth for low-risk women stands far ahead of the alternative.
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