A recent trip to Fort Worth and Dallas showed me a range of choices that I wish was available to every pregnant woman in the U.S. Women who live in this part of Texas can choose to give birth in a hospital, any one of several birth centers, or their own homes. A few other U.S. cities offer real birth choices as well, but there are still states and vast areas of small-town and rural U.S. where there are no midwives and no choice.
Because of the scarcity of midwives and birth choice in much of the U.S., citizen organizations have sprung up to advocate for reform. These include Where's My MidWife?, The Push for Midwives.org, ImprovingBirth.org, and Childbirth Connection. Most women choosing midwifery care are aware of the research indicating that midwifery care is associated with lower rates of medical intervention than in obstetric practice.
I became a midwife in the only way I could find in 1970 (a time when there were only one or two U.S. hospitals that employed them): I was able to locate several physicians who provided me with direct instruction in the principles and practice of midwifery. The fact that I published our outcomes (which were good) and demonstrated our techniques within medical circles provided a degree of acceptance and support even when we were comparatively new on the scene. From Ob.Gyn News, 1979: "Remarks among the physicians in the audience initially indicated a negative, almost condemning attitude, but reactions changed markedly after they listened to Ms. Gaskin and viewed the [video] tapes."
It was clear to many obstetricians then that home birth could be a kind of laboratory for innovation in birth techniques that could be used in hospitals to good advantage. The Gaskin maneuver is just one example of a home birth technique that has, according to several obstetrician friends, saved their careers while avoiding loss of life or permanent injury.
During the months since I received the 2011 Right Livelihood Award in Sweden's Parliament last December, I've been interviewed or mentioned several times concerning my midwifery work. A New York Times article put some beautiful photos together with a rather shallow treatment of home birth, Daily Beast reporter Michelle Goldberg took a dim view of home birth without shedding much light on why a fairly small but growing segment of the population of birthing women choose it, and Slate reporter Jennifer Block chided Goldberg for biased reporting. If I had just dropped in from another planet, I'd find it fascinating that something that less than 0.7 percent of U.S. women choose has caused such a furor. Is the excitement because certain celebrities have been credited for causing an increase of home birth ? Do they realize that even counting the increase, the rate of home birth is still less than it was in 1969? Are the women who are so vocal in their opposition to other women choosing home birth aware that there is no danger that U.S. birth outcomes have been adversely affected by choices made by a fraction of one percent of birthing women?
I know of no country in the world that has passed a law specifically denying a woman's right to choose where she intends to give birth. In the U.K., a woman's right to choose her place of birth is built into the midwives' code, requiring that a midwife stay with a woman in labor who refuses to be transported to a hospital, even if she happens to have chosen a forest or a hayfield as the place of birth. The priority is to make sure that the woman is provided with the maximum help available, meaning that the midwife is duty-bound not to abandon her during this vulnerable time.
I have recently spoken in several countries where the government is using police power to keep women from having home birth. Croatia, for instance, has midwives, but they are not allowed to provide prenatal care at all. Pregnant woman who have associated with women who want the choice of home birth have been visited by the police, whose main aim is apparently to intimidate her from carrying on with her plan. A visit to a pediatrician with a home-born baby, planned or not, may turn into a police interrogation instead of the requested examination of the baby. Croatia includes many inhabited islands with no hospitals. With ferries providing the main transportation to the mainland, the ferry sometimes becomes the place of birth when a woman has a fast-moving labor. In the U.K., there would be midwives on these islands.
When there is little or no access to midwives in any country, obstetrics itself becomes deskilled to a degree that alarms wiser obstetricians, who acknowledge the need for better options in birth or a strong midwifery profession. In the U.S. today, we have no way to count how many women choose an unassisted birth for lack of access to a licensed birth attendant willing and able to provide care for a woman wanting assistance with a breech, twins, a prior cesarean, or just a straightforward home birth.
When women have little or no choice in birth and birth totalitarianism becomes the new norm, obstetrics knowledge itself is reduced. I have run into reports of women who aren't pregnant who have only learned this after their abdomens were cut open for cesarean section. These women had false pregnancies, a condition that has always happened in some women but which is not diagnosed because of reduced skills.
It's not an exaggeration to say that midwifery worldwide is in danger of extinction unless countries figure out a way to reverse the current trend of ever-increasing rates of induction of labor and cesarean section. China now leads the world with national cesarean rate of 50 percent, following a trend set by Brazil, where in several cities there are private hospitals with cesarean rates of 98 to 99 percent. Midwifery no longer exists in cultures and countries where this development has already taken place. None of the countries with the highest cesarean rates has an enviable maternal death rate. Neither do we.
When cesarean rates go above the recommendations made by the World Health Organization in the mid-1980s, there is strong evidence that the lifesaving benefits that availability of the surgery provides begin to be outweighed by the dangers presented by the surgery itself. More babies begin their lives in neonatal intensive care units because they are born with respiratory problems that are directly associated with cesarean birth. More women die from complications such as accidental injury to internal organs, infection, hemorrhage, anesthesia, pulmonary embolism, abdominal adhesions leading to bowel obstruction, and placental problems in a subsequent pregnancy. The U.S. is one of four countries in the world with a rising maternal death rate. California reported a tripling in the maternal death rate between 1996 and 2006. This problem, in my opinion, should occupy more of our attention than the tizzy over the home birth rate, which affects such a small portion of our population.
We should be able to agree that women deserve to be supported on their terms. Similarly, we can all agree that open and respectful public discourse is the best path to democratic policy-making. The first amendment to the Constitution rests on the assumption that it is through the free exchange of ideas and information that good public decisions can be reached. The best a health care system can do is to equip itself to meet the needs of each individual woman and birth. Those needs run the gamut from undisturbed home birth to planned cesarean section.
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