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Is birth normal?
High-tech childbirth has marginalized natural delivery, says SPH nurse-midwife
By Tricia Brick
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Nurse-midwife Mary Barger, director of SPH’s Nurse-Midwifery Education Program, and Therese Fitzgerald (SSW’99) with Fitzgerald’s daughter at Brigham and Women’s Hospital. Photo by Fred Sway |
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Students in the School of Public Health’s undergraduate introduction to public health course are asked: do you believe that birth is a normal process that should not be interfered with unless absolutely medically necessary? In recent years, the number of students answering yes to that question has dwindled to fewer than half, says Mary Barger, an SPH assistant professor of maternal and child health and a certified nurse-midwife.
“When I first became a nurse-midwife, it was the era of the Boston Women’s Health Collective and Our Bodies, Ourselves, and the women’s movement worked to reclaim birth and insisted on making hospitals friendlier and making birth welcome for the whole family,” Barger says. “Women were saying, ‘We want to become educated about the birth process, and we want to do it our own way.’ I think the pendulum is swinging to the other side now.” In recent years the perception has been growing that birth is a high-risk condition that requires medical intervention to be successful, she says, and the trend worries her.
Barger is director of SPH’s Nurse-Midwifery Education Program, which enables registered nurses to earn a master of public health degree while preparing for the national nurse-midwifery certifying exam. She has spent 25 years delivering babies and providing well-woman gynecology, prenatal, and postpartum care, and she balances her teaching and research with a practice at Brigham and Women’s Hospital.
But as a nurse-midwife, Barger is more than a medical practitioner; she is also an educator and an advocate for women and their families. To that end, she is determined to help women understand the full range of childbearing procedures available to them so that they can make informed decisions about their own bodies.
Normal no longer?
Last spring, Barger returned to her alma mater to present a 30th-reunion talk titled Is Birth Normal? at the Stanford University Nurse Alumnae meeting. “I think that the process of birth is under threat today,” she told fellow alums. She referred frequently to the Maternity Center Association’s Listening to Women study, which surveyed new mothers about their birth experiences and their attitudes toward childbirth. “For all practical purposes, natural childbirth no longer exists in the United States,” Barger said in her speech. “Ninety-nine percent of labors in this country, according to the testimony of the mothers themselves, are what the study authors call technology-intensive.”
Barger works with obstetricians in her practice at Brigham and Women’s, and she understands well the value of medical technology — when used properly, it certainly saves the lives of mothers and babies. But she sees a spectrum in the use of technology, ranging from natural childbirth through pharmaceutical pain relief and induction to elective cesareans. And as she noted in her talk, she believes that the technology-intensive end of that spectrum is increasing.
As an example, she points to the Listening to Women findings that half the women surveyed had experienced certain widespread interventions: electronic fetal monitoring, IVs, epidural analgesia, artificially ruptured membranes, pitocin to induce or augment labor, bladder catheters, and stitches. The need for some of these routines has “absolutely no basis in evidence,” Barger explains. “There’s absolutely no research to support them, and in some cases they are not only ineffective but are actively harmful.”
What once was
Barger adds that a reported 27 percent of American babies were born via cesarean section in 2003, and the number of elective cesareans — surgeries performed for reasons other than medical necessity — has also been increasing.
For many women, cesarean delivery promises a birth that is quicker, less painful, and more easily controlled by their doctors. These women and their doctors view a cesarean as just another birth choice, akin to opting for a nurse-midwife instead of an obstetrician. It’s a viewpoint that seems to be gaining popularity in recent years, in both the obstetric professional literature and among moms-to-be. It’s as common to read about celebrities who have planned their cesarean dates to fit into busy schedules — or to avoid the weight gain that can accompany the last few weeks of pregnancy — as it is to hear about the comparative risks of cesarean versus vaginal births.
But women are still six times more likely to die during a C-section than a vaginal birth, Barger says. “As a midwife, my job is to inform women fully, and then they can make a choice,” she says, “and ultimately, if a woman really wants an elective C-section, and she was fully informed, fine. But I’m not sure that in this debate, women are being fully informed.”
This article appeared originally in the spring 2005 SPH newsletter Health Sphere.
29
April 2005
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