There was a time, not so very long ago (early 1900’s), when the majority of pregnant women in North America gave birth at home, attended by a midwife. Roughly 95% did. Then in 1955 that figure became the number birthing in a hospital. What happened? What brought about this dramatic decline in home births?
During that time, a few prominent obstetricians, like Dr. Joseph DeLee, the inventor of forceps, pursued the adoption of massive universal changes in obstetric protocol for birthing women. These changes weren’t based in research studies or scientific evidence. The paradigm shift moved from the understanding of birth as a normal healthy process of biology to one of pathology. From the obstetrician’s perspective, birth was dangerous and in need of specialized care – their care.
This reframing of birth fostered two major beliefs that have become etched in our global consciousness. First that birth was risky, until doctors saved it, and second, pregnant women are sick and so naturally they should, like any sick person, rely on a physician’s help. Based on this premise came the medical ‘technocratic’ model of birth. Viewed through this lens it defines the body as a machine, birth as pathological and mechanistic. There is the use of aggressive intervention for short term results, and pain medications, which disturb birthing hormones, increasing risk of complications in a normal labour. This is an ‘illness’ model, with the patient as object.
Certainly it’s not so black and white as this. Among maternity care providers a blending of these two models can operate. The humanistic model isn’t solely attributed to midwives. Regardless of which model is practiced, the primary focus that must be at the forefront of care is respect for a woman’s autonomy.
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Conversely, the ‘humanistic’ or midwifery model defines the body as an organism, and birth as a normal physiologic experience. This model takes an evidence based approach; promotes birthing hormones which optimize safety, benefitting both birthing mother and baby. This is a ‘wellness’ model and one that is relationship-centered.
With the change in birth setting, the hospital required women to labour in bed, on their backs, with legs strapped into stirrups. Obstetricians routinely did episiotomies and used forceps. Women were also often drugged to make them compliant. These conditions were a huge departure from how women had been birthing. Surrounded by the comforts of their own home, they had the freedom to move and adopt various positions that aided their natural labour process. It was a family centered, not a medical, event. The birth attendants were there to assist, if and when needed. It’s not surprising that with institutional restrictions came increasing difficulty to birth normally, which brought about complications. As expected, women needed more medical assistance and pain medication use rose.
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Since those initial years when birth moved from home to hospital there has been an ever increasing use of intervention and surgery. This is a growing concern internationally because interventions may lead to iatrogenic effects; iatrogenic effects meaning unintended consequences of the intervention. As an example, in a large review published in 1987 covering tens of thousands of births in Australia, Europe and the US, it was found that the only statistically significant effect of continuous foetal heart monitoring during labour was an increase in the rate of Caesarean and forceps deliveries.
A pregnant woman sits in bed in a hospital birth center during her natural child birth laboring process. She is wearing a fetal monitor to check the vital signs of the baby. She has been laboring for about six hours, but the baby will not be delivered for another 20 hours. (Daniel MacDonald/Getty Images)
Currently, obstetric interventions are overused and misused in many maternity settings. When we examine birth practices today, particularly in institutions, we still see more than two-thirds of women give birth in the supine position, despite evidence that this position increases the likelihood of instrumental vaginal delivery and episiotomy. More than half of all birthers receive synthetic oxytocin to induce or augment labour, which increases the risk of caesarean. One third give birth via surgery – caesarean section.
The rate of caesarean birth in Canada has risen dramatically over the past few decades, a trend consistent across other developed countries. The Canadian caesarean rate has risen steadily since the mid 1990s, from 18.7% in 1997 to 26.7% in 2007 and then to 28.2% in 2016.The caesarean rate in British Columbia is the highest in Canada, at 35.3% in 2016-2017.
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When medical intervention is necessary, and there are situations certainly where it is, caesarean birth, for example, is life-saving. It’s not the use of technology that is under scrutiny, but the over use, leading to complications in otherwise normal labours and births.
Too Much, Too Soon: Addressing Over-Intervention in Maternity Care by Nancy Chong
Doctor Nails Reasons Behind 500% C-Section Increase Since The 70s by Maria Pyanov
Even with recent efforts to implement changes there is an emerging population of new mothers sharing their stories of ‘birth trauma’ and what is termed ‘obstetrical violence’. These stories are becoming more prevalent. Unless the rampant over medicalization of birth ceases, this will be the reality of our birth culture. We are at a turning point. We can no longer afford to adhere to an outdated paradigm of birth as a pathology, where birthing women are managed and their labour controlled; where a cascade of routine interventions leads to unnecessary surgery; where a risk averse attitude instils fear leading to unnecessary harm. A new paradigm is needed.
Part of this ‘new’ paradigm (birth as a healthy physiologic process) is the resurgence of midwifery care. The return to midwives, care providers that are not only highly respected , but the predominant providers for birthing women, brings benefits for upcoming generations of healthy pregnant women. Research studies show that midwifery care has lower rates of intervention and caesareans, with low pain medication usage.
A Caesarean Birth
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by Bethany Lindsay
Midwives Association of British Columbia - Midwifery Care
The current shift in awareness means inquiring minds are also questioning our culture’s belief that the safest place for birth is the hospital. At this point with the climbing rates of caesareans and interventions, birthing in a hospital can be risky for healthy pregnant women. A 2018 research study involving 500,000 labouring women showed only 38% had a spontaneous vaginal birth without any type of intervention.
There have been seventy years of institutionalized birth compared to thousands of years of home birth. Home birth is not a trend. Research into birthing at home shows it to be safe for low risk healthy pregnant women. The hospital is the optimal setting for those with pre-existing medical conditions, or conditions that occur during the labour process, which put them at risk. Yet for healthy pregnant women, their home or a birth centre are safe alternatives. This movement away from institutionalized birth is gaining momentum. Although a small percentage of total births, home birth rates are increasing.
Home birth with midwife not riskier than hospital birth: study by Sheryl Ubelacker
It’s also a movement that has educated and well informed women desiring a physiologic birth,viewing birth as a healthy normal process and not being influenced by fear – a fear that is escalating to terror, perpetuated by our society. We are coming full circle. As it stands today, physiologic birth in many industrialized countries is in danger. Our reliance on technology and our belief that it is superior to nature is wreaking havoc for birthing women and their babies. That, combined with the belief that birth is a medical emergency waiting to happen keeps the old paradigm intact. The work to be done is to de-program. Fear runs deep in the collective unconscious.
SOGC Statement on Planned Home Birth February 2019
But a consciousness is awakening that remembers birth as a rite of passage, with trust in women’s bodies. Thousands of years of evolution can’t be wrong! Hopefully the pendulum will swing to attain balance: that normal birth is wholly supported, not interfered with, and medical technology is accessible when it’s truly needed, not as routine. This vision isn’t only possible, it’s imperative.
Debra Woods is a seasoned birth & postpartum doula who’s cared for more than 800 childbearing families. She has been practicing professionally for 30 years. She is also a certified childbirth educator and placenta encapsulation specialist. Mother to one son, who was born at home, she is passionate about educating expectant parents on evidence based birth. She specializes in supporting couples who believe in birth as a healthy process and desire a physiologic birth, without the use of intervention and pain meds.