What Do You Think?
Editor's note: This is the final installment of responses to a news item
[Issue 3:23] about an American obstetrician who believes vaginal birth creates
"needless" pelvic floor disorders later in a woman's life. The news
story appeared to favor cesarean section as an acceptable alternative.
The overriding medical paradigm still acts as if women's bodies are defective
and teaches women to dissociate from their bodies from an early age so that they
don't trust their own wisdom about how to birth. Nor is the variation in natural
processes and knowledge sufficiently regarded as the basis for obstetrical protocol.
Why then be surprised that some of these women are unaware of how to prepare for,
move through and heal from intrusive birthing practices?
How fortunate that medical professionals can now accurately document the damage
their practices induced. And of course the implication is that women's bodies
are faulty and will need "protection" from those inherently high risk
We do not assume all hearts are defective and need to be surgically altered
or replaced by pumps simply because SOME (the ones with heart-weak constitutions)
cannot function well when the effects of toxic lifestyles and dissociation from
emotional stressors cannot be corrected by surgery. Rather, risk factors and ineffective
therapies are identified and environment taken into account.
Why not be proactive and provide opportunities for women to rediscover, explore
and teach each other the beauty and power of their body and birthing wisdoms,
evolved from eons of genetic pressure? Women's bodies and birth work in MANY cases
because we have evolved for it to work or we wouldn't be here. What works survives.
There will always be variation in the "norm." Some will be superbirthers,
some poor birthers. We are not carbon copies in uniform environments. It is when
interference outstrips the body's ways of dealing with change that health is compromised
on both the physical and spiritual levels.
Perhaps it is too audacious to suggest that the intervening 20 years' worth
of hindered wisdom, further dissociation and nonsupportive healthcare practice
also contribute significantly to the final dis-ease state. Having worked for the
last 15 years within a healing paradigm that recognizes individual physical constitutions,
I believe that women vary in their health potential, and that some women are more
susceptible to carrying long-term damage into their reproductive organs. But more
surgical births are not the answer.
- Julei Busch, B.Sc., S.C., midwifery student
The research states there is no difference in perineal floor damage for cesarean
vs. vaginal delivery at 40 weeks. Apparently it is the weight of the baby during
the last four weeks of pregnancy that may cause urinary sphincter tone loss and other pelvic floor damage. In order to prevent this damage, the c-section must
be done at 36 weeks.
This means OBs are not taking into consideration the prematurity factor, which
in the case of elective cesareans is a "preventable" neonatal complication.
The Hippocratic Oath to "first do no harm" has been ignored. How many
newborn infants will needlessly die from routine cesareans performed at 36 weeks?
I am sure as the 36-week cesarean increases, the neonatal death rate will increase.
This is certainly another argument to do away with OBs and send all pregnant
women to midwives, let midwives refer the "high risk" women to perinatologists,
and let the obstetrician revert to just being a gynecologist.
- Sandra Stine, CNM
The very idea of this doctor's proposal burns me more than my son's 15"
head did! I have had seven natural deliveries and I have been scolded because
my pelvic muscles are still tight. This man would not be able to even try such
a scheme if women didn't embrace it hook, line and episiotomy. I am appalled by
the number of women who still believe obstetrics is synonymous with godhood. A
large part of this acceptance is ignorance and a belief in myths. I have been
told more times than I could remember that since one's mother had to have everything
either tacked back in place or removed, then she probably will, too. There are
many who don't want to learn any further than what their OB has told them. It
can be extremely frustrating when I try to talk with them about a more natural
It seems to be a process of educating one woman at a time. And it can be a long
uphill road when the area medical staff are not mamatoto [mother-baby] friendly,
regardless of the sheep's clothing they wear. The high rate of cut perineums,
extractions and sections speaks for itself. One mother at a time, we need to teach
women that God made their bodies to function with strength. We need to teach them
how to listen when their body is speaking, building that bond between mother and
child so the little one arrives to rejoicing even if through pain instead of being
viewed as "a royal pain" before they are born. Women are cut apart from
their children as they are being "delivered" and society racks its brain
to understand why child abuse is soaring.
- Mel, agent of social change
It seems there has been a significant change in the instructions birthing women
get right at the stage of crowning. When my child was born 23+ years ago, I'd
read somewhere that if I felt the stinging sensation, I should react by NOT pushing
for an instant--just drop back a little. That happened, I did it, and didn't tear
or need any cutting. I was 38 at the time, which was considered "elderly"
back then. However, I was at home as well and the midwife did extensive perineal
massage for the whole pushing stage. These days, women are urged to "push
through the stinging." I think that's wrong and a contributing factor to
Also, the phrase "get the baby out of there" sounds good to a woman
who is worn out. The phrase sounds so benign, unlike the process of major surgery.
- Suzanne Fremon, doula and hypnobirthing practitioner
I highly recommend finding a copy of the book "Episiotomy and the Second
Stage of Labor" by Kitzinger and Simkin and reading it cover to cover.
- Natalya Lukin, CPM
Mill Valley, CA
It is one thing when doctors cite true medical reasons for a necessary cesarean.
It is another when they shout "convenience" and "women's right
to choose." ....Doctors want to give choice to women, freeing themselves
from having to contrive a diagnosis to explain and excuse a cesarean. Obstetricians
are not trained in normal, natural birth practices, obstetrics being a surgical
field. The cesarean section has become the solution to any and all "problems"
that may arise in pregnancy and labor. It makes the justification easier if they
can claim "Patient Choice Elective Cesarean" as a reason for the surgery.
Obstetricians blame the mom for unnecessary surgery they themselves perform, as
the abuser blames the abused for the act of violence.
Does the use of informed consent protect women from manipulation and coercion
from the doctor? OBs are well aware that they can "consent you into making
whatever decision they are more comfortable with," according to a local physician.
Just a few choice words spoken with emphasis, such as "Your baby will die
if you go into labor" or spoken with detachment, such as "It doesn't
matter" leaves the decision up to the patient, and can persuade a mom to
choose whatever the doctor wants her to. Doctors hold an authoritative position,
which gives weight and power to their opinions, easily overriding the mother's
opinion, desires, and rights.
An administrator at a local hospital is quoted as saying, "The most cost-effective
way to deliver babies would be to schedule every one of their births. Line them
up, Monday through Friday, from nine to five." He added he was not advocating
it. Interesting though, isn't it?
....The physician sees the real benefits of elective patient choice cesareans,
not the birthing family. Obstetricians will continue to encourage the birthing
mom to sacrifice her body on the operating room table until women begin to take
responsibility for their birth.
- Pam Udy
DOZEN: Read Nancy Wainer's remarkable article about c-section and VBAC.
Read more great articles from Midwifery Today issue 57: VBAC and Cesarean Prevention
Check It Out!
A Web Site Update for E-News Readers
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Midwifery Today's Eugene 2001 conference
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PLUS, two new tape packages are based on two of the Eugene preconference classes:
Influences on Labor Tape Package
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Humane Hospitals/Tricks of the Trade in Hospital Birth
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Durango, CO August 20 and 21, 2001
Critical issues in pregnancy and neonatal care with current interventions for
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Midwifery Today's Online Forum
Could we discuss birth language--words that are routinely used that might block
a woman in a subtly negative way e.g., deliver: pizza, not babies. I prefer the
word BIRTHING the baby; contractions: sensations; ruptured membranes: released
membranes; false start: warming-up sensations?
Forums Reply: Oh yes language is SOOOOOOOOO important!!
Every aspect of our ability to care or be cared for boils down to communication
Empowered birth after Caesarean (as it could be deemed as failure to not "succeed"
and have a vaginal birth after trying.)
To share your thoughts and experience, go to Midwifery Today's Forums. Click on "Aspiring Midwife Chat" and "Birth
Language." PLEASE DO NOT SEND YOUR RESPONSES TO E-NEWS!
Question of the Week
Editor's note: E-News received several wise and heartfelt responses to
last week's question about how to comfort a pregnant/birthing mom who has a history
of having been sexually abused. The responses will become the main feature of
next week's edition of E-News. Our sincere thanks to all those who offered their
Send your responses to:
Midwifery Today Magazine Question of the Quarter
What are the essential elements of good prenatal care? How does prenatal care
create better birth? As a midwife/doula, what do you hope to accomplish in the
prenatal period with a pregnant woman?
Please submit your response by June 30, 2001 to firstname.lastname@example.org.
Your responses will be considered for publication in Midwifery Today, our quarterly
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Re: dilating "on time" [Issue 3:24]:
Emmanuel Friedman, an obstetrician, did a study of women in labor. Having the
inability to birth, he assumed that averaging women's labors would predict the
safest delivery. This curve states that dilation under 1.2 cm/hr for primagravidas
and 1.5 cm/hr for multiparas is abnormal. This study is the basis for hurry-up
obstetrics seen in the hospital setting today. Of course, it would never occur
to physicians to allow each woman to birth in her own time--that would not be
profitable for hospitals and physicians. Anon needs someone telling her she can
do it, not echoes of doubts that implant images in her mind that she is unable
to keep up with the rest of Friedman's curve. In the absence of fetal distress,
she should just say no to the cesarean section.
- Lynda Comerate, RN, BSN, PHN, LCCE, HBCE
When talking about VBACs, the birth attendants and midwives I know prepare VBAC
women to have slower labors than their friends. Many of us theorize that the wise
uterus will create a gentle labor to put less strain on the incision.
- Karen Ehrlich, CPM, LM
More on the language of pregnancy and birth [Issues 3:24 & 25]:
I am a practicing chiropractor and my wife is a CPM. It seems to me midwifery
is undergoing many of the struggles my own profession went through not so long
ago. May you learn from our successes and failures.
One of the more subtle ways professions become assimilated is by adopting the
language of medicine to describe non-medical events. It is a very slippery slope
regarding professional identity. There are many historical examples of this in
chiropractic, osteopathy, nutrition, etc. Though I am not an expert in the politics
of midwifery, I do see some disturbing shifts toward assimilation. For instance,
each protocol that relies more heavily on lab work and/or diagnosis shifts the
professional focus from health to disease. Dangerous territory. Diagnosis and
treatment of disease is clearly the practice of medicine.
Who will define the terms of practice for midwives? State regulators? (Anyone
following the struggle in North Carolina or Indiana may have a sense of how scary
this can be.) MANA? Accredited midwifery schools? Practicing midwives? Your clients?
Though it may seem easy to pass terminology off as semantic nonsense, very clear
and unique definitions of professional objective and central area of interest
are crucial as a profession grows and attempts to gain legal footing. What exactly
is it that makes midwifery unique, distinct, and not part of or a subset of any
other profession? The daily language used to describe the philosophy, science,
and art of midwifery should reflect your uniqueness and objectives. This is the
very beginning of winning the ability to practice free of medical interference
and/or control. With these clear professional boundaries established, I even think
that it could be argued that OBs who care for women with uncomplicated, normal,
natural pregnancies are practicing midwifery without a license. Don't sell yourselves
- Brad Eldridge, DC
El Paso, TX
Can anyone suggest articles/books to support the claim that midwives have lower
episiotomy rates than OBs and better outcomes? I am teaching a birth class and
one husband (in med school) wants the "proof."
I recently heard about a town near London, Ontario that is having an obstetrician
crisis. In order to give these caregivers a day off, the obstetrics department
is having to close for about one weekend a month. If I lived in that town, I would
volunteer as a doula at the hospital during those hours to help cover for emergencies.
I wonder if the hospital has considered putting these doctors on call, and bringing
in doulas for the regular hours to cover for them? Is this practical?
I just read that Congress is planning to open another round of HMO debate.
It wants to provide ALL Americans with health insurance. This looks pretty benign
on the surface and sounds wonderful. But is it so wonderful for maternity care?
How many who women call requesting homebirth services are covered by major insurance
companies and are denied homebirth services? Direct-entry midwives aren't reimbursed
at all. [Even with a CNM, the client has to get a letter from the doctor in the
third trimester, belong to the PPO list, and be a medicare/medicaid provider].
How many physicians are willing to "front" their imagined liability
of homebirth? Very few. And how many women actually need that permission, medically
speaking, who give birth at home?
CNMs are reimbursed about $600 for a home delivery. The cost of a hospital birth
to "out of pocket payers" is $5,000+ depending on services. Prenatal
appointments are made in a centralized location, are 5-8 min in length, and the
woman gets "policy and procedure" standardized births. Homebirth is
time-intensive, and labor is often long and tiring, especially for a first birth.
$600 per birth doesn't cut it! Would Medicaid reimburse DEMs as much as CNMs?
$600 is an insult and barely covers my expenses.
Congress is not thinking about "homebirth" or midwifery care. They
have their minds on other agendas, mostly medical. They are influenced by the
AMA. They lump prenatal care into an "illness" category.
Clients who are now "private pay" would have the "Medicaid"
option. Sadly, maternity services for all Americans would leave out the "homebirth"
option, except under physician consent. The DEM and CPM are left out of the loop.
We need to act as a group. WE need to address Congress about the need for all
women to be provided with the opportunity to have a homebirth with a DEM, CPM,
CNM (midwife of clients choice). How can Congress know there are alternatives
that work if we don't do our part to inform them? It is important for us to begin
the process of unification, rather than divide our energies state by state.
- Sandra Stine, CNM
Re: the woman with acute glomerulonephritis [Issues 3:22 & 24, in which
three E-News readers responded by suggesting evalution by a specialist, sufficient
hydration, supplements, and high protein intake]:
This is a concerning exchange to have been published. This issue is being discussed
as if it is normal and desirable that homebirth midwives should be taking care
of women with severe kidney disease instead of referring them for medical care.
The philosophy here seems to be "homebirth as the first priority" rather
than safety as the highest priority. What special knowledge/training qualifies
each of these women to be experts on pregnancies of unhealthy women? Is this what
is meant by "each one, teach one"? I hope that this was an oversight.
- Ina May Gaskin, CPM
The abdominal massage described in Issue 3:25 for constipation is also a lifesaver
for really painful gas that you can feel bubbling around in there. You practically
can feel the bubbles descend as you massage.
- Susan Skinner
EDITOR'S NOTE: Only letters sent to the E-News official email address,
will be considered for inclusion. Letters sent to ANY OTHER email addresses will
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Midwifery Today: Each One Teach One!