The author, Nathaniel Johnson notes that,
In 1923, Mary Breckinridge started the Frontier Nursing Service in rural Appalachia….Within a decade, the astonishing impact of that care was apparent. The women the Frontier Nursing Service cared for, who were desperately poor and usually gave birth at home, were 10 times less likely to die in childbirth than the average American at the time. The nation as a whole wouldn’t catch up until the 1950s, after the widespread acceptance of antiseptic and the discovery of antibiotics.
Given that antiseptic practices and the use of antibiotics are available and in use in midwife-attended home births today, it makes sense that, as Sheila Kitzinger has argued, it is not a high level of medicalization that makes birth safer – it is overall health: access to good pre-conception, prenatal and postpartum healthcare, good quality nutrition, access to clean water and access to skilled birth attendants. This has been borne out the world over, regardless of whether women are typically birthing at home or in hospitals. Access to medical interventions for the few women who actually need them is important, which is why midwives are thoroughly trained to detect possible complications before they become problematic and why they only support home births for women who are not at risk. Obstetricians are trained to deal with problems when they arise, but midwives are far more likely to be able to prevent them in the first place.
The main thesis of Johnson’s article, is that the overly medical approach to birth that is taken in the US (and in Canada, to a slightly lesser extent) is not only not making birth safer, but is actually increasing rates of maternal morbidity and mortality. In other words, an approach that prioritizes medical technology over continuous and thorough prenatal care and compassionate, respectful birthing room practices is making birth less safe. On the other hand, Johnson suggests it may be,
that the real reasons that birth has gotten riskier have to do with a changing population; women are giving birth later in life, they are more likely to be obese, more likely to have heart disease. All of this is true. The profile of the American mother has changed, and she’s much more likely to have a C-section.
I support his assertion that obesity and heart disease and their increased prevalence are serious issues that need to be addressed and that they have an impact on our birth outcomes, but what this statement obscures is the fact that birth has gotten riskier for all women in the US, not just the over-35 or -40, the obese or the women with heart disease. Women with healthy low-risk pregnancies are having surgical births more than ever for reasons that have nothing to do with care and safety and everything to do with convenience, misunderstandings (or no knowledge at all) of risk and straight-up impatience with natural, healthy birth processes. The WHO states that a nation’s Caesarean rate should be between 5% and 15%. Below 5% and women aren’t getting the medical attention they need, above 15% indicates that unnecessary surgeries are being performed and the risk of iatrogenic complications is being increased. With C-section rates over 30% throughout the US and close to that (or equally high depending on region) in Canada, we know that something is very wrong with how birth is being treated, i.e. as a pathological problem to be ‘fixed’, rather than a normal, healthy process. This is as much a cultural problem, reinforced by our media and the stories that we tell, as it is an issue with our healthcare system.
As a doula, I work hard to be part of the solution, both by influencing the system through clients and interactions with healthcare workers, and by talking about birth and encouraging others to think critically about media (mis)representations and popular myths. I’m always pleased to see articles like this one that reaffirm the need for “high-touch, low-tech” approaches, not just for things like respect, compassion and emotional well-being, but equally for the safety and good physiological health of mothers and babies.