The following article, written by editors Kiki Zeldes and Judy Norsigian, was published in the September 2008 edition of the journal Birth. It is posted with permission from Birth and from Blackwell Publishing.
Encouraging Women to Consider a Less Medicalized Approach to Childbirth Without Turning Them Off: Challenges to Producing “Our Bodies, Ourselves: Pregnancy and Birth”
The idea for creating a book focused solely on pregnancy and birth began in 2005, as we were writing the 35th anniversary edition of our flagship book, “Our Bodies, Ourselves.” Frustrated by the space constraints that forced us to cover topics such as childbirth, aging, and sexuality in only a chapter or two, we began to think about creating “single-topic” books that would allow us to cover certain topics in depth. Two years later we published our first single-topic book on menopause. Then we turned our attention to pregnancy, birth, and the early months of mothering.
To begin, we called a few brainstorming meetings and gathered together mothers, doctors, midwives, doulas, childbirth advocates, and Our Bodies Ourselves staff and board members to ask key questions and explore what content would be most useful. What kind of book was most needed now? What was missing from other childbirth books? What were criticisms of other pregnancy books? What could we offer women that would be different from the other resources out there? What should our core messages be?
We heard the following: I want a book that celebrates birth. I want to hear lots of birth stories. I want a book that inspires confidence in women and reassures them that for the vast majority of women, childbirth is a normal, healthy process. I want women to question the high-tech birth that is so common in the United States today. I want them to know they have choices other than the medicalized births standard in most hospitals. I want women to understand the many social, economic, and political factors that shape and often constrain their childbirth choices. I want to give women something they’re not often offered: tools to help them increase their chances of having not only a safe but a positive and satisfying pregnancy and birth experience.
Many of those gathered had worked on previous editions of our books, and so, not surprisingly, were in agreement with the core principles of Our Bodies Ourselves: to provide women with clear, accessible, research-based health information; to critique the medicalization of women’s bodies and lives; and to inspire and empower women to become engaged in the political aspects of sustaining good health.
But when the discussion turned to how to convey the birth messages on which we all agreed, we heard more conflict: Yes, I want women to understand that birth is inherently a safe and satisfying experience, but I want women who don’t have the childbirth experience they envisioned to know that it isn’t their fault. Yes, most women and babies do just fine, but birth is, at its core, unpredictable, and complications sometimes occur, even when you do everything ‘‘right.’’ I don’t want women to feel guilty for their choices. Yes, I want to show women what birth can be, but how do we address the needs of the vast majority of women who give birth in traditional hospital settings with little or no access to alternatives?
We left these meetings hopeful and a bit daunted by the magnitude of our task. We took a breath and plunged into a two-year project that involved more than 130 writers, photographers, and content reviewers –and many tough decisions.
HISTORY OF “OUR BODIES, OURSELVES”
The origins of “Our Bodies, Ourselves” go back to 1969, when a group of women met at a women’s liberation conference in Boston, in a workshop on women and their bodies. They shared stories about their sexuality, their relationships, their bodies, and their health. When their time ran out, they still had much to say and decided to continue to meet.
Over the next several months, the group realized they were profoundly ignorant about the most basic aspects of women’s sexual and reproductive functioning. They began to read medical articles and talk to doctors, researchers, and public health workers to learn more. They began to ask questions about common procedures such as hysterectomies, cesarean sections, and the use of hormones. They found, to their great surprise, that not only did they know very little, but that in many cases, far too little research had been done, and there were many open questions about the safety and efficacy of common medical procedures and treatments.
Realizing that the need for the information they were discovering was enormous, they turned to the New England Free Press to publish a stapled newsprint booklet to share what they had learned. Thus, the first “Our Bodies, Ourselves” was born.
Back then, few doctors in the United States were women. In 1970, more than 92 percent of all physicians were men (1), as were an even greater percentage of obstetricians and gynecologists (2). Those figures are radically different today, with women making up about 28 percent of all physicians (1) and an unprecedented 75 percent of those now training to be obstetrician-gynecologists (3). The influx of women and the impact of feminism have helped lessen the condescension and paternalism that were once so rampant. More research on women’s health has been done, and women have been included in many more studies of general health concerns.
However, access to accurate health and medical information still remains an issue. Whereas women’s health is now openly discussed and information widely available, too much of what we read and hear is created or biased by pharmaceutical and medical device companies. Medical care in the United States too often focuses solely on surgery and medications, rather than on prevention, self-care, or strategies for managing illnesses. And as was true when the women’s health movement began, women’s life experiences — such as childbirth, menopause, and aging — are too often viewed and treated as diseases, rather than as natural life processes.
BACKDROP OF CHILDBIRTH IN THE UNITED STATES
In the United States, women routinely confront negative and distorted ideas about birth. The media have increasingly adopted a view of childbirth as fraught with peril, each birth an accident waiting to happen. Highly medicalized birth is now the norm for most women, and the perception is that they should fear birth — or at least worry about it incessantly. Many women believe labor and birth will involve insurmountable pain and suffering that can be controlled only with an epidural, and that a medicalized, high-tech birth is the best and safest option for them and their babies. The question was how to counteract these messages and to instill a voice of reason.
Women are profoundly uninformed about the risks posed by unnecessary birth interventions (4). For example, many view elective cesareans as safe — or even safer — than a vaginal birth for an uncomplicated low-risk pregnancy. Some of the book’s contributors felt that the book went out on a limb in stating that cesarean births pose more risks to mothers and babies than vaginal births. They argued that the evidence did not clearly support this. Other contributors interpreted the data differently.
Since our manuscript was put to bed, we have learned more about these risks; for example, one recently published study found that the neonatal death rate for babies of low-risk mothers who had cesarean deliveries is 2.4 times higher than that of babies whose mothers had vaginal births (5). Another recent study found that women who had cesarean deliveries were 44.7 percent more likely to suffer a stroke in the 3 months after birth than those who had vaginal births (6).
We also tried to address the commonly held belief that a cesarean birth is less painful than a vaginal birth. Most women are not aware that the pain of a cesarean birth may extend well beyond the postpartum period. A recent Birth article on postpartum problems showed that 18 percent of women who had a cesarean section reported pain at the site of the incision 6 months after surgery (7). The authors noted that although fear of pain can be a huge factor in the small number of women choosing cesareans without a medical reason, ‘‘Far less attention has been paid to alerting mothers to problems associated with recovery from surgery in the postpartum period at a time when she is also caring for an infant’’ (7, p. 23).
WRITING THE BOOK
In creating the book “Our Bodies Ourselves: Pregnancy and Birth,” we faced challenges we’ve confronted during each edition of the primary text “Our Bodies, Ourselves”: How do we fit all the practical and medical information and still have room for the personal stories, which are the heart of our books, as well as a critique of how our health care choices are constrained by political, social, and economic forces? How do we reflect the diversity of experiences, so that women whose pregnancy and birth stories have traditionally been ignored or silenced — single women, lesbian couples, HIV positive women, women who are experiencing violence or abuse — feel included?
Somehow, even though we now had a whole book to devote to pregnancy and childbirth, there was still never enough room for all the rich debates, deeply felt personal experiences, and scientific research and analysis that we wanted to include.
Our book encourages women to be better informed and to choose a caregiver and place of birth that matches their philosophy. We also wanted to make sure that this philosophy was grounded in an accurate understanding of the best available evidence. Sometimes, when ongoing controversies precluded any definitive statements about an issue, we included varying viewpoints for the reader to consider.
Language and Perspective
Probably our biggest challenge was to find a tone and style that didn’t alienate women or make them feel judged. We decided early on not to use the phrase ‘‘natural childbirth,’’ since the word conjures up negative associations for far too many women. ‘‘What does that mean?’’ one woman asked rhetorically, at an early gathering of mothers, ‘‘My birth was ‘unnatural’ because I had an epidural?’’
We worked with many writers and reviewers and mothers to identify and eliminate language that could contribute in any way to making women feel guilty. In the end, we used the phrases ‘‘physiological labor and birth’’ and a ‘‘less medicalized approach to birth.’’ We included a wide range of voices, from those who felt their contractions were ‘‘surges of energy’’ to those who felt like the pain was unending and unbearable.
We made a strong effort to discuss the potential harms of unnecessary interventions while avoiding language that contributes to a mindset that birth is a moral issue. The quest is to have a good birth experience, not to be heroic. Birth isn’t about a woman’s success or failure as a woman, nor is it about whether an individual is strong or tough enough to do it without interventions. The questions we wanted to raise were whether the routine use of certain interventions was truly helpful to mothers and babies and whether women were aware of the array of birth techniques and approaches that optimize outcomes. Using women’s personal stories helped us forge a tone where women felt supported and understood, not judged:
At first I was really scared of labor. I knew I wanted a birth as free of interventions as possible, but I thought this meant I had to be some kind of Amazon who squatted in the field, grunted out her baby, then stood up to pick the crops. Or else a superfit marathon runner who had endless endurance and tolerance for pain. But the more I learned, the more I talked to other women, and the more support I got from my midwife, the more confident I felt. I took great comfort in the fact that women have been giving birth forever — every one of us had a mother who managed to birth us!
We struggled with how to challenge readers in a supportive way to think outside the box about birth. We didn’t want to alienate our readers, yet we needed to reach them with information they were not getting from mainstream sources. One approach we used was to describe the forces that conspire to keep women profoundly uninformed about the risks of unnecessary birth interventions. We also talked about the things that all women deserve and factors that increase a woman’s chances of having a safe and satisfying birth: access to prenatal care, healthy food and time to rest and exercise; childbearing leave; clear and accurate information about pregnancy and birth; encouragement, love, and support from friends and family; and skilled and compassionate health care providers. It is about ensuring that all women have access to the support, care, and information that lead to positive birth experiences.
Coping with Pain
Evidence-based research shows that routine use of epidurals, continuous electronic fetal monitoring, and certain other procedures can cause problems. Although most women who have epidurals do fine, as do their babies, there are risks. Most books and many doctors present having epidural analgesia as a completely safe option; we wanted to address this discrepancy and look not only at the efficacy of epidurals, but at the potential risks.
We also wanted to cover aspects of pain that are frequently ignored or given short shrift. The book explores the kinds of pain laboring women experience, offers different ways of thinking about pain, and provides extensive information about underused and safe comfort measures and coping strategies. We point out how a woman might begin with no risk or very low-risk methods and progress to more interventionist methods only if necessary. We discuss the differences between labor pain and other types of pain, and the difference between pain and suffering.
In the section on epidurals, we included details about the small but not insignificant potential risks, including longer labor and an increased risk of having a forceps or vacuum delivery. One anesthesiologist who reviewed the chapter thought that we gave too much space to the rare harms of epidurals. After much discussion, we decided to include the full list, to counteract the prevailing mindset that epidurals are a no-risk, sure-fire way to manage labor pain.
We believed it was important to carefully examine other options for women who need pain relief beyond low-tech comfort measures and coping strategies. For this reason we decided to include a somewhat controversial sidebar on nitrous oxide written by Judith Rooks and Tekoa King and reviewed by Mark Rosen, an anesthesiologist at University of California, San Francisco. Another anesthesiologist who reviewed the sidebar had concerns about the safety of nitrous oxide and didn’t think we should include the information. We decided that advocating for additional research and the reintroduction of nitrous oxide was wise, and in the end, the text reflected what we did and didn’t know at the time. (Since publication, the dialogue on nitrous oxide has continued at our blog.)
The Natural Flow of Labor and Birth
One of the biggest controversies occurred around the chapter on giving birth. Some contributors wanted the chapter to follow the natural flow of labor and birth that can occur without medical interventions, to emphasize what is possible when women give birth with support and help from skilled caregivers who have low rates of intervention. Others argued that such a birth was uncommon in the United States, where most women experience interventions, and we should therefore describe birth as it is for most women, not as we wish it would be.
Finally, we attempted to do both. The labor and birth chapter focuses primarily on the natural progression of labor, but includes information on common interventions such as continuous monitoring and IVs. A second chapter, Special Concerns During Labor and Birth, gives attention to the range of complications that can occur and the interventions that are supported by the best evidence.
Breastfeeding was another hot topic. How do we discuss the multitude of breastfeeding benefits to mothers and babies without contributing to the guilt that some women who can’t or don’t choose to breastfeed might feel? Again, focusing here on the politics helped. We talked about the many forces that undermine women’s ability to breastfeed successfully: the discouragement some women face in the hospital; the free formula handed out to new mothers; the lack of legal protections for nursing mothers; and the lack of clean, accessible workplace spaces where women can pump. We discussed Baby-Friendly hospitals, women’s feelings about breastfeeding in public, and how to find support and help. The focus was not on convincing women who don’t want to breastfeed to do so or on contributing to the guilt of women who can’t, but on addressing the obstacles that keep many women who want to breastfeed from doing so.
What is Possible?
In the early planning discussions, some participants expressed concerns that by advocating for a birth led by the natural rhythms of labor we were setting up for failure the large percentage of women who give birth in a traditional hospital setting. By encouraging women to believe their choices will shape their childbirth experience, were we discounting the many political, economic and social factors that are beyond a woman’s individual control? Were we creating expectations and desires that can’t possibly be met in a traditional setting?
We took these concerns to heart, yet we wanted to inform women that places exist where the natural flow of labor and birth is respected, and we wanted to underscore that the midwifery model of care is an option for many women. For example, at Group Health in Seattle, Washington, where nurse-midwives attended 60 percent of births in early 2008 and the overall institution had a 12 percent cesarean delivery rate, many women have had births with minimal interventions.We share the view of midwives who produced a 2007 documentary, ‘‘It’s My Body, My Baby, My Birth,’’ that it is crucial to offer images and stories of women who have had such births and who can speak eloquently about these experiences.
Certainly enormous obstacles are present to establishing hospital-based settings that support the choice of less medicalized childbirth, but the stakes are high here. If practitioners don’t reduce the primary cesarean delivery rate, if advocates don’t fight for the option of vaginal birth after a previous cesarean, then the U.S. maternal mortality rate will rise, and women’s choices for safe and satisfying births will dwindle even further. That is one reason why our book included the stories of activists like Barbara Stratton, who worked with other community women to restore the VBAC option in her community hospital in Maryland. Such reform can happen with good organizing and advocacy.
“Our Bodies, Ourselves: Pregnancy and Birth” was published in March 2008, accompanied by a 33-city book tour that produced overwhelmingly positive feedback. Women have told us that in contrast to other books that scared them unnecessarily, our book felt much more positive and informative, setting just the right tone for them. We hope that this book — along with other texts such as “Pushed,” by Jennifer Block (8), and Tina Cassidy’s “The Surprising History of How We Are Born” (9) — will help shape a very different cultural discourse about pregnancy and birth. We still dream of creating a ‘‘climate of confidence’’ rather than a ‘‘climate of doubt’’ for women and their loved ones, as they progress through the life-changing experiences of pregnancy and birth.
We, the authors, also believe that much greater access to midwifery care in communities across the country will be a key element in improving birth outcomes as well as women’s satisfaction with their births. Doulas and other sources of labor support can play a critical role as well.
Although the vast majority of women do not choose out-of-hospital birthing alternatives, such as home birth and free-standing birth centers, these options remain important beacons for childbearing families. They continue to offer safe and less medicalized birth alternatives that many women seek, and their very existence helps to show more clearly how hospitals could improve their outcomes. Advocacy for the full range of safe and satisfying birthing options will remain at the top of our agenda for years to come.
We thank Christine Cupaiuolo, Heather Stephenson, and Rachel Walden.
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