Contrary to popular misconception, Holland has a widely diverse population, with as many as 23 la

nguages spoken at prenatal clinics. Many immigrants to Holland come from societies where women have little education, economic power or freedom of choice. These women would be at higher risk for developing complications in birth. Yet Holland has consistently fine statistics in maternity care and mother-infant and child-family health.

Like several other Northern European countries, Holland has a national policy that guarantees every woman a midwife from the beginning of pregnancy through the first year after birth. In Holland, 30-40% of births still take place in the home under the care of a midwife. This is because home birth with skilled midwives has been proven to be safe and cost-effective in the long run. Obstetricians and hospitals are reserved for women and babies at risk for developing complications in birth.

A second important feature is that a community-based team of primary care practitioners has the responsibility of seeing that every child and family have the healthcare and social services they need to maintain good health. This team consists of a family physician and includes a midwife and social worker. Any one of them can initiate hospitalization or call a specialist physician such as an obstetrician or neonatologist when a baby’s condition necessitates that response.

When the home birth rate dropped to 30% in the 1970′s because more and more women began seeking obstetricians (a direct result of the impact of American obstetric practices infiltrating world health), the government recognized it as a dangerous and costly trend. A multi-disciplinary commission was formed to evaluate maternity care and make recommendations.

The national health policy of Holland had always recognized the importance of maintaining a balance of power between family physicians, sub-specialist physicians and midwives, with each profession needing to be independent in order for the team to work.

Before the commission, family physicians had slowly been phased out of attending home births in favor of midwives, leaving a power imbalance toward hospital based physicians (OB’s, natalogists, peri and neo). Midwives, who earned less money than obstetricians and were beginning to have less prestige with the public, needed special support. Otherwise, the government recognized, obstetricians and perinatologists would soon take over, resulting in a loss of normal birth and the runaway costs associated with routine hospitalization for birth and unnecessary procedures and interventions.

Current policy in Holland assures that any woman who has a complicated pregnancy or birth has guaranteed care by physicians in a hospital. Because every Dutch adult is required to have some form of health insurance, there is no direct cost to a family when a woman or baby needs a physician or hospital care.

Any woman has the option of choosing to be cared for by an obstetrician and birth in a hospital. However, if she has no medical indication for her choice, then she is responsible for paying for the privilege. In addition, every midwife has guaranteed hospital privileges. Because the midwife is the gatekeeper (for maternity care in the neighborhood), she is responsible for all physician referrals, and helps insure that physicians do not abuse either technology or their patients by doing unnecessary procedures.

This has kept Holland’s cesarean rate well below 10%, despite the eagerness of obstetricians to perform more cesareans. Holland’s maternal and infant health statistics constantly rank among the highest in the world. Note: For decades Holland’s cesarean rate was below 4%; increasing pressure to “modernize” has brought rising rates of intervention.

A third important component of Dutch maternal-infant care is that every mother is offered postpartum doula care at minimal cost. From two to eight hours a day (depending on the family’s need or the woman’s preference) a doula comes to the house and cares for the mother, helps with breastfeeding, does housekeeping, runs errands, and cares for siblings. Doulas in Holland have special training as a profession, keep records on the family’s health, report to the midwife, and play a crucial role in maintaining high quality care, with the support of government subsidy. This is because they have been found cost effective.

Contrary to what U.S. medical organizations lead us to believe, Holland has shown that it is possible to identify those women at risk for developing complications during labor and predict the vast majority of serious problems with a high degree of accuracy. Only 20-30% of all birthing women fall into this category, and most of them do not develop any complication. The remaining 70-80% can safely birth at home or in a birth center.

A midwifery-based maternity-child healthcare system does not train more specialist physicians than is needed. It utilizes them and hospitals as important adjunct services for those mothers and babies who are likely to benefit from medical treatment. In such a system, midwives, obstetricians and neonatal pediatricians are colleagues who respect and support each other.

Holland, along with Denmark, Sweden and Britain, supports at least nine months of breastfeeding in addition to a complete system of paid maternity leave. Mothers who work are allowed time off to breastfeed their baby during the day. Despite the initial cost of such a complete well-integrated maternal-child-family system, Holland has proven the long term benefits of such a policy. This is probably the best model today for us to look towards.

Whether birth is covered under an insurance plan, or whether a woman or couple are paying “out-of-pocket”, birth is still costing them – and us – money. Question: Are we getting the value fr

om the money it costs to have a baby today? Another Question: Are parents in many places being limited in their choices regarding 1) where to birth, 2) how to birth, and 3) with whom to birth… by what is covered under their government health plan or insurance?

When it comes to modern childbirth, it’s important to think about how much money is involved and how it is being spent. There are so many pressing social and health problems that need resources such as money. So, when you read this, we hope you’ll dream and envision how best money can be spent when it comes to birth.

If you or someone you know is preparing to have a baby, it’s wise to ask the question: “Are you (or Am I, or Are we) limiting the dreams and hopes for bringing a child into the world by money decisions. Think about this: It costs tens of thousands of dollars for the average wedding, yet half of all those marriages will end in divorce, often within just a few years. A baby is a lifetime and that child a lifetime responsibility. The decisions we make about what is and is not important about that birth and this baby will last a lifetime. It’s not only about the kind of birth your baby would like to have, but also the kind of life you want for yourself and your baby, especially in the first 9+ months after birth.

FACT: All human babies, even those born full-term and looking perfectly healthy and robust, are actually born many months premature in terms of physical development. We should behave as if the second 9+ months (the ones after the baby is born) are as important as the womb-time. Science has shown us that we humans are really more like kangaroos (who need to be “gestated” outside the womb, as well as inside, for many months) than we are like baby horses, needing to be “worn” on a parent’s body and fed from that body for many months. That is how long it takes for a human infant to develop physically to the point where most other large mammals are at birth – where they can stand on their own legs and follow their food source!

When it comes to money and birth, just imagine what it would mean if every mother was paid to be with her baby for the first nine months after birth, and paid an extra bonus every month she continues to breastfeed that baby! With that in mind, let’s see what the economics of modern birth look like using the United States as an example.

Hospital Birth

One of hallmarks of birth in the U.S., which differs from birth in most other countries, is that it is a huge, profit-driven industry. There are nearly four million births each year in the U.S., costing over $ 100 billion per year, when you include the cost of caring for our nation’s prematurely born babies. Today, 1 out of every 8 births in the U.S. is premature (born more than 3 weeks before the “estimated due date.”

99% of all births take place in hospitals, and the rate of planned home births is now less than one quarter of 1% , the U.S. lacking a model for normal birth. As a result, the U.S. today spends more money on birth than any other nation in the world. Yet we have one of the worst/highest rates of infant and perinatal mortality. “It is safer to have a birth in Cuba than in the U.S.”

The typical “drive-through” American-style hospital birth today consists of a 24-hour stay in a hospital following a vaginal birth and just three days following cesarean surgery. Vaginal birth costs an average of $6,000-$8,000 for the hospital, including the cost of all the medical interventions and drugs, plus the cost of the obstetrician, which adds another $4,000-$5,000. Cesarean surgery often triples that cost. However, Americans who have insurance coverage that pays for birth don’t realize what they are paying for.

The total cost of a midwife-attended birth at home is just $3,000-5,000. This includes a full course of prenatal visits done by the midwife, with each visit lasting half an hour or more (instead of the typical six minutes per OB visit). Midwife-attended birth has been proven to be as safe as physician care, and home birth with a midwife as safe as a hospital birth. Yet few insurance companies in the U.S. will pay for it or for birth in a birth center.

Each year in the U.S. more than 500,000 healthy full-term newborn babies are placed in a hospital intensive care nursery for “observation” or for “just in case” treatment. Typically this entails a 3-day ICU stay, which includes many painful tests and procedures done on the newborn baby and drugs given intravenously at a minimum cost of $2,000 per day. In addition, U.S. intensive care nurseries routinely separate babies who are in ICU’s from their mothers, rather than caring for them as a pair, where each newborn baby is in bed with, or next to, its mother, as is done in some European hospitals with excellent results.

In the U.S. today, in most hospitals, families are billed for a 1-day newborn nursery charge, averaging $300, whether or not their baby ever goes to the nursery. The cost of this routine separation of mother and baby is nearly $1 billion a year. This money is needed to see that every pregnant woman receives good food and housing. Insurance may cover much of these unnecessary hospital costs, but the American public actually pays the bill.

The cost, in dollars, to circumcise the penis of newborn baby boys in the U.S. is more than $300 million per year. The cost in human suffering is immense. Recent evidence proves there is no scientific basis for doing any circumcision. Furthermore, the U.S. is the only country in the world that continues the practice circumcision routinely on newborn baby boys. The number of baby boys in the U.S. who are circumcised has dropped from over 90% to 60% or less, as a result of an active grass-roots campaign by parents and some physicians, nurses, attorneys and rabbis and will eventually be eliminated entirely.

Midwifery Attended Birth at Home or in a Birthing Center

Midwifery training and midwifery care costs far less than obstetric training and care yet produces equal or better results, according to the most recent studies around the world. Providing a “doula” (a trained professional proving support throughout labor) to every woman giving birth in a hospital also reduces costs dramatically because one-to-one skilled labor support reduces the use of artificial stimulants to speed up labor, reduces dramatically the requests of women for drugs (narcotics and epidurals) for pain, and also reduces dramatically the numbers of babies brought into the world by forceps, vacuum extraction or cesarean surgery.

Midwifery care makes it possible to provide home visits during pregnancy and the postpartum, as well as home birth, all of which have been shown to improve safety and the quality of mother-baby health in measurable ways.

Although labor-intensive, this approach is cost-effective over the long-term. It reduces unnecessary hospitalizations, overuse of emergency rooms, and over-dependence on physicians because mothers who have been cared for (at least in part) in their own homes or neighborhood are more self-confident in making judgments and decisions about their own and their child’s health.

Birth centers run and staffed exclusively by midwives have been proven safe and appropriate choices for healthy women who cannot or do not wish to birth at home. They too reduce costs measurably and improve outcomes. We need to remove the obstacles to midwives, doulas and birth centers that currently exist and create a system that supports and encourages use of them, one that is not controlled by the medical or insurance industry.

We can save $40-50 billion per year and set a standard for natural, healthy birth

This is money needed to reduce poverty and reduce the number of babies born prematurely in America.

Any country needs a reasonable rate of healthy women giving birth in the setting where they feel most comfortable, because that is the place where you are most likely to see how women behave when they are not inhibited and where you are most likely to see truly “normal” birth. Birth attendants, doctors and midwives must see normal, natural, spontaneous birth in order to know what the range of normal is and what is abnormal. The place where most women feel most comfortable and at ease is usually the place where they live. Without a model for normal, natural birth, birth becomes abnormal and the cost in dollars and human terms is too high.

Imagine if only complicated births (and births where there was a high chance that problems would arise during labor) took place in the hospital and the rest took place in homes and birth centers. Then the vast majority of births would occur outside of a hospital. (Remember that a hospital is a place of infection and disease and carries risks).

Imagine if the national cesarean rate were 10% instead of over 30%, as it is today in the U.S. and many other countries as well. According to the World Health Organization any country should be able to have a cesarean rate of no more than 10%.

Imagine if there were 10,000 practicing obstetricians and perinatologists (specialists in problems in birth) and 80,000 practicing midwives, instead of the current figure of 35,000 OBs and just 8,000 midwives.

Imagine if every mother was cared for by a midwife, or a pair of midwives, who worked together and followed her from early in pregnancy until the baby were a year old.

Imagine if obstetricians were available to any women who needed them. Most women would never need to see an obstetrician because most women would come to birth in a high state of health and most birth would be natural. Drugs and surgery in birth would also be rare.

It is possible to have a maternity system like we have just described. One country already has it, and also has fine statistics in health and safety for mothers and babies. That country is Holland. In The Netherlands (Holland), every woman first sees a midwife. The midwife is the one who refers the woman to a physician, but only if she has serious problems that might need a physician. The midwife consults with a physician whenever she thinks there may be a problem but continues giving the primary care to the mother-baby.

Here’s a safe and cost-saving idea: For many years, in Holland a woman has had to pay extra to birth in a hospital with an obstetrician if she is healthy and has no medical need for hospitalization or a physician. She has the right to birth wherever she wants and with the practitioner of her choice, but she must pay for the privilege of using services that she does not need!

You can figure out the savings possible if we simply changed the place of most births by removing births from the hospital, those that didn’t need to be there, and the care from costly physicians whose expertise is surgery, drugs and handling serious complications, to midwives, whose expertise is preventing complications and keeping birth natural. The full savings would be greater than $50 billion because there would be many fewer newborn babies who needed “special” or intensive care. With so few mothers and babies seen by doctors, and so many cared for by midwives, we would also see the rate of breastfeeding rise dramatically and most mothers would breastfeed longer. Midwives love breastfeeding and are skilled in helping help women breastfeed successfully. This alone, full breastfeeding, would result in many fewer babies needing to be seen by doctors or hospitalized for sickness in the first year after birth.

Most of these savings would then be given back directly to the people of this country. Some of it could provide every pregnant woman and postpartum mother and baby with the education and preparation for birth and parenting and the social support and healthcare they need and deserve. This care could effectively be delivered primarily through neighborhood clinics and home visits, as is already done in Australia, New Zealand, Britain and other western European countries. We already have the appropriate professionals to carry out such an integrated system: family physicians, midwives, nurse practitioners, physician assistants, social workers, health educators, etc., with specialist physicians and hospitals providing technical backup when needed, and with the emergency transport and paramedic system we have in place. This policy itself would reduce our long-term national health costs well beyond the direct savings in birthing costs. This is because so many chronic ailments in children and adults are a direct or indirect result of how we bring babies into the world and how we care for that mother-baby pair from conception to the first birthday.

As a nation, we can no longer afford the exorbitant costs of unnecessary, invasive, painful, and often traumatizing procedures done to the most sensitive and vulnerable members of society – our pregnant and birthing women and newborn babies.

We can no longer afford to neglect the real needs of childbearing women for guaranteed, fully-paid maternity leave of at least six months, with another six months of part-time paid leave, so that mothers can care for their babies.

There is so much to be done, and there is so much that we can do, right here and now, with the resources we already have available.

The economics of birth is just one dimension of a bigger picture.

The over-arching need is for us to create a system of caring that supports and protects the natural biological processes of conception, gestation and pregnancy, birth, breastfeeding, infant and baby care, and care for the postpartum woman. These natural processes are both subtle and sophisticated and, when interfered with, especially for no urgent medical reason, result in long-term problems – mental and spiritual, as well as physical.

We can use this same model – supporting the natural biological processes and using the least amount of intervention to achieve the greatest benefit with the least harm – for solving fertility issues and other issues, as we can for solving prematurity.

Where do we start? We start with an understanding of the value and importance of protecting and supporting natural processes and creative problem-solving to provide the very best of education, care and support for our childbearing women, mothers and babies.

The economics of birth is about how to prevent problems before they arise, how to treat problems that do arise with the least amount of harm, both immediate and long-term. The result is not only a savings in money but an increase in health and well-being and the quality of life, and the joy of living.

Creating the Most Natural, Healthy Birth for a Baby, a Woman and Family

Rethinking birth, how much money is it worth to parents to give their baby the healthiest start in life? Imagine you are pregnant, or thinking about it. Consider what it would mean to a woman, a baby and a family if she found a way to take a holiday from work for the last three months of pregnancy and the first 9+ months after birth… especially since how much stress a woman has in her life, how much ease and joy, directly affects how her baby develops and how likely this baby is to be born full-term and healthy.

What would men and women need to do to change the circumstances of their life to make that possible – if they live in a country or work for a company where the woman gets no paid maternity leave? How could they (or you) “down-size” life, cut living expenses, in order not to have to work for that 12 month period? What would it be worth for mothers to be allowed and supported to do the life-saving work of growing a healthy full-term baby and being a happy, at-ease mother?

ave maintained.

The majority of these major surgeries—cesarean will always remain major surgery—are performed on healthy middle or upper class women, not on women who are at high risk. Physicians are paid more for doing a cesarean than for a vaginal birth.

The increased direct revenue from medically unnecessary cesareans (including ones done just because the mother had an earlier cesarean) is $20 billion per year. The indirect costs (mothers and babies who end up in ICUs as a direct result of cesareans) are much higher.

Surgical risks

The hazards of any major surgery, including cesarean, are:

• Life-threatening drug reaction
• Unstoppable bleeding
• Massive infection

In addition, babies born by cesarean are known to have more breathing problems and difficulty with breastfeeding.

For all these reasons, as well as the fact that abdominal birth denies the baby the special benefits of vaginal birth, cesarean should only be used for the small number of mothers and babies who require it. Yet today many cesareans are done for convenience, others to avoid labor, and many because other interventions cause complications in labor.

Birth trauma risks

The experience of missing out on vaginal birth is traumatic to many mothers and babies. Any early traumatic experience leaves traces in a baby’s developing nervous system and brain. Birth trauma must be acknowledged and healed in order for mothers and babies to thrive.

By Barbara Harper, Founder and President of Waterbirth International and Global Maternal-Child Health (www.waterbirth.org)

August 21, 1999 should be remembered as a landmark in t

he history of birth pools. On that day the British Medical Journal published an unprecedented study about waterbirth. This study is authoritative for several reasons: The conclusions are based on large numbers: the authors traced the 4,032 babies born under water in England and Wales between April 1994 and March 1996; the authors belong to a prestigious department of epidemiology and public health (Institute of Child Health, London, UK); the report has been published in a respected peer review medical journal.

Methods

From April 1994 to April 1996, all 1,500 consultant pediatricians in the British Isles were surveyed each month by the British Paediatric Surveillance Unit and asked to report whether or not they knew of any births that met the case definition of “perinatal death or admission for special care within 48 hours of birth following labour or delivery in water.” At the same time a postal questionnaire was sent to all National Health Service maternity units in England and Wales in 1995 and 1996 to determine the total number of deliveries in water during the study period.

Results

There were five perinatal deaths among 4,032 births in water; that is a rate of 1.2 per 1000. In the context of the UK this rate is similar to low risk deliveries that do not take place in water. Furthermore, none of these five deaths were attributable to delivery in water. There were 34 babies admitted for special care; that is a rate of 8.4 per 1000. Rates of admission for special care of babies born to low risk primiparous women are significantly higher than for babies born in water.

Recommendations

Give great importance to the time when the laboring woman enters the pool. The BMJ survey clearly indicates that many women stay too long in the bath. The midwife should help women be patient enough so that they can ideally wait until five centimeters dilation to enter the water. Avoid planning a birth under water. When a woman has planned a birth under water she may be the prisoner of her project; she is tempted to stay in the bath while the contractions are getting weaker, with the risk of long second and third stages. There are no such risks when a birth under water follows a short series of irresistible contractions. Temperature: It is easy to check that the water temperature is never above 37 degrees C (the temperature of the maternal body). The fetus has a problem of heat elimination.

Michel Odent, excerpted from A Landmark in the History of Birthing Pools
Midwifery Today Issue 54
Read this article online at:
http://www.midwiferytoday.com/articles/landmark.asp

Waterbirth Facts and Tips— by Barbara Harper, RN Founder of Global Maternal Health

Practitioners throughout the world recognize increased safety for the breech baby if it is born in water. The most experienced doctor we know of is Herman Ponette, an obstetrician who practices in Ostend, Belgium. He has attended well over 2,000 waterbirths, including breeches and twins. To him, a frank breech position is an indication for a waterbirth.

Perineal trauma is reported to be generally less severe, with more intact perineums for multips, but some of the literature reports the same frequency of tears for primips in or out of the water (Burn, Garland).

A useful way to identify the extent of postpartum hemorrhage is how dark the water is getting. Can you still assess skin color of the mother’s thighs even though there is blood in the water? A few drops of blood in a birth pool diffuse and cause the water to change color.

A waterproof flashlight comes in handy at this point. Dropping a flashlight onto the bottom of the birth pool allows you to look for bleeding as well as meconium during the birth.

Some hospitals still restrict a woman from laboring in the water if her membranes are ruptured. Based on the current and past literature, this is absurd. No evidence exists of increased infectious morbidity with or without ruptured membranes for women who labor and/or birth in water (Eriksson et al., Garland).

Some parents are concerned about mother-to-mother infections or contamination from viruses such as HIV or hepatitis. There is no reason to restrict an HIV-positive mother from laboring or giving birth in water. All evidence indicates that the HIV virus is susceptible to the warm water and cannot live in that environment (Favero). Universal precautions still must be adhered to, however, and proper cleaning of all the equipment after the birth must be carried out.

From Midwifery Today, Issue 54

References:

Burn, E., Greenish, K. (1992). Pooling information. Nursing Times 89(8): 47-49

Garland, D., Jones, K. (1997, June). Waterbirth: Updating the evidence. British Journal of Midwifery 5(6): 371

Erikkson, M. et al. (1996, Aug.). Warm tub bath during labor: A study of 1385 women with prelabor rupture of the membranes after 34 weeks of gestation. Acta Obstetricia et Gynecologieca Scandinavica 75(7): 642-44.

Garland, D., Jones, K. ibid. Favero, M. (1986). Risk of AIDS and other STDs from swimming pools and whirlpools is nil. Postgraduate Medicine 80(1): 283

By Barbara Harper, Founder and President of Waterbirth International and Global Maternal-Child Health (www.waterbirth.org)

Waterbirth is simple.

Within

the simplicity of water labor and birth lies a complexity of questions, choices, opinions, research data, women’s experience and practitioner observations.

Over the past five years as more hospitals within the United States examine waterbirth and create programs to support the use of water for labor and birth, newspaper reporters latch onto the sensationalism of this simple option and publish stories of successful waterbirths in local publications.

Each reporter does their best to simplify waterbirth and at the same time answer the most common questions. Each story shows a happy beaming mother, a quiet peaceful baby and a proud father, who usually successfully set up a portable birth pool. The surprise headlines like, “watery birth” or “baby’s birth goes swimmingly” or “junior makes a splashy entrance,” are countered with the simple stories of couples who have made this decision for themselves and are proud of it.

It is hard to think of another “method” of childbirth that receives such praise from women and practitioners alike. Dr. Lisa Stolper is an obstetrician practicing in the quaint New England town of Keene, New Hampshire. She began offering waterbirth to her clients at Cheshire Medical Center in October of 1998. One year later she reported an overall waterbirth rate of 37% for all vaginal births and 33% for all births, including cesarean sections. Her hospital has purchased just one portable jetted birth pool but they use it to labor almost 50% of their clients. They are now considering installing permanent pools to make it available for more women. Her comment about her job as an obstetrician was, “Waterbirth just makes my job so much easier.”

One of the final questions that newspaper reporters pose and birthing couples ask is: Why aren’t more hospitals in the U.S. offering waterbirth?

Hospitals in the United States have made incredible advances in the waterbirth movement in the past five years. Monodnock Community Hospital in Peterborough, New Hampshire, was the first hospital in the country to embrace waterbirth and install a permanent birth pool, imported from England. They still offer this option to women and can now look back on almost ten years of great outcomes and lots of satisfied families. The rest of the country has taken some time and there are certain areas of the country that are making greater strides than others.

In almost all cases where there are successful waterbirth programs going, they have been started by Certified Nurse Midwives. Midwives are more open to exploring the issue with their clients and doing the research necessary to get protocols accepted in hospitals. Some midwives have even purchased portable birth pool equipment with their own funds in hopes that it would pay for itself by generating more business. In most instances that investment has paid off.

The whole U.S. movement is at least five years behind the European movement in acceptance in hospital environments, but home birth midwives in the U.S. have been offering waterbirth longer than most of their European counterparts. The UK has had the benefit of government-sponsored research and data reporting as well as the Cumberlege Report. The House of Commons Health Committee recommended that all hospitals should provide women with the option of a birthing pool. The underlying philosophy of the “Changing Childbirth” report recognized that women have the right to choose how and where they wish to give birth. In a 1994 statement, the UKCC stated, “…waterbirth is preferred by some women as their chosen method for delivery of babies. Waterbirth should therefore be viewed as an alternate method of care and management in labour and one which falls within the midwife’s sphere of practice.”

The states that have made the most progress for hospital waterbirth are New York, Maine, New Hampshire, Illinois, Ohio, North Carolina and Massachusetts. Obviously, the East Coast is changing faster than the West Coast. It is surprising to some people when they find out that the whole state of California only has a handful of hospitals that provide waterbirth services. More than two thirds of the birth centers in the U.S. offer waterbirth as an available option.

Mothers who call Waterbirth International wanting advise on how to get their particular hospital to allow them to have a waterbirth are advised that it takes three ingredients to make policy changes within a hospital setting.

• A motivated mother
• An open and supportive practitioner
• A compassionate nurse manager or perinatal coordinator who is willing to take on the training of staff and the creation of new policy.

Note: Waterbirth International will supply the necessary research studies, the sample protocols, the pool kits, the videos and the experience to help couples get policy changed, but without these first three components some hospitals will continue to deny the request. Time is the other factor. The more advance notice a hospital is given the better chances there are for change.

The final key to change is education. Waterbirth 2000: A Vision for the Future, an international waterbirth conference held in Portland, Oregon, September 21-24, 2000, provided a forum for evaluating current waterbirth practice and discussing the needs of the both practitioners and the families they serve.

There are so many areas of waterbirth yet to explore. Waterbirth is more a philosophy of non-intervention than a method or way to give birth. Waterbirth combines psychology, physiology, technology, humanity and science. Waterbirth is ancient and yet new at the same time. Waterbirth embodies a spiritual aspect of birth that is hard to express. Cynthia, who gave birth in water, said it better, “The water made me so completely connected to my body and my baby. The water held me and cradled me so that I could surrender more completely to this amazing and wonderful grace that was happening to me. This is the way that God intended childbirth to be.”

By Barbara Harper, Founder and President of Waterbirth International and Global Maternal-Child Health (www.waterbirth.org)

The first and

foremost question in everyone’s mind and the lead in all of these newspaper accounts is simple: How does the baby breathe during a waterbirth?

There are several factors that prevent a baby from inhaling water at the time of birth. These inhibitory factors are normally present in all newborns. The baby in utero is oxygenated through the umbilical cord via the placenta, but practices for future air breathing by moving his intercostal muscles and diaphragm in a regular and rhythmic pattern from about 10 weeks gestation on. The lung fluids that are present are produced in the lungs and similar chemically to gastric fluids. These fluids come out into the mouth and are normally swallowed by the fetus. There is very little inspiration of amniotic fluid in utero. 24-48 hours before the onset of spontaneous labor the fetus experiences a notable increase in the Prostaglandin E2 levels from the placenta which cause a slowing down or stopping of the fetal breathing movements (FBM). With the work of the musculature of the diaphragm and intercostal muscles suspended, there is more blood flow to vital organs, including the brain. You can see the decrease in FBM on a biophysical profile, as you normally see the fetus moving these muscles about forty percent of the time. When the baby is born and the Prostaglandin level is still high, the baby’s muscles for breathing simply don’t work, thus engaging the first inhibitory response.

A second inhibitory response is the fact that babies are born experiencing acute hypoxia or lack of oxygen. It is a built in response to the birth process. Hypoxia causes apnea and swallowing, not breathing or gasping. If the fetus were experiencing severe and prolonged lack of oxygen, it may then gasp as soon as it was born, possibly inhaling water into the lungs. If the baby were in trouble during the labor, there would be wide variabilities noted in the fetal heart rate, usually resulting in prolonged bradycardia, which would cause the practitioner to ask the mother to leave the bath prior to the baby’s birth.

Another factor which is thought by many to inhibit the newborn from initiating the breathing response while in water, is the temperature differential. The temperature of the water is so close to that of the maternal temperature that it prevents any detection of change within the newborn. This is an area for reconsideration after increasing reports of births taking place in the oceans, both now and in eras past. Ocean temperatures are certainly not as high as maternal body temperature and yet the babies that are born in these environments are reported to be just fine. The lower water temperatures do not stimulate the baby to breathe while immersed.

One more factor that most people do not consider, but is vital to the whole waterbirth and aspiration issue, is the fact that water is a hypotonic solution and lung fluids present in the fetus are hypertonic. So, even if water were to travel in past the larynx, they could not pass into the lungs based on the fact that hypertonic solutions are denser and prevent hypotonic solutions from merging or coming into their presence.

The last important inhibitory factor is the Dive Reflex and revolves around the larynx. The larynx is covered all over with chemoreceptors or taste buds. The larynx has five times as many as taste buds as the whole surface of the tongue. So, when a solution hits the back of the throat, passing the larynx, the taste buds interprets what substance it is and the glottis automatically closes and the solution is then swallowed, not inhaled. God built this autonomic reflex into all newborns to assist with breastfeeding and it is present until about the age of six to eight months when it mysteriously disappears. The newborn is very intelligent and can detect what substance is in its throat. It can differentiate between amniotic fluid, water, cow’s milk or human milk. The human infant will swallow and breathe differently when feeding on cow’s milk or breast milk due to the Dive Reflex.

All of these factors combine to prevent a newborn who is born into water from taking a breath until he is lifted up into the air.

So, what does happen to initiate the breath in the newborn? As soon as the newborn senses a change in the environment from the water into the air, there is a complex chain of chemical, hormonal and physical responses, all resulting in the baby breathing. Water born babies are slower to initiate this response due to the fact that their whole body is exposed to the air at the same time, not just the caput or head as in a dry birth. Many midwives report that water babies stay just a little bit bluer longer, but their tone and alertness are just fine. It has even been suggested that water born babies be given the first APGAR scoring at one minute thirty seconds, not at one minute, due to this adjustment.

There are several things that happen all at once for the baby. The shunts in the heart are closed; fetal circulation turns to newborn circulation; the lungs experience oxygen for the first time; and the umbilical cord is stretched causing the umbilical arteries to close down. Nursing and medical schools taught their students for years that the first breath was dependent on the pressure of the passage through the birth canal and then a reflexive opening of the compressed chest creating a vacuum. That action has no bearing on newborn breathing whatsoever. There is no vacuum created. The newborn who is born into water is protected by all the inhibitory mechanisms mentioned above and is suspended and waiting to be lifted up out of the water and into mother’s waiting arms.

All the fluids that are present in the lung alveoli are automatically pushed out into the vascular system from the pressure of pulmonary circulation, thus increasing blood volume for the newborn by 1/5th or 20%. The lymphatic system absorbs the rest of the fluids through the interstitial spaces in the lung tissue. The increase of blood volume is vital for the baby’s health. It takes about six hours for all the lung fluids to disappear.

When we look back at the analysis of the statistics of babies born in water it proves that these inhibitory factors are more than theories. A study conducted in England between 1994 and 1996, and published in 1999, reports on the outcomes of 4,032 births in water. Perinatal mortality was 1.2 per 1000, but no deaths were attributed to birth in the water. Two babies were admitted to special care for possible water aspiration. From 1985 to 1999, it is estimated that there have been well over 150,000 cases of waterbirth worldwide. There are no valid reports of infant deaths due to water aspiration or inhalation. In the early days of waterbirth a baby was reported as dying from being born in the water. This particular newborn death was caused not by aspiration, but by asphyxiation due to leaving the baby under the water for more than fifteen minutes after the full body was born. At some point the placenta detached from the wall of the uterus and stopped the flow of oxygen to the baby. When the baby was taken out of the water, it did not begin breathing and could not be revived. On autopsy the baby was reported to have no water in the lungs and its death was attributed to asphyxia.

This is the reason that we bring babies up out of the water within the first few moments after birth. Some people have commented on the long time that some babies remain in the water in the film, “Water Babies: The Aquanatal Experience in Ostend.” Video tape is deceiving, but so are our senses. When timed, the film sequence is only forty-seven seconds, but when viewers are asked to judge how long the sequence of immersion for the baby really is, reports range anywhere from one minute to five minutes.

Bringing a baby out of the water too quickly can be just as traumatic but it can also lead to either torn or broken cords. This has been reported by a number of midwives and doctors. If the practitioner is not looking for a torn cord the possibility of the baby needing a transfusion increases. Torn or broken cords can be avoided by bringing baby out of the water slowly and gently. Mothers who desire to pick up their own babies need to be reminded to not do it too quickly, either.

The inability to accurately assess blood loss in the water is a reason that some midwives have stated for either not “allowing” the birth to take place in the water or asking mother to get out right away after the baby is born. Blood loss assessment is easy to judge after a few births. Garland and Jones report in a review of waterbirths at Maidstone Hospital in Kent, England, that the midwives are much better at judging and reporting blood loss in the water after experiencing over 500 births. A useful key to judge post-partum hemorrhage is how dark is the water getting? Can you still assess skin color of the mother’s thighs even though there is blood in the water? A few drops of water in a birth pool diffuses and causes it to change color. A waterproof flashlight comes in handy at this point. Dropping a flashlight onto the bottom of the birth pool allows you to look for bleeding as well as meconium during the birth. It also helps you spot floating debris and remove it.

Which brings us to the second most frequent question among hospital nurses and newspaper reporters: Won’t the mother get an infection?

There are still hospitals that restrict a woman from laboring in the water if her membranes are ruptured. This is totally absurd based on the current and past literature. There is no evidence of an increase in infectious morbidity with or without ruptured membranes for women who labor and/or birth in water. The oldest reference that researches the possibility of infection during a bath is mentioned in a 1960 American Journal of OB/GYN. Dr. Siegel posed the question, “Does bath water enter the vagina?” In his experiment he placed sterile cotton tampons into thirty women and them asked them to bath in iodinated water for a minimum of fifteen minutes. In all cases when the tampons were removed, there was no iodine present. His conclusion states, “we can now stop restricting women from bathing in the later stages of pregnancy and labor.” Laboring mothers have an advantage when the baby is descending and moving out. Nothing is moving up and in. Things that we put into laboring vaginas may cause an increase in infections, such as probes, fingers, amnihooks, scalp hooks, etc. Janet Rush, RN, and her Canadian group of investigators have conducted the only randomized controlled trial of the effects of water labor. They reported that there were no differences noted in the low rates of maternal and newborn signs of infection in women with ruptured membranes.

Infection control, especially in a hospital setting, requires diligence and the following of strict protocols between and during births. Cleaning and maintaining all equipment used for a waterbirth will prevent the spread of infection. In a random study conducted at the Oregon Health Science University Hospital in 1999, cultures were done from the portable jetted birth pool before, during and after birth, as well as from the fill hose and water tap source. In all instances no bacteria cultured from the birth pool but the water tap did culture Pseudomonas. In a British study of 541 water labors no serious infections were reported during the three year period of data gathering. Again, Pseudomonas aeruginosa, was the only persistent bacteria discovered in two babies who tested positive from ear swabs. No treatment was necessary.

Some parents are concerned about mother-to-mother infections or contamination from viruses such as HIV or Hepatitis. There is no reason to restrict an HIV positive mother from laboring or giving birth in water. All evidence indicates that the HIV virus is susceptible to the warm water and cannot live in that environment. Universal precautions still need to be adhered to and proper cleaning of all the equipment after the birth needs to be carried out.

Using disposable liners has become the norm for use with portable birth pools, but attention must also be paid to proper cleaning of drain pumps, hoses, filter nets, taps and any other items that are reused from one birth to the next. The issue of cleaning the jets of permanently installed baths has generated some concern and discussion over the past few years. Many hospitals remodeled their labor units in the late eighties or early nineties, installing jacuzzi-type whirlpool baths. These baths are great for women in labor, but often are not deep enough or are situated within very small bathroom spaces, boxed in and making birth in them difficult in all respects. The protocol for cleaning jetted tubs is simply to completely clean the tub with a quaternary ammonium solution, refill with water and add some kind of brominating agent to circulate through the jet system for a minimum of ten minutes. A number of hospitals report that they use a half cup of powered dish washing crystals such as Cascade and it works fine. Lynn Springer, RN, the perinatal coordinator for St. Elizabeth Hospital in Red Bluff, California, chose to install a beautiful corner Jacuzzi brand jetted bath on her unit in 1995. They have routinely performed monthly cultures of the bath and the jets throughout the past five years of their water birth program without any significant bacterial growth. They follow the above-mentioned cleaning protocol and report over 1,000 water labors and 400 births in water.

One issue that is repeated in the literature and voiced in the concern of mothers and their midwives is: When should the mother enter the bath?

Many hospitals use the 5-centimeter rule—only allowing mothers to enter the bath when they are in active labor and dilated to more than 5 cms. There is some physiological data that supports this rule, but each and every situation must be evaluated and then judged. Some mothers find a bath in early labor useful for its calming effect and to determine if labor has actually started. The water sometimes has the effect of slowing or stopping labor if used too early. On the other hand, if contractions are strong and regular with either a small amount of dilation or non at all a bath might be in order to help the mother to relax enough to facilitate the dilation. It has been suggested that the bath be used in a “trial of water” for at least one hour and allow the mother to judge its effectiveness. Women report that often the contractions seem to space out or become less effective if they enter the bath too soon, thus requiring them to leave the bath. Then again, midwives report that some women can go from 1 cm to complete dilation within the first hour or two of immersion.

Deep immersion seems to be a key factor. If the pool or bath is not deep enough, at least proving water up to breast level and completely covering the belly, then the benefits of the bath may be less noticeable. The warm water will still provide comfort and the mother will benefit from being upright, in control and drug free, but full immersion adds more physiological responses. The most notable being a redistribution of blood volume, which stimulates the release of oxytocin and vasopressin. Vasopressin can also work to increase the levels of oxytocin. The immediate pain reduction upon entering the bath is quite noticeable. It is what I refer to as, “the ahh effect.” The smile, the sound and the inner peace that mothers display are unmistakable. This response can happen at any point in the labor, but most notably when contractions are long and strong and close together. Some midwives who assume that there is little or no progress in dilation because the mother is not displaying any outward signs of discomfort are often surprised to find rapid dilation in the first hour of immersion. Having experienced a waterbirth myself, I can verify the incredible difference in perception of pain from the room to the water. When I am with a woman in labor I generally assess her pain on a scale of 1 to 10 before she enters the bath. Most report at least a 6 or greater. Then after no less than a half an hour, I will make another assessment. The second subjective answer of course varies from person to person, but the typical response is 2 to 4. The mother is experiencing more than the sum of her physiological responses to warm water immersion. Most women feel inherently safe in the water.

The water creates a wonderful barrier to the outside world. It becomes her nest, her cave, her own “womb with a view.” If the pool is large enough to include her partner or husband, it then becomes an intimate place for the two of them to labor together and experience the love dance of birth. If the midwife or physician wants to do a vaginal examination while the mother is in the water, it is much easier for the mother to refuse. Her mobility allows her to move quickly to the other side of the pool. Vaginal exams can be easily done in the water, but for Universal Precautions to be maintained, long shoulder-length gloves need to be worn.

The control that women gain by being able to move freely in the water often aids them in assessing their own progress either through feeling the movements of the baby more intensively or actually being able to examine themselves internally. Women report that the water intensifies the connection with the baby at the same time that it reduces the pain. They can feel the baby move, descend and push through the birth canal. The prospect of the midwife becoming an active observer increases as mothers assume more and more responsibility for the birth and have the ease of mobility in the water. For many reasons, including reducing the risk of infection for the provider, many midwives suggest a hands-off birth for the mother. The water slows the crowning and offers its own perineal support. This ‘minimal-touch’ approach also gives the mother a greater sense of controlling her own birth.

Perineal trauma is reported to be generally less severe, with more intact perineums for multips, but about the same frequency of tears for primips in or out of the water in some of the literature. One of the best benefits of waterbirth is the zero episiotomy rate that is reported throughout the literature. Rosenthal mentions that episiotomies can be done, but no one else offers this suggestion. The combination of being upright, having the mother in a good physiological position to birth her baby, giving her the freedom of control and not telling her to push when her body is not indicating it, all contribute to better perineal outcomes.

Midwives have a great deal of influence over the outcome of a birth. From the suggestions they make to a laboring mother to how they handle potential complications. There is an interesting phenomenon within the waterbirth movement that deserves some discussion. When a mother is laboring undisturbed, as Odent has written and lectured about, she will find her own place and time of birth, whether that place is the bathroom floor, under the piano, on the bed or in the bath. If practitioners remain silent observers to the process, the baby is born wherever it happens. But if the mother has stated her intentions for a waterbirth and the necessary arrangements have been made to have water available, is the midwife influencing the mother by reminding her as second stage approaches or in the middle of second stage that the bath is ready and waiting if she wants to get back in? In observing the statistics that Waterbirth International gathers from midwives and doctors on waterbirth, it is hard not to notice the variance from practice to practice. Those midwives that report an 80 to 90 percent waterbirth rate are usually set up with either a birth center facility which uses easily accessible bathtubs or every single one of their home birth clients rent or use portable birth pools. When the mother is in the midst of her subconscious birth responses, if someone tells her that the bath is ready and waiting, she often will immediately dash for the pool and climb in, even in the pushing stage. On occasion she simply states that nothing in heaven and earth can move her beyond where she is.

A midwife’s or physician’s hesitancy for using water for birth can also be felt by the mother and she often acquiesces just to make her practitioner feel more comfortable, instead of following her own instincts and staying in the water. Many women in hospitals get out of the pool because they don’t want to get their midwives “in trouble” by insisting on giving birth in water. And in the reverse, midwives often must insist that mother get out of the pool because protocols have not been set up for birth or the practitioner is just not comfortable with the process. The decision to birth in the water should be left up to the mother, but based on sound advice and assessment of fetal well-being by the practitioner. The mother who presents prenatally and is insistent that she is going to have a water birth no matter what, is usually destined to birth anywhere but the birth pool. I seriously counsel women who are taking on the system to evaluate their reasons for wanting to birth in water. If they are seeking to avoid pain only, that is a serious red flag and needs to be addressed on many different levels. If they have experienced one birth already and know what to expect and are looking for a better birth experience, then they are usually open to using the water to be in greater control and seeing how they feel at the time of birth. Flexibility is always required in birth, but especially for those women who add the element of water. In my own case, the first time I felt that I wanted to birth in water because it was the best thing I could do for my baby. I hear many women say this and that is a reasonable motivation. But, the benefit that women derive from being in the water and gaining control over their experience is passed on to the baby. It is better to focus on the mother and what she needs. For my second waterbirth, no one could keep me out of the water. I was completely focused on my experience and not the baby’s. Fathers will often call our office and make all the arrangements for the birth pool rental. On occasion that is because the dad wants his baby to be born in water and no other place, not taking into account what the mother really wants. Usually it all works out just fine, but occasionally it can influence the outcome of the labor.

Protocols differ from place to place, but as more experience with waterbirth emerges, we find that some previous reasons for asking a woman to leave the bath prior to birth are no longer hard and fast.

Meconium used to mean that the mother would have to leave the pool to birth her baby on the bed to facilitate immediate suctioning. This requirement has relaxed a bit as it has been seen that meconium washes off the face of the baby and even comes out of the nares and mouth while the baby is still under the water. DeLee suctioning can still be accomplished as soon as the baby is up in mother’s arms.

Tight nuchal cords were a reason to ask mother to stand for the birth so that the practitioner could cut the cord and then deliver that baby. Now, the universal practice is to no even feel for a cord in a waterbirth, unless there has been a very slow second stage and you are afraid of cord compression. No attempt is made to clamp and cut the cord. The body is birthed and then the cord it unwrapped. It is amazing to watch a baby somersault and unwrap begin to unwrap their own cord in the expanse of the birth pool.

Breech position was definitely a reason for a more controlled birth or even an automatic cesarean section. But there are practitioners throughout the world who recognize that there is increased safety for the baby if it is born in water. The most experienced doctor that we know of is Hermann Ponette, an obstetrician who practices at H. Surreys Hospital in Ostend, Belgium. He has attended well over 2,000 waterbirths including breeches and twins. He uses a frank breech position as an indication for a waterbirth. There are other reports of a few hospitals in the U.S. attending breech waterbirths and approximately 50 reported breech births in water at home.

Shoulder dystocia is considered an obstetric or midwifery emergency by most practitioners. Protocols require mothers who are anticipating large babies to leave the bath. Now there is a growing body of experience that suggests that shoulder dystocia can be managed easier in the pool. Canadian midwife, Gloria Lemay, has written a protocol for management of shoulder dystocia in the water. It appears that tight shoulders happen more often because of practitioners or moms trying to push before the baby fully rotates. Position changes in the water are so much easier to effect and the mother doesn’t panic but remains calm. A quick switch to hands and knees or even to standing up with one foot up on the edge of the pool if shoulders are really tight can help maneuver baby out.

Prematurity has always been considered a reason for a controlled and monitored bed birth. Some doctors who have experienced the great results of waterbirth for babies born from 36 weeks gestation on, are now questioning whether waterbirth might be good for some babies who are less than 36 weeks gestation. With the advances for waterproof fetal monitoring there are fewer reasons to require a woman to leave the pool especially if her baby is tolerating the labor well. A few cases of waterbirth for 33, 34 and 35-week-old babies have been reported.

Once a woman has experienced a waterbirth she will more than likely want to repeat the experience. To that that end, Waterbirth International gets some pretty interesting referral requests from women all over the world. If circumstances have changed and the mother is no longer living in a place where waterbirth facilities or practitioners are readily available, she will go to almost any length to recreate the opportunity to give birth in water. A research project that Waterbirth International has been conducting for ten years is a survey of women who have given birth in water. On the survey form is a questions that states, “Would you consider giving birth again in water?” With over 1,500 surveys collected, there has only been one woman that answered no to that question. On her particular survey she emphatically stated NO in bold print with two exclamation points and then drew an arrow down to the bottom of the page where in very small print she wrote, “this is number seven, I’m done!”

ces in America disempower and often traumatize the very people they are meant to serve… mothers and babies.

Our prevailing paradigm views birth as a “medical condition” that must be controlled and managed to “safely” and efficiently “deliver” a “product” called a baby from a “vessel” called a mother. The result is birth trauma, breastfeeding failure, compromised bonding, and a national policy that accepts early and prolonged separation in the first year of life as “normal and healthy,” all of which have ominous implications for the human species.

We are led to believe our birth, infancy and early mothering experiences have no lasting significance on the rest of our lives. Current scientific research and mounting clinical evidence show the opposite — our earliest experiences, from womb to toddlerhood, create patterns in our nervous system and brain that become the physiological foundation for life-long thinking, feeling and behavior.

These patterns affect all of our relationships, especially our ability to trust and feel connected to ourselves, others, the earth and spirit. These are the roots of our society’s epidemic levels of anxiety, depression, anger, addiction and violence.

The Problem and Solution

These issues are missing from our public discourse and media. The fact that today’s parents seldom question contemporary birth and parenting practices is not because they are irresponsible or uncaring. They lack the information, modeling and support to make different choices. Change will come only when a better informed and impassioned public demands it. A well-focused series can do that and more.

For example, in 1975 the BBC aired A Time to be Born. The issue: a whopping 90% of all births occurred between the hours of nine and five due to the costly, risky, routine practice of artificially inducing labor. As a direct result of this one show, public outcry changed medical practice overnight.

Breast milk is the only appropri

ate fo

od for infants through six months of age. To give women the notion that breastfeeding is a matter of personal choice is to undermine breastfeeding and women’s desire to do what is best for their babies.

Health safeguards

Nature designs breast milk to provide continuous immune protection for the newborn until the baby’s own immune system can get started, which does not begin until approximately six months after birth. While the baby’s gut is being bathed in this continuous protection and the components of breast milk and the comfort of suckling are calming the baby, the mother is also receiving benefits. Her body is releasing dozens of different hormones that are designed to keep her calm and focused on her baby. They also increase her feeling of “falling in love,” which is a crucial part of strong bonding.

No perfect substitute

Pediatricians in America for decades actively undermined breastfeeding. It is still common for a mother who takes her baby to the pediatrician because she is having difficulty breastfeeding, or because her baby has a cold, to be told that she needs to consider switching to formula. How is a woman to know the truth when an entire industry advertises that infant formula is “just as good” or “almost as good” as mother’s milk and implies that most mothers will have to turn to formula sooner or later?

1. Rapid drop in the moth
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   er’s blood pressure

2. A fever in the mother
3. Stopping the progress of labor
4. Making it impossible for the baby to properly negotiate its way through the pelvis

Complications

An astounding 96% of all women who get a fever in labor have had an epidural. A tragic 86% of newborns who are put on full-spectrum antibiotics, and have full septic workups while in the ICU, have been born to mothers who had epidurals in labor.

Nurses and breastfeeding consultants have observed that babies born following epidurals often seem to be numb around the mouth. This may be the reason why so many babies have difficulty getting breastfeeding started. The domino effect of this one intervention is broad, yet the full information about its adverse effects is seldom given to parents.

The heart of the physician’s Hippocratic Oath:

Above all, do no harm.

For a brief period in the late 1970′s, rigid hospital policies across the United States started to break down.  In direct response to a growing vocal minority of birthing women and their families who desired truly natural birth in the hospital setting, nurses and physicians began to simply turn their back on such rules as “only one family member may be with a woman in labor.”  Others got their hospitals to change the rules to permit two or even more family members and friends.

Women were refusing to sit in a wheelchair upon admission, insisted upon walking to Labor and Delivery, and walked out of the unit carrying their baby instead of being pushed in a wheelchair.  Women were refusing to be moved from labor bed to gurney when it came time to go to the delivery room and were walking the halls with family members during labor.  They wanted more than ice chips for nourishment and were bringing picnic baskets of food into the hospital, to feed themselves and their doctor and nurses.  They brought candles and flowers, some brought their own sheets, a poster to focus on during contractions, tape recorders and music.

Labor and delivery

For the first time in the history of hospital birth, the labor and delivery unit became a lively place.  Children were snuck into labor and into postpartum rooms, where a growing number of mothers were insisting on “rooming-in” with their babies and refusing to allow their babies to be taken to the nursery at night or given sugar water or silver nitrate in their eyes.  And almost overnight a growing number of hospitals across the country changed their long-standing policies to allow children to be present at birth and with the new baby.

In many communities women banded together, formed organized groups with names like The Tri-City Mothers, did literature searches and produced volumes of scientific material proving that things they wanted were safe.  These individuals and groups confronted chairmen of obstetric departments and heads of nursing with findings that ran directly counter to standard hospital policies that had never been successfully challenged by doctors and nurses in the system.  These included scientific proof that:

• Putting an IV in woman’s arm and administering glucose water was an inadequate and inappropriate way (not to mention inconvenient and uncomfortable) to keep a laboring woman well-hydrated.
• It was safer and more effective for women to eat and drink at will during labor.
• Drugs given to women in labor did get to their babies, had a negative effect on labor, and were hazardous to the babies as well.
• That cutting an episiotomy was not necessary or beneficial in most births and that a good midwife could prevent more than superficial tearing.  Healing from an episiotomy was, in fact, more troublesome than healing from a naturally caused tear (and that episiotomies tended to extend, whereas natural tears tended to be minimal).
• That a baby can be kept warmer lying skin-to-skin on its mother’s body than under warming lights on a warming table.
• The routine practice of taking every baby to the nursery for “observation”, and the bottle-feeding the baby sugar water undermined breastfeeding.

Home Birth Resurgence

Home birth and “lay” midwifery practices were producing changes in the practices of some nurses and doctors (even some hospital nurses and doctors began to have home births with these “lay” midwives!).  Home birth midwives and couples explored various non-invasive, non-medical practices to keep labor on course, get contractions going or going stronger, to cope with pain, to prevent tears, and to stop excessive bleeding after birth.

Many self-trained midwives became skilled in handling complications without resorting to taking the birthing woman to the hospital.  An entire body of wisdom regarding how to keep birth normal and resolve problems safely coalesced. Much of it came from indigenous practices of granny midwives, verterinarians, and others familiar with animal births. Books were published and knowledge was shared at conferences.

Because of the control that hospitals, doctors and medical management practices now had on birth, they sought out and talked to rural “granny” midwives and midwives from other countries who had been unable to practice legally in the U.S. so were working as labor and delivery nurses.  They learned, for example, that with a big baby, having a woman lying on her side for delivery or being on her hands and knees brought the baby out without a tear.  They researched and experimented with herbal and homeopathic remedies.  They read Dr. Gregory White’s “Emergency Childbirth” manual and a manual for Mexican midwives.

Learning

A growing percentage of American women and men became knowledgeable and skillful in birth and dared to stay home.  When some of these same couples did go to the hospital for one reason or another, they brought their bag of skills and knowledge with them.  Today in many hospitals, one or two labor and delivery nurses and physicians might use these practices, which they never got in training but learned from home birth couples and lay midwives of the 1970′s.

As a result, in some communities in the U.S., Canada, Mexico and some other countries, women can sometimes find nurses and doctors who will use warm compresses or oil on the vulva to keep a woman’s perineum from tearing or being cut as the baby is born.  They might find doctors who will place a newborn that is stressed directly skin-to-skin on the mother’s abdomen or chest to help it stabilize rather than whisk it across the room or down the hall for medical intervention.

“Change” in Hospitals

From the late 1970′s into the early 1990′s in the U.S., approximately 5% of women birthing in the hospital labored, gave birth and recovered in the same room, where policies included the allowance of siblings, family and friends to be present.  In the 1990′s, a growing number of hospitals, responding to consumer demand, converted their separate labor and delivery rooms to single “LDR” rooms, where women could labor, birth and recover in the same room.  Birth centers in hospitals, some complete with Jacuzzi tubs and kitchenettes and double beds are no longer as rare.

However, such humane environments for birth are few and still underutilized by physicians who resist doing a delivery anywhere except in a sterile delivery room, on a metal table with the woman on her back in stirrups.

Fancy wallpaper and high-tech equipment like electronic fetal monitors hidden behind drapes or in cupboards do not signal fundamental changes in attitude of staff.  It’s still a rare hospital in North America that “permits” woman-directed birth, that keeps all healthy newborns with their mothers and works actively to keep babies out of neonatal intensive care.

Too many “sick” babies?

Today the newborn ICU (NICU) usually has the highest occupancy rate in the hospital.  And high occupancy, especially in expensive ICU rooms spells big profit.  That, plus the standard policy of paying physicians more money for doing medical interventions and cesareans than for doing natural births keeps natural birth to a bare minimum in the hospital.

And a small number of nurses and physicians today are as frustrated and angry about hospital birth practices as the parents who want alternatives are.  As for the rest, it’s birth as usual.  What that means is complications where there should be none.  It means high-tech and hazardous invasive procedures where low-tech and hands-on human care would work better or at least equally well.  And, it means women entering and leaving the hospital certain that what goes on inside those walls is good for them and their babies.  Birth trauma is seldom acknowledged, especially from iatrogenic (physician/nurse caused) complications.