American Sexuality magazine - ASM

Welcoming Baby, or Not

Are men, machines, and hospitals really necessary for a healthy childbirth?

By Marsden Wagner

Childbirth is not a medical issue; it is a social issue that may or may not have medical consequences.

Day care for children, spousal abuse, and care of the elderly are all social issues that may or may not have medical consequences. If maternity care were included with other social and family services, it would mean an entirely different approach. I would then expect to see family-centered maternity care. This might include home visits; attention paid to prevention issues, such as nutrition; screening tests provided selectively (not routinely), with fully informed choice; counseling as needed; and good continuity of care before, during, and after pregnancy and birth, with emphasis placed on the woman and her family knowing the care provider. Maternity care will become fully integrated into social and family services only when it has escaped the hospital.

Childbirth is a very personal, emotional phenomenon, analogous to sexual intercourse. Most people would balk at an expert coming in to tell them how to make love. In fact, if you want to make love-making impossible, have a stranger walk in. Childbirth is like sex in that it is much more than a physical act and it requires privacy and intimacy. Childbirth is not just about a head coming out, just as sex is not just about a head going in. Sexual intercourse has medical risks as well (one of the partners contracting AIDS or gonorrhea, for example), but that doesn’t justify having a doctor in the room.

There is a basic physiological fact that strongly favors childbirth outside a hospital: women have hormones (endorphins, oxytocins) that do not function normally in a strange environment or if there is a stranger present. In order for a woman to have a personal, private birth experience, it is essential to get her out of an institution that by its very nature is impersonal and not private—the hospital.

The key issue in the question of where to give birth, however, is who is in control. Physicians, hospitals, electronic fetal monitors, and drugs do not have babies—only the mother of the child can do that. To give birth, a woman must open up her body, wide. This profound social and biological act requires everything a woman has and is. All maternity services should reflect this fundamental fact and should be designed to assist and support the woman. Most of the present care system for birthing women in the United States is designed not to assist the mother but rather to control her.

Doctors control women with fear. They have succeeded in convincing the great majority of American women that they cannot safely give birth outside the hospital; that nearly half of them have uteruses that are nonstarters and need to have labor induced or augmented with powerful drugs; that up to two-thirds of them cannot tolerate labor pain and must be made numb from the waist down with an epidural block so they cannot feel the birth of their babies; that one-third of them cannot push out their babies but must have it pulled out with forceps or a vacuum or cut out by C-section. When we try to make women believe that they can’t give birth without the help of men, machines, and hospitals, we take away their confidence and their belief in their own bodies—and with their confidence gone, any feelings of power and autonomy also disappear. Women in the United States have become victims of a medical vision of female reproduction, and that needs to change. The most effective way to avoid this medicalization of birth is to stay away from where it goes on—the hospital.

A family must be allowed to own the birth of their child and to create the birth experience they want and need. The only way families can do that is if women are in control of their own bodies. The doctor is not the important person at a birth. It is the woman’s childbirth. It is her life. It is her family. It is her baby.

As a physician with decades of experience, I can assure you that at any birth, the level of concern and value is very different for the woman and family than it is for the doctor. For the doctor, it is one out of hundreds of births. For the family, it is one of very few, or the only one. When a woman is seventy years old, she will almost certainly remember every detail of giving birth, whereas the doctor who was there will have forgotten it a week later. We’ve gone astray in this regard. To honor the family and preserve the sanctity of birth, we must get birth out of an institution that is designed and managed for the care of the sick.

We live in a diverse society that includes people of many religions and cultures, and childbirth has always been associated with religious and cultural traditions. In fact, religious and cultural issues are so integral to maternity care for some families that the issue of separation of church and state arises. I tell a story of an orthodox Jewish family who insisted on their right to a home birth attended by a midwife, and when their birth later became a legal case, they refused to answer questions about the birth of their child before a grand jury—a representative of the state—for religious reasons. In an out-of-hospital birth, a family can orchestrate their special childbirth needs either in their own home or in a neighborhood birth center where there are people to assist who share their beliefs. In the United States, families have the right to practice their religion. They have the right to have Santa Claus at their birth if they want to. And there is no way a hospital can begin to provide for the special childbirth needs of all religions and cultures.

In addition to providing assistance with low-risk, out-of-hospital births, neighborhood women’s centers, staffed primarily by midwives, would also provide a wide array of primary care services for women, including social services such as individual counseling, support groups, and services for abused women. They would also provide preventive health services such as family planning, cancer screening, prenatal care, postnatal care, breast-feeding support, and so on.

This is not a new idea. Groups of women in the neighborhood who gather to support and serve one another have existed in one form or another for thousands of years, but they are scarce today in the United States. These gatherings have traditionally been informal networks of female relatives and friends, surrounding the local midwife. For much of history, they have flown under the male radar, so they have not been formally documented in what has been a male-dominated authoritarian society. It is highly likely that Hanna Porn, the midwife in Massachusetts who was persecuted at the beginning of the twentieth century, attracted such a group of women. But over time, midwives were driven out of American communities and it became unusual for members of extended families to live near one another. Neighborhood women’s gatherings began to fade away as well, although they still exist in some parts of the country.

In Europe and other parts of the world where midwives have not been driven out, these groups thrive. I have personally spent time with out-of-hospital midwives in London, Amsterdam, Copenhagen, Sydney, Kyoto, St. Petersburg (Russia), and elsewhere, and have seen the groups that surround them. Sometimes the members of the group are a familiar sight at the midwife’s home, and sometimes they are not, but they come out of the woodwork when needed. In the 1990s, a midwife in a small town in the south of France was attacked by the local obstetrician, who had a vendetta against her and was trying to get her license to practice revoked. He used the excuse that she attended planned home births, even though home birth was not illegal. A group of local women quickly organized, circulated a petition, and presented it to the city council. They also contacted me, and others who support the midwifery profession, and requested letters of support.

I’ve seen the same support appear when a midwife in the United States is caught up in a witch-hunt. Groups of local women come to the rescue. When a Mennonite midwife in Ohio was in trouble with the law for not testifying in a grand jury investigation (she refused to break her code of confidentiality), an outpouring of support came from women all over the Midwest.

*from Marsden Wagner’s Born in the USA:  How a broken maternity system must be fixed to put woman and children first  published by the University of California  Press, 2006

Marsden Wagner, M.D., M.S., is a perinatologist and perinatal epidemiologist. He was director of Women’s and Children’s Health in the World Health Organization for 15 years and is the author or editor of eight books. He has been featured in U.S. News and World Report, Health, Mother Jones, The New York Times, and the Los Angeles Times, as well as appearing on Dateline and Good Morning America.