I recently picked up a copy of the new book, Birth Matters: A Midwife’s Manifesta by Ina May Gaskin. Her practice was based on principles of prevention and wellness, as well as a focus on both the physical and emotional needs of laboring mothers. Appendix D of the book shares the birth statistics for The Farm Midwifery Center from 1970-2010. I had previously seen the stats through the year 2000, but was again astonished at the amazing outcomes the practice was able to achieve.
There were 50 cesareans out of 2,844 births.
Their practice included women who had breech babies, twins, and VBACs (vaginal birth after cesarean, which incidentally had a 96.8% success rate). In general maternity care in the US, these factors classify many women as high risk and often result in automatic c-sections performed by doctors who are unwilling or unable (due to training issues) to attend a vaginal birth attempt.
These and other issues have caused the cesarean rate to climb each of the last 13 years to its current 33%. (Though I have noted rates in individual hospitals ranging from 9%-72%). A cesarean section is usually not the end of the world (and can be lifesaving in a true emergency), but it is major surgery that carries risks to both mother and baby. Immediate risks to cesarean birth include a 19% post-operative infection rate, compared to a 3% rate for vaginal births (according to the 2005 listening to mothers survey). Babies born by c-section have more respiratory illness, asthma and lower rates breastfeeding. Additionally (to say nothing of the difficult physical – and sometimes emotional – recovery while adjusting to life as a new mom), the risk of complications with future pregnancies looms. Placental abnormalities can result in future miscarriages and other complications, as well as, of course the potential for uterine rupture. So, if a large number of unnecessary (or preventable) cesareans are being performed, mothers are experiencing higher rates of these related complications. This likely plays a role in the United States being ranked 50th in the world for maternal mortality (despite spending the most money on maternity care).
Many would argue that the numbers from The Farm Midwifery Center cannot be compared to the general U.S. rates. I do understand that the women represented by these numbers opted into this practice. They weren’t just ‘any women’. They embraced the midwifery model of care and were highly motivated to participate in this preventative, wellness model of care. A random pregnant woman off the street may not be in a place emotionally to have this type of birth experience. She may not even desire it. But does she even realize that she has a choice? Does she even realize how possible and safe and rewarding natural birth could be with a different approach to maternity care? If she is giving birth with a typical Obstetric practice, she certainly would not have the type of education and support offered to the women at the Farm . . . but don’t these numbers tell us what is physically possible?
Of the nearly 3000 women, 98+% gave birth vaginally. Certainly we can’t expect every maternity caregiver to start producing these types of results, but doesn’t it plant the seed that we could do better? Ina May Gaskin’s pioneering efforts show us that it is possible for women to have healthy and empowered births that look something like this.
Unfortunately, even women who plan to labor in hospitals with minimal interventions are faced with many routine procedures that impede the natural process and result in a highly medical experience without proven benefit. Many low risk women end up having cesarean sections and other interventions, in large part, because of their providers’ style of care. I believe that there are many who have these experiences, not because they consciously chose them, but because they don’t even realize that they have a choice.
There is certainly a point when interventions are necessary and appropriate, but for many doctors and midwives, interventions are done routinely. I question where that line has been drawn by many of these providers. “Ina May Gaskin has gained an international reputation in obstetrics for demonstrating the magic key to safe birth: respect for the natural process.” I would argue that “respect for the natural process” is what is missing from maternity care in the United States today.
We can do better.