Birth Options: Evidence Based Choices in Childbirth

Tina Overton, AAHCC, birth assistant, certified Bradley childbirth educator
Soren Huber, Co-Coordinator NotJustSkin.org
Ryan McAllister, Ph.D., Executive Director, NotJustSkin.org

Pregnancy and childbirth are incredible times in life. The physical and emotional changes they bring can be beautiful, yet a bit confusing. Information varies widely and wildly regarding health care and birth options. Knowing your options and choosing the care you deserve will positively influence your birth outcome and the overall satisfaction of your experience. Greater comfort and safety of birth is achieved when the needs of the birthing woman and her supporters are met. Here are options, some new and some time-tested, that you may find helpful in meeting such needs.

Your choice of care provider and birth place have perhaps more influence over birth outcome and overall satisfaction then any other choice you will make. Most women in the U.S. believe that the best, safest, and most evidence-based maternity care available is found in large hospitals under the care of an obstetrician. Research suggests, however, that a more intimate space and fewer interventions are safer and more comfortable for giving birth for the majority of women. When a laboring woman is subjected to powerful medications, restricted nourishment, restricted movement, and when her "progress" is invasively monitored, her own innate wisdom of birth may be inhibited. Her body in turn produces less of its normal birthing hormones causing more pain and often slowing labor leading to an increased perceived "need" for intervention.

Care Providers

Midwives: A midwife is a childbirth professional trained in the normal processes of pregnancy, labor, and delivery. A good midwife recognizes the wonder/importance of pregnancy and birth in a woman's life, and respects its normality -- not treating it as if it were a disease or sickness. The majority of pregnant women would benefit from the Midwives Model of Care, which has been shown to result in reduced risk of complication, fewer interventions, and a healthier birth for mom and baby. It is worth noting that not all midwives follow this model of care. Some work within institutions where "policy" overrides their midwifery training. As with any care provider, ask plenty of questions so that you get a clear picture of the provider's approach. For example, ask about rates of labor induction, cesarean section, episiotomy, epidural use, etc. Midwifery care can be obtained in some hospitals, hospital based "birth centers," free standing birth centers, and home birth services.

The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes and includes:

  • Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle;
  • Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support;
  • Minimizing technological interventions; and
  • Identifying and referring women who require intervention or obstetrical attention.

Research evidence for the Midwifery Model of Care can be found at:
MidwifeInfo
More info on midwives including how to find one to care for you and full text of The Midwives Model of Care can be found at:
Midwives Alliance of North America
Citizens for Midwifery
North American Registry of Midwives

Doulas: Doula comes from the Greek word meaning "Woman Servant." There are generally two different kinds of doulas, birth and postpartum doulas. A birth doula is a woman trained and experienced in childbirth who provides continuous physical, emotional, and informational support to a woman prior to birth, during labor, and during the immediate postpartum period. A postpartum doula is trained to care for new families in the first weeks after birth providing household help, advice with newborn care and infant feeding, and emotional support. The benefits of continuous labor support are impressive and include shorter labors, fewer complications, reduced intervention rates and fewer cesarean section.

Research supporting the use of continuous labor support:
For information about doulas and where to find one contact:
Association of Labor Assistants and Childbirth Educators
(888) 222-5223
or
Doulas of North America (DONA)
888-788-DONA (3662)

Place of Birth

Freestanding Birth Centers offer maternity care to low-risk women outside of the hospital environment. They have been shown to be safe and effective in supporting a woman and her family in a low-tech, high-touch style of birthing. Parents are encouraged to participate in all decision making regarding tests and procedures. Information is supplied to the parents who in turn make the choices that are in the best interest of their family. Labor moves at its own pace, and laboring women are encouraged to nourish themselves, move to facilitate comfort and progress, and seek whatever position works for them. The care providers, usually midwives but occasionally obstetricians, monitor the mother and baby throughout labor by non-invasive methods, ensuring continued safety. A freestanding birth center certified by the National Association of Childbearing Centers does have life-sustaining equipment in the rare case of an emergency and is within reasonable transfer distance to a full-service maternity hospital. Studies show much lower rates of intervention including a Cesarean section rate far below the national average. Many insurance plans recognize the economic advantages of freestanding birth centers and offer 100% coverage.

For more information on Free Standing Birth Centers including safety research and where to find one, contact the National Association of Childbearing Centers.

Home Birth Services may be just what the doctor ordered! A large prospective North American study recently published in the British Medical Journal concluded that planned homebirth with a certified professional midwife is a safe option for low-risk women. (BMJ 2005;330:1416 (18 June)) The study showed significantly lower rates of all measured interventions and a rate of neonatal death similar to that of low-risk women birthing in the hospital.

Today more women are seeking alternatives to questionable routine hospital birthing practices such as IV fluids, continuous fetal monitoring, labor augmentation, and denial of privacy. Families are finding out that they don't have to sacrifice safety for a private, meaningful birthing experience. Women who birth at home report high satisfaction with the birth process. The laboring woman is able to be in her own comfortable surrounding, invite only those who she wishes, assume any position she chooses, and vocalize freely. At the hospital, mother and child are exposed to hosts of foreign germs, unlike at home. Birthing at home therefore significantly reduces the risk of infection. Families report stronger bonding with their new baby because the baby stays with mom and/or dad from the beginning. Siblings are also welcomed, and are given the opportunity to bond with the new baby from the onset. The home birth service, usually made up of midwives but occasionally utilizing obstetricians, brings any needed equipment, and many offer the option of a water birth tub and aseptic liner. They may ask you to purchase a few inexpensive items as well. Homebirth services routinely clean up everything after the birth. Many also come to your home a few days after the birth to see that mother and baby are adjusting well. Some insurance companies do offer home birth coverage. For those that do not, payment plan arrangements can often be made with a care provider.

Home birth services are sometimes harder to find. Look in the local phone books, and birth friendly organizations such as your local La Leche League. Local independent childbirth educators are also a good resource in finding a home birth practitioner. Ask educators who teach outside of the hospital such as; Hypnobirthing, Bradley Method, or Birthing from Within. Also see:
Midwives alliance of North America (MANA)

Research information for home birth:
BMJ Journals

Wherever you choose to birth your baby, make sure your decision is based on available evidence, not assumption. Whether birth center, home, or hospital, you should choose the place that you feel most comfortable. Make sure that you are comfortable with the primary care giver, as well as with their back-ups and partners. (This is important because back-ups and partners don't always share the same approach as their counterparts. Just because four other OB's/Midwives practice with your chosen care provider, it doesn't mean that they will all be supportive your care choices.)

Make sure it is your choice, not the preference of well-meaning, but possibly ill-informed loved ones, friends, or care providers.

Safe Pain Relief Options

Birth positions: Lying flat on the back during labor is harmful to both mother and child. Throughout pregnancy a pregnant woman is told not to sleep on her back due to the compromised blood flow to the uterus, which may decrease the oxygen flow to her baby. However most women in this country are medicated during labor and forced to lie on their backs. This may not only compromise the baby's oxygen supply but can also slow labor and reduce the size of the pelvic outlet. Upright positions during labor can help to cope with pain and naturally assist labor by utilizing gravity. Walking, stair climbing, lunges, dancing, etc. are effective ways to move the pelvis, helping the baby to descend and find his proper position. As labor progresses, squatting opens the outlet of the pelvis by more then 10%. This is a common pushing position in many cultures because it shortens the birth canal by putting pressure on the uterus and also helps keep the woman from arching her back. Most hospital beds are equipped with squat bar attachment, though many care providers do not know how to use them. A woman can also squat with the assistance of her partner or doula. Many birthing centers also have squatting stools, low supportive stools that allow the woman to keep her legs out and open. Women who are not restricted to bed by epidural anesthesia can find the position that best suits them helping them to labor more efficiently.

Waterbirth: The vast majority of women who have had a waterbirth report high levels of satisfaction and would choose it again. Warm water relaxes muscles, reduces pain, and supports weight. Many birthing mothers find that laboring in a tub alone, or with their partner holding and supporting them, helpful in giving them a better sense of control. Nicknamed "the midwives epidural," the comfort of water immersion leads to fewer requests for pain medications (which have been proven to be transmitted to the baby). The baby is born into warm water, which is similar in temperature and consistency to the amniotic fluid in which she or he has lived in for approximately nine months, making his entrance a smooth transition. Research has shown this to be a safe and gentle way to birth. It is also flexible, allowing women the option to leave the water just before the baby emerges. These women have still benefited greatly from the pain relieving benefits of the water during their labor.

For information on waterbirth including safety research go to:
Waterbirth International
For information about renting or purchasing a tub go to: AquaDoula
Dolphin Circle Waterbirth Tub Kits

Relaxation and natural breathing: Relaxation reduces pain and allows labor to progress more smoothly. When she is tense and fearful, the woman's body releases adrenalin, triggering rapid chest breathing, increasing tension, and pain, hampering the natural progress of labor. In a hospital, or intervention-centered setting, this often initiates a cycle of complications leading to intervention leading further complications and interventions. If, on the other hand, she is able to relax and cooperate with the labor process, her unhindered body is able to do its work more easily and in less time. With the reassurance that she is fully capableboth physically and emotionally--of successfully delivering her baby, the woman is free from the mindset that she must control her labor, and the birthing hormones work at their peek to reduce pain and facilitate labor. Relaxation can be practiced alone or with a partner. Some use music, candles, massage oil, soothing herbs, or poetry -- the list is unlimited -- to help them "let go." During pregnancy, practicing relaxation is also an opportunity to become closer with your partner, your baby, and to gain more insight into yourself. During labor, repeating phrases like, "let go," "stay out of its way," and "surrender" can be good reminders to help keep you on the right track. If during labor, you feel that you are loosing focus, either you or your partner can bring your attention to your breathing, gradually slowing and bringing it back down. The tension will disperse again, letting you get back into your healthy labor zone.

Action in Maryland:

Maryland Families for Safe Birth, Inc. (MFSB) is a grassroots, consumer-driven, 501 (c) (4) advocacy organization. MFSB’s mission is to ensure the health and wellbeing of Maryland families by expanding access to the evidence-based maternity care provided by Certified Professional Midwives. In order to meet this mission MFSB will introduce legislation to recognize licensure of Certified Professional Midwives and regulate their practice of midwifery. MFSB will monitor and deter legislation that would be detrimental to families and care providers who choose out-of-hospital birth. MFSB will also support organizations who offer, through education and other means, information, support, and advocacy regarding the midwifery model of care.

Published Monday, December 14, 2009 - 17:43; Last updated Tuesday, January 17, 2012 - 14:41