A New Age, a New Birth Mentality: Patient-Centered, Evidence-Based Care

I can't tell you how often I hear things like, "Well, back in my day we just did what our doctors said," and "We didn't know all this stuff when I had kids," and, "Why does this even matter, the point is to have healthy moms and babies, no matter how they get here," and, "Only hippies care about this kind of thing," and, "You must be a terrible patient if you question everything," and, "I don't even want to know, I'll just do whatever my doctor recommends and hope for the best," and the like. I understand where this is coming from. I really do. But where has that line of thinking taken us? Where has blind trust in our care providers and US medicine really gotten us?

Let's take a look back in time. Until about 1900, most every baby was born at home, attended by a midwife. But birth took a turn for the terrible in the early 1900's with the introduction of the specialized field of obstetrics, hospital births, and "Twilight Sleep". Essentially, women were drugged with a combination of morphine and scopolamine, which induced a hallucinogenic state that erased all memory of the birth. Women were strapped down to the bed because the medicines made them violent, they were left alone to labor without comprehending what was happening, and when it came time to deliver the baby, they were given a saddle block, an automatic episiotomy, and the baby was usually delivered by forceps because the mother didn't have the presence of mind to push. She would wake up with a baby in her arms and no memory of the atrocities done to her while birthing. Once the side effects this method produced in both mother and baby (such as "depressed" newborns who were difficult to resuscitate so that they could breathe and feed on their own) were discovered, it fell out of favor, which wasn't until 1960 -70. Twilight Sleep is now a much-hushed chapter in obstetric history, but at the time, the doctors who practiced it were revered as heroes for "taking away the pain of childbirth." Trusting the (relatively new) doctors of that time got women into a very bad place in regards to obstetrics, and all respect for the birthing process was lost.

Fast forward to the late 1950's, early 1960's, and we find thalidomide. It was supposed to cure morning sickness in pregnant women, and began to be prescribed regularly. Instead, it was discovered that the drug stunted limb growth in developing embryos, and after countless children were born with such birth defects, the drug was withdrawn. Again, just "doing as the doctors said" brought tragedy and misfortune to women and babies, simply because there wasn't enough research done on the drug prior to its practical use.

So where are we now? With all of our developments and research and medicine? Have we learned from our mistakes? Nope. Only about 1% of births occur at home, and not all of those are planned, but the home birth rates are on the rise. Why? Women are starting to seek options other than OB's and hospitals when it comes to giving birth. Women are forming communities where they can help each other recover from traumatic birth experiences. Postpartum Depression is becoming all too common, as well as Post Traumatic Stress Disorder in new moms with negative birth experiences. Sites like Improvingbirth.org and Evidencebasedbirth.com have become beacons of light for moms who want to "know better, do better" when it comes to childbirth. Women are wanting to take back control of their bodies and their births. Why? We, as a nation, have a 1 in 3 cesarean section rate, which is over 30% of all births. The WHO (World Health Organization) states that the "best outcomes for women and babies appear to occur with cesarean section rates of 5% to 10%. Rates above 15% seem to do more harm than good (Althabe and Belizan 2006)." We are far above the recommended rate for cesarean sections, and why? Childbirthconnection.org has a great breakdown:

"Reasons for the High Cesarean Section Rate

The following interconnected factors appear to contribute to the high cesarean rate.

Low priority of enhancing women's own abilities to give birth
Care that supports physiologic labor, such as providing the midwifery model of care, doula care providing continuous support during labor, and using hands-to-belly movements to turn a breech (buttocks- or feet-first) baby to a head-first position, reduces the likelihood of a cesarean section. Quite a few cesareans are carried out because the fetus seems large, even though this estimate is often wrong and a cesarean has not been shown to offer benefits in this situation. The decision to switch to cesarean is often made during labor when caregivers could use watchful waiting, positioning and movement, comfort measures, oral nourishment and other approaches to facilitate comfort, rest, and labor progress. Providing more women with such care would lower the cesarean section rate.

Side effects of common labor interventions
Current research suggests that some labor interventions make a c-section more likely. For example, labor induction among first-time mothers and/or when the cervix is not soft and ready to open appears to increase the likelihood of cesarean birth. Continuous electronic fetal monitoring has been associated with greater likelihood of a cesarean. Having an epidural early in labor or without a high-dose boost of synthetic oxytocin ("Pitocin") seems to increase the likelihood of a c-section, and epidural analgesia appears to increase the likelihood of cesareans performed in response to "fetal distress."

Refusal to offer the informed choice of vaginal birth
Many health professionals and/or hospitals are unwilling to offer the informed choice of vaginal birth to women in certain circumstances. The Listening to Mothers survey found that many women with a previous cesarean would have liked the option of a vaginal birth after cesarean (VBAC) but did not have it because health professionals and/or hospitals were unwilling (Declercq et al. 2013). More than nine out of ten women with a previous cesarean section are having repeat cesareans in the United States. Similarly, few women with a fetus in a breech position have the option to plan a vaginal birth, and twins are increasingly born via planned cesarean section.

Casual attitudes about surgery and variation in professional practice style
Our society is more tolerant than ever of surgical procedures, even when not medically needed. This is reflected in the comfort level that many health professionals, insurance plans, hospital administrators and women themselves have with cesarean trends. Further, the cesarean rate varies quite a bit across states and areas of the country, hospitals, and maternity professionals. Most of this variation is due to "practice style" rather than differences in the needs and preferences of childbearing women (Baicker et al. 2006, Clark et al. 2007).

Limited awareness of harms that are more likely with cesarean section
Cesarean section is a major surgical procedure that increases the likelihood of many types of harm for mothers and babies in comparison with vaginal birth. Short-term harms for mothers include increased risk of unintended surgical cuts, infection, blood clots, emergency hysterectomy, going back into the hospital, a challenging recovery, and death. Babies born by cesarean section are more likely to have breathing problems and to develop several chronic diseases: childhood-onset diabetes, allergies with cold-like symptoms, and asthma in childhood and beyond. Perhaps due to the common surgical side effect of scarring and "adhesion" formation, cesarean mothers are more likely to have ongoing pelvic pain and to have infertility in the future. Of special concern after cesarean are various serious conditions for mothers and babies that are more likely in future pregnancies. For mothers, these include ectopic pregnancy, placenta previa, placenta accreta, placental abruption, emergency hysterectomy, and uterine rupture. Babies in future pregnancies are more likely to need breathing help and have extended hospital stays. Preliminary research suggests that many other harms are more likely with cesarean section, and more studies are needed (Childbirth Connection 2012).

Incentives to practice in a manner that is efficient for providers
Many health professionals are feeling squeezed by tightened payments for services and increasing practice expenses. The flat "global fee" method of paying for childbirth does not provide any extra pay for providers who patiently support a longer vaginal birth. Some payment schedules pay more for cesarean than vaginal birth. Even when payment is similar for both, a planned cesarean section is an especially efficient way for professionals to organize their hospital work, office work and personal life. Average hospital payments are much greater for cesarean than vaginal birth, and may offer hospitals greater scope for profit.

All of these factors contribute to a current national cesarean section rate of over 30%, despite evidence that a rate of 5% to 10% would be optimal."

          ( http://www.childbirthconnection.org/article.asp?ck=10456 )

We have reached a point of crisis. We, in the US, have the worst infant and maternal outcomes of any developed nation. There are third world countries with better birth outcomes than us. We are living under the delusion that the US has the best maternity care in the world, when the truth is the exact opposite.

"The US ranks 1st with the highest infant mortality rates among the top 33 most 'advanced' nations."

"One in every 7,700 US women dies from pregnancy and childbirth related causes every year."

"The U.S. maternal mortality ratio, at 12.7 (deaths per 100,000 live

births) was 3 times as high as the Healthy People 2010 goal, a national target set by the U.S. government."

Think about it this way: if your doctor recommended that you undergo major surgery (or any procedure/treatment, for that matter), and you weren't sure why (or if) it was necessary, you would seek a second opinion, correct? You would do as much research as you could before consenting to any medical procedure. You would make sure that the choices you made were the ones best for you, and that they were really your choice and not forced on you by your doctor. Why is pregnancy not treated the same way? 

Why wouldn't women want to know the risks and benefits of everything that touches them and their babies? If you would educate yourself about gallbladder surgery, why not epidurals? Episiotomies? C-sections? Forceps or vacuum delivery? Gestational diabetes testing? Ultrasounds? Routine vaginal exams? Laboring and pushing positions? Anything and everything concerning you and your baby and what is happening/may happen? Why is it okay to put on a blindfold and be led about by someone who is (statistically) likely to lead you astray? Why risk having regrets because you "didn't know better," when it is in your power to find the truth and make your own choices?

Why is it that you are told not to take any medicine other than Tylenol during pregnancy, or eat cold lunch meats or raw sushi because of possible bacteria, or consume any alcohol, etc., but as soon as you're in labor (or want to be), it's okay to pump you full of drugs to induce labor, take away pain, stop nausea, and any other number of things? Why aren't the risks of medication in labor discussed (or even disclosed) as thoroughly as the risks of prenatal medications? The hypocrisy is blinding.

Putting blind faith in doctors has been proven by our own history to lead to disastrous consequences for mothers and babies. Yes, we have come a long way. But the direction we're heading is no better than the paths we've taken in the past. Women have almost as little say in maternity care as we did in the 1900's, and with all our women's rights movements (remember fighting for the right to vote?), you would think that our right to call the shots concerning our bodies and babies would be at the top of that list. Yet instead, it's been shoved into the background and turned almost into a taboo, because "doctors know best," when historically, and by our current statistics, that's been proven false.

It's time to call for patient-centered, evidence-based care. If you want to have a c-section, you should have access to all the information on the risks and benefits, and your choice should be respected by your doctor. If you want an all-natural, intervention-free hospital birth attended by a midwife, the same should apply. As well as VBACs, medicated vaginal hospital births, home births, birthing center births, and anything else a woman might choose. The evidence points to a woman's comfort and confidence in herself and her care provider being the biggest factor in a successful birth and a sense of satisfaction with her birth experience, whatever it may be. 

We do indeed have fabulous medicine at our disposal should there be any complications. There is no denying that there are cases where it is needed. But 1 in 3 moms is induced. 1 in 3 has a c-section. 2-3 women die per year due to pregnancy and childbirth related causes. Our outcomes have not been improved by medical intervention. In fact, it could be argued that it is that medical intervention that causes many of our problems. 

We should be able to trust our doctors. We should be able to have faith that anything our doctors suggest is truly necessary and the best course of action, because all other options have been exhausted. We shouldn't fear the hospital, but rather be able to relax and know that our wishes will be respected, and emergency care is there if needed, but will not be forced on us for reasons of "convenience." Doctors should be knights in shining armor, heroes to be revered, and our biggest advocates. But that is not going to happen unless we demand it. That will not come to pass until we know the truth and are willing to fight for our right to birth when, where, and how we choose. If we become educated and demand evidence-based care, they will have to give it to us in order to continue practicing, and perhaps we will finally be able to truly put our trust (and our bodies) into their hands with confidence. 

The statistics don't lie. We have a problem. So let's "be the change we want to see in the world," and demand that we be ones to call the shots as far as our bodies, babies, and births are concerned.

Due Dates: When is Baby Really Ready?

Every first-time mom anxiously awaits their due date. They hit the 20-week mark in the pregnancy and think, "Halfway done!" Plans are made for the days surrounding the due date, the calendar is marked, and everything seems to be focused on that all-important day. But where did that idea even come from, and is it accurate?


"The 40 week due date is based upon Naegele's Rule. This theory was originated by Harmanni Boerhaave, a botanist who in 1744 came up with a method of calculating the EDD based upon evidence in the Bible that human gestation lasts approximately 10 lunar months. The formula was publicized around 1812 by German obstetrician Franz Naegele and since has become the accepted norm for calculating the due date. There is one glaring flaw in Naegele's rule. Strictly speaking, a lunar (or synodic - from new moon to new moon) month is actually 29.53 days, which makes 10 lunar months roughly 295 days, a full 15 days longer than the 280 days gestation we've been lead to believe is average. In fact, if left alone, 50-80% of mothers will gestate beyond 40 weeks."

So here we are, 200-odd years later, basing our method of calculating babies' due dates on a theory formed by an OB that was inspired by another theory from a botanist nearly 70 years prior. Never mind that it's been proven that the majority of moms deliver later (only about 3-4% of babies come on their exact due date), most first-time moms deliver around 41 weeks, and the ACOG guidelines -based on modern evidence- state that a pregnancy is only considered post-term if it lasts longer than 42 weeks. Your doctor will still, more than likely, give your due date based on your LMP (last menstrual period), calculate your due date for 280 days from your LMP, and that is when you/they will expect baby to arrive.

But is that method of calculation accurate, either? Nope. Women's cycles aren't all exactly the same, and the LMP method assumes that your cycles are 28 days long, and that you ovulate on day 14. This is simply not true for all women. Only an estimated 10% of women fit into the "perfect" 28-day model, so why are all women's due dates calculated this way? It can lead to inaccurate due dates, off by 1-4 weeks depending on your individual cycle. This can lead to an induction happening because the doctors think you're past 41-42 weeks, when in reality, due to your cycle length, you're only 37-40 weeks, and as ACOG does not recommend inducing prior to 39 weeks unless medically indicated, you run the risk of your baby being what is called "early term," which can bring with it many complications (jaundice, difficulty breathing, NICU admission, etc.).

A healthy pregnancy is classified as lasting anywhere from 38-42 weeks, so think of your "due date" as the average time your baby might come. But you are not, I repeat not, "overdue" until you are 42 weeks or beyond. If you pass that long-anticipated 40 week mark, don't panic. It's perfectly normal, and no cause for concern in and of itself. There are plenty of things your OB/midwife can do to make sure you and baby are still doing fine (non-stress tests, ultrasounds to check that the placenta is still functioning, etc.), but simply being in the 40-42 week window is not an automatic issue. So think of your due date as more of a due month, and try to relax. If you and your baby are healthy and strong, there's no reason not to wait it out, even past 42 weeks! All babies are different, and so are their moms.