A Wise Birth

Bringing Together the Best of Natural Childbirth with Modern Medicine

Penny Armstrong, Sheryl Feldman

• Publisher: Pinter & Martin
• Year: 2007
• eBook ISBN: 9781905177738
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

This work is an informative exploration of the politics behind modern child-birthing strategies. This thoroughly researched and well written volume explores the multitude of issues that can influence the way women give birth in modern society. "A Wise Birth" makes a detailed examination of all the main areas of influence, from different cultural backgrounds, medical histories, psychology, and relationships, to technology and modern medicines. This informative volume is a must read for all expectant parents interested in the politics of birth, midwives, childbirth educators and obstetricians.

PART I

THE NATURE OF BIRTH

Introduction

In the first chapter we contrasted the hospital birth of Leslie, a well-educated urban woman, to the home birth of Rachel, a woman who knew how to keep a farm kitchen. One can argue that the comparison is specious, the women’s lives and cultures being so different. Or complain about it. Incantations about lovely, natural births tend to call up outdated images from the sixties or suggest a holier-than-thou mentality. Worse, they can cause guilt: they suggest that today’s women, who already have overwhelming work and home responsibilities, should also be second-guessing their physicians, challenging state-of-the-art medicine, assuming the unknowns (for them) of home birth, and withstanding pain for the sake, as Leslie so aptly put it, “of some ideal.” American women are getting their babies and Leslie and her son are hardly doomed.

In interviewing women, we quickly learned that the truly natural birth – that is, the one without drugs and technological interventions – was not attractive. Since these were well-educated, highly responsible women, we knew that their opinion of natural birth was not an unexamined one. These were women who chose to have children, who understood (as much as that is possible before the fact) the responsibility they were taking on, and who wanted to do the best they could for themselves and their children. Considering their personal qualities, we had to conclude that the natural birth was not serving them well.

Our question was, why not? If it was not a matter of character – non-Amish women toughed their way through difficulties as much as, if not more than, Amish women did – neither was it a question of information: for two decades, the benefits of the unmedicated birth have been advertised. Since that message has been rejected, one must assume that it misses something significant in the realities of childbearing today. Women have good reasons for giving birth as they do.

Penny and I, sitting in her living room, home from yet another lovely birth, reckoned with the problem. Why would the natural birth work for Amish women and fail other women? Why does that power flood rural bedrooms and dry up in hospitals? Most important, why should Penny’s client population routinely enjoy outcomes that are dramatically superior to those of other women?

Penny has assisted more than twelve hundred births. At home, she uses no analgesics or regional anesthetics because they can repress infant respiration; nationally, the rate of use of epidurals (a regional anesthetic) is 60 percent. Her episiotomy rate is less than 1 percent; the national rate is 61 percent. Her transfers to physician and/or hospital care are less than 10 percent. Cesareans (which she, of course, does not do and which are included in the transfer rate) represent 6 percent; the national figure is 24 percent. Her perinatal mortality rate – which includes stillbirths and infant deaths in the first seven days of life is 5 per thousand; nationally the figure is 10.4 per thousand (1986).¹

Penny’s an excellent practitioner. Furthermore, she’s developed some skills that are unique in the birthplace today. She is the first to say, however, that clinical expertise cannot account for the disparity between her statistics and national ones. If her skills then, are not the controlling factor in outcome; if we reject as absurd the idea that non-Amish women are intrinsically lesser birthers than Amish women, we are forced back to the objection we began with: birth may be as much a product of culture as it is of physiology.

If that is so, then the next question was whether it was possible to identify those factors that benefited birth in one culture and transfer them to another. Our opportunity, we realized, was to think of the Amish as a naturally occurring control group, a laboratory, a tool for understanding how culture infiltrates the physiologic process of birth. By comparing and contrasting Amish and mainstream experience, we might be able to get down to the generic cultural factors that favored birth. If we could do that, then we could see if they were or were not transferable. If they were transferable, then mainstream women might be able to have births from which they did not have to heal.

Ultimately we considered the effects of place on birth, we examined the traditions of medical science, we looked at what women learned from their mothers about birth and mothering, we compared the way doctors and midwives perceived and managed birth, we reexamined the information birth reformers and educators have been providing, we considered the influence of men in the birthplace and in parenting, and we tried to understand how women’s other responsibilities affected their births. By these inquiries, we were able to see how to transpose the benefits of one culture to another.

We didn’t begin the project until Penny had put in eight years as a midwife and the same eight taking apart the education she’d acquired during her training as a certified nursemidwife (CNM).² Her education had not adequately accounted for the births she saw in farmhouses and she was obliged to develop a revised definition of the nature of birth. In the sections that follow, she describes what she found and how she came to explain it.

The Nature of Power

I’ve explained elsewhere how I ended up doing home births for the Amish people of Lancaster County¹ and will only repeat what seems necessary here. I took my midwifery training in Scotland and at Booth Maternity Hospital in Philadelphia. I had just gotten my accreditation as a certified nurse-midwife when I responded to a call from a general practitioner out in agricultural Lancaster County, Pennsylvania. He was interested in expanding his practice among the Amish people and wanted a midwife as part of his service team. I had been raised in the country and it appealed to me to return.

When I went out for the interview, I was disturbed to find that I would be expected to do home births. All my experience with birth had been in the hospital and I was keen on having emergency equipment nearby and doctors available. I wondered if the doctor wasn’t being a bit cavalier about his Amish clients. They had only eigthgrade educations, they did not sue, and so could easily be taken advantage of.

But he took me around to chat with some of the women in their homes and they told me in their own words that they preferred to have their babies at home because it was economical and it suited their farm- and family-centered, low-tech lives. Until recently, Dr Grace Kaiser² had assisted them at home, but she had retired, and they were forced to choose between the hospital or one other home birth practitioner – a person whose methods, when I heard about them, I couldn’t condone. What the couples said convinced me that one didn’t force mainstream standards – that is, everyone goes to the hospital – on the Amish. I accepted the job and its requirement of attending home births.

I was a well-prepared midwife, exacting of myself and, in one way, ambitious. I was determined that the women I cared for would have the safest, best births possible. I immediately assessed the realities of home birth – being alone in the middle of the night at an Amish farm with my work area lit by gaslight and the closest phone a five- or ten-minute walk away – and compensated. I bought a two-way radio. I equipped the suitcase that Sheryl mentioned in the first chapter with all the drugs that midwives are licensed to carry. I put in Pitocin for the resistant placenta, Methergine for postpartum bleeding, Valium to counteract a suddenly elevating blood pressure, Epinephrine to compensate for the sometimes ill effects of numbing drugs used for episiotomy, pills for severe afterpains, antibiotics for the person at risk of infection. I put in Amni-hooks (plastic instruments for breaking the bag of waters), syringes, intravenous (IV) fluids, a ring forceps for examining the cervix, a variety of clamps and scissors, a suture kit, needles, a DeLee’s suction catheter for clearing the baby’s air passageway, a heavy oxygen tank, a laryngoscope for viewing the baby’s throat, an endotracheal (ET) tube to slip down its airway to get oxygen to the lungs, and a bag for forcing oxygen into the baby’s lungs.

The doctor and I eliminated (we call it risking out) those women whom we thought unsuitable for home birth. No mothers whose babies were in an odd position, no mothers having their tenth child (or more), no twins, no women with high blood pressure, no women with severe medical problems, no small-bodied women who seemed to be carrying big babies. Any known chance of a complication sent a woman to the hospital.

Meanwhile, I began attending births at home. I hadn’t made many forays before I realized that I was seeing births for which I had not been prepared. Accustomed as I was to the taut, often breathless birth atmosphere of hospital births, I was struck by the casual, comfortable movements of the women laboring in their kitchen and giving birth among quilts. Having based much of my assessment of myself as a practitioner on my ability to respond swiftly and accurately to emergency situations, I was undone by the infrequency of the need for me to display my masterly strokes. Birth appeared to be another animal out in the country. Labors were shorter than I was accustomed to. Pain appeared to be less severe. Cuts and tears fewer. Hemorrhage controllable. Babies did not need my suctioning devices or my tubes pressed down their throats; they gurgled when they were born and began to breathe. Their mothers took them to their breasts and nursed without much complication. If problems did arise anytime during a birth, most of them appeared to resolve themselves in short order.

I had an eerie sense of unreality. The births had not only power, but grace and simplicity. Coming home at four or five in the morning after births, each one seeming to unwind to a fruitful, healthy end, I groped for explanation. I wondered if I was witnessing a statistically aberrant population of women, ones who were, by genetic predisposition, good birthers. At other times, bewitched by the grace of the starry landscape and disarmed by the humility of the Amish, I indulged in the magical idea that God rewarded people who followed a religious way of life by giving them easier births. By daylight, the clinician in me credited the food the women ate, the number of hours they spent squatting in the garden, the herbs they took, and their experience with animals giving birth. Sometimes, when sleep-deprived, I considered the self-serving possibility that it was me making all the difference. Finally I countenanced the possibility that I had stumbled upon – as I vaguely put it – something extraordinary.

I yearned to have a more experienced professional explain to me what was going on, but I was reluctant to discuss my statistics, which were becoming astounding, with my mentors back at Booth. Once I mumbled something about them and it was suggested that I wait for the other shoe to drop. That sounded like good advice, so I kept my mouth shut and maintained my style of attending women. I kept the hospital ways I had been able to bring with me into homes. I stayed with the women through the early parts of their labor, I scrubbed carefully, I watched the clock, I shone a strong flashlight on the perineum while I worked, I recorded elaborate detail on charts.

One August night, I was led yet another time by a typical Amish husband into a typical Amish bedroom. Silla, the mother, was propped up in her bed in a moonlit room calmly awaiting my arrival. She smiled, and then, conspiratorially, placed her index finger to her lips. She beckoned me to her side, pulled my head down so my ear was next to her mouth, and whispered. Would it suit me, she wanted to know, to leave the lamp unlit and to talk quietly? Her two-year-old, Joseph, was asleep in the corner of the bedroom and she didn’t want to wake him.

My first reaction was to disabuse her of her easygoing confidence by lecturing her on the disasters that can accompany birth: how babies’ lives had been saved because practitioners had picked up a tint in the amniotic fluid (waters), because they had been able to use their scissors precisely, because they were able to see when the color of a baby’s face shifted. But while I was preparing this speech, my eyes followed Silla’s over to damp, tousled Joseph, sleeping in his crib as contented as a puddle after a summer rain; I glanced at Silla’s husband, who had competently assisted me at Joseph’s birth, and I realized what was bothering me. If I assisted Silla as she requested, I would be admitting that birth probably could be trusted.

My decision to do so was based on a number of considerations. I knew, for example, that Silla had had four births, each of them manifestly uncomplicated. This pregnancy had proceeded in perfect order. I knew that she was a responsible person, one who would not cling to her request for quiet and darkness if circumstances changed. I knew Joseph could flare up a lantern in an instant. I acknowledged that Joseph and Silla had a mature and subtle religious faith, one that embraced, as God’s will, the unpredictable turnings of nature. I decided, in other words, to trust the accumulation of my experience among the Amish and the judgments that followed from it.

I held the flaps on the locks of my medical case so they wouldn’t click; I stepped out into the kitchen to tear open the packages of rubber gloves; I laid my flashlight on the doily on the bureau so it wouldn’t startle; I used my stethoscope instead of a doptone (which throws the sound of the baby’s heartbeat around the room); I heard the bedsprings creak when Silla’s husband climbed onto the bed beside her. Within the half-hour, I felt the slippery dome of a baby’s head filling my palm and their little girl eased out. I slid her onto the mounded landscape of her mother’s abdomen.

I reached over toward her and saw that she was breathing, that her eyes were open, that they were avidly exploring the bedroom around her. She was as alert and as clear-sighted as a person who has just risen out of deep meditation. When a smile slipped across her face, her perfection skimmed through me. She had come up as effortlessly and as reassuringly as the sun.

I had never seen a smile on the face of a child at birth; indeed, I’d never heard of such a thing. And even supposing, as I did later, that it was just a look of contentment I’d seen, the impact remained the same. If birth could be as easy for a mother as it was for Silla and as comfortable as it apparently was for her baby, then I needed to be able to explain why and how. Urged along by that confounding child, I began to think systematically about the causes of power and grace.

Clinical Factors

I knew that my clients’ births were favorably influenced by the women’s general good health. They scrub floors on their hands and knees, sling baskets of wet wash about, climb stairs, work out in the fields, and squat in their gardens. The air they breathe is relatively unpolluted. They don’t drink or smoke and, while their diets are not ideal, they are quite adequate. Also, their bodies are not assaulted every day by the psychological stresses of urban life. These are such important physical advantages that, in theory, they should have served the women equally well no matter where they gave birth.

The theory, however, held up no further than the local hospital where, I knew from experience...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Foreword
• A Wise Birth Revisited
• On the Power
• Part I: The Nature of Birth
• Part II: Legacies
• Part III: Perpetuating the Loss
• Part IV: Compensating for the Loss
• Part V: The Giving in Birth
• Epilogue
• References
• Acknowledgments
• Index