p. 132In what settings are babies born in the United States today?

In 1900 more than 95 percent of American women gave birth at home. Fourteen years later, anesthesia, or “twilight sleep,” was first used to dull labor pains, accelerating over time the transition of birthing from home to hospital. By 1960, today’s pattern—almost all women have hospital births attended by physicians—had become the norm. Many women choose hospital births over birthing centers or home births because certain anesthetics are uniquely available in this setting, as is complete emergency equipment.

A large-scale recent study of women in twenty-seven states who had singleton births (one baby) in vaginal deliveries showed that nearly two-thirds had epidural or spinal anesthesia during labor, with non-Hispanic white women, more highly educated women, those who began prenatal care earliest, and those attended by a physician more likely than other groups to use these drugs. The study also showed that older women were less likely to use these particular anesthetics.¹ The American College of Obstetricians and Gynecologists, pointing out that “there are no other circumstances in which it is considered acceptable for an individual to experience severe pain, amenable to safe intervention, while under a doctor’s care,” p. 133↵recommends that women in labor receive pain relief upon request.

Critics of in-hospital, physician-attended deliveries cite ­various aspects of the medicalization of birth, including fewer choices for the parturient woman under hospital rules, such as those regarding food, drink, body position, mobility, use of electronic monitoring, intravenous (IV) preparations, and medical induction.

The World Health Organization reports that over 90 percent of births worldwide are classified as “normal,” or uncomplicated, a fact that bolsters the decisions of some pregnant women to de-medicalize their birthing process. A very small percentage of total births in the United States occurs in licensed birthing centers, usually attended by midwives or nurses, and occasionally by physicians, with a backup hospital nearby. These low-tech settings usually stress a family-centered, natural childbirth philosophy, inviting the pregnant woman to include her family and others in the experience, and encouraging women to make their own choices about many matters that are regimented in hospitals. Staff usually expect the woman to have received childbirth education, such as Lamaze or Bradley training, and to commit to natural pain management. About 6 percent of women who have had prior babies and 25 percent of first-time mothers transfer from the center to hospitals for delivery, mostly for nonemergency situations.² While these facilities are usually less expensive than hospitals, some insurance plans do not cover birthing centers, a situation that has limited access to these settings. The Patient Protection and Affordable Care Act of 2010 includes guaranteed facility fee payments to birth centers.

The economics of pregnancy and giving birth have structured many aspects of the childbearing experience. Birthing options, including access to midwives and birthing centers, have only been available to women with excellent insurance or extensive resources of their own. Undocumented women, immigrants who have been in the United States for fewer p. 134↵than five years and therefore are not eligible for Medicaid, and other uninsured women have been limited to hospital births, whether they want a medicalized experience or not, often under the supervision of a doctor they have never met before. (Most of these women have been eligible for Emergency Medicaid, which covers labor and delivery in the hospital, but not for prenatal care, except in cases of complicated ­pregnancies.) Women living in rural settings have also generally had few birthing options, especially since so many small hospitals have been closed during periods of fiscal austerity over the past generation, and as health care has been increasingly corporatized and facilities consolidated. From 2014 onward, the Affordable Care Act is scheduled to cover pregnancy and newborn care as “essential health benefits.” Also, insurers will no longer be able to exclude a current pregnancy or any feature of delivery (such as a previous cesarean or episiotomy) as a preexisting condition.

What status do midwives have in the United States?

In the middle of the twentieth century, the practice of midwifery—usually by a nurse certified by a nationally accredited program to assist women throughout the childbearing cycle, including in childbirth—began its slow climb back to obstetric respectability after having been de-credentialed through the efforts of the American Medical Association and other regular medical organizations approximately 100 years earlier. In some parts of the United States, chiefly the South within African American communities, midwives had continued to practice to some degree. Generally, however, as birthing moved into hospitals and came almost fully under the authority of medical doctors, midwifery was outlawed in many states and all but died out.

In 1955, Columbia-Presbyterian-Sloan Hospital in New York became the first mainstream medical institution to allow midwives to deliver babies, and five years later the US Children’s p. 135↵Bureau started funding several nurse-midwife education programs. In the 1970s, some participants in the women’s movement championed natural childbirth, women-centered birthing practices, and the revival of lay midwifery.

Today most states have legalized midwifery, although nine continue to completely outlaw it. Other states have laws that limit the situations in which midwives can practice. Of midwife-attended births, about 95 percent take place in hospitals (making up approximately 6 pecent to 8 percent of all hospital births), 3 percent in birthing centers, and 1 percent in home settings. Midwives employ practices that aim to obviate the need for medical induction, and births under the supervision of midwives end up with a dramatically lower percentage of caesarean sections (C-sections) than physician-supervised births.

Why is the rate of caesarian section so much higher in the United States than it used to be?

A caesarean delivery is one in which the infant, the placenta, and the membranes are extracted from the woman’s body through an incision in her abdominal and uterine walls. Generally, a C-section is performed when, due to dangerous maternal or fetal stress, the delivery must occur at once.

Around 1999, after nearly a decade of stability, the rate of caesarean sections began to rise sharply; today nearly one out of three births is a caesarean delivery. The rates have increased for mothers in all ages and racial groups. They have increased in all states, with some states (Colorado, Connecticut, Florida, Nevada, Rhode Island, and Washington) seeing increases of up to 70 percent. At present, even in the states with the lowest rates (Alaska, Idaho, New Mexico, and Utah) about one in four births is caesarean. In the states with the highest rates (Florida, Louisiana, Mississippi, New Jersey, and West Virginia), over one in three births is caesarean, in some hospitals as high as four or five out of ten. The World Health Organization has p. 136↵stated that the cesarean rate for any region should not exceed 10 percent to 15 percent.³

Public health experts and other researchers and observers have suggested a number of reasons for increased reliance on this surgery today; many are nonmedical reasons. These include physician practice patterns, that is, a desire to fit births into the hours of the physician’s work schedule; insufficient hospital staffing; more conservative practice guidelines, such as lowering the number of permissible hours of labor before intervention; and financial and legal pressures, including physicians’ beliefs that surgical intervention is more likely to guarantee a positive outcome and avoidance of malpractice actions. Other possible reasons include more older women giving birth (although rates have increased among all maternal ages); more multiple births today (and caesarean rates are high for this group, although the rates for singleton births have increased substantially more than for multiples); and more women choosing for various reasons to give birth by caesarean.

In addition, studies show that the practice of inducing labor is closely related to incidence of caesareans. About 44 percent of women in a large study who attempted to deliver vaginally were induced (administered a drug to speed up and intensify their labor, shortening the period before delivery). Members of this group were two times more likely to deliver by caesarean section than women who went into labor on their own. Other studies have reported a rate of induced labor of about one in five, which is approximately twice the 1990 rate.⁴

In the mid-1990s, 30 percent of women who had delivered by C-section went on to give birth vaginally. Approximately twenty years later, about 10 percent of women who have previously had caesarean sections are having subsequent deliveries vaginally, perhaps because success rates for VBACs (vaginal birth after caesarean) have been reported between only 60 percent and 80 percent. Still, prominent analysts have argued that the reduced rate of VBACs is conditioned by nonmedical factors such as physicians’ pressures on ­parturient p. 137↵women to have subsequent C-sections, despite the dangers associated with multiple caesareans.⁵ As some causes of high caesarean rates appear to be nonclinical, the rapid-rate increases suggest that pregnant women themselves may not be well informed about the risks associated with caesarean sections, or may be giving birth in facilities that do not adequately follow (or loosely define) informed consent procedures. These risks include higher rates of surgical complications and maternal rehospitalization following this major abdominal surgery; higher rates of neonatal admission to intensive care when mothers encounter complications; and high costs and longer recuperations associated with caesarean sections.

What is natural childbirth?

In 1944, Grantly Dick-Read, the British obstetrician who had promoted nonmedicalized birthing for some years, published his groundbreaking book, Childbirth without Fear: The Principles and Practices of Natural Childbirth, in the United States. The book appeared only a few years after anesthesia became standard practice in obstetric medicine and at about the time that three-quarters of all American women living in cities gave birth at hospitals rather than at home as they had before.

Dick-Read, responding to such developments, wanted to remind women of the success of earlier, natural (nonmedicalized) birth practices and alert them to the risks and degradations, as he saw it, that attended many hospital deliveries. As founder of the natural childbirth movement, he aimed to educate modern women about the superior experience of ­giving birth with as limited a degree of medical intervention as possible. Dick-Read was a champion of women entering into the birthing experience fully educated about what to expect, possessing breathing strategies and other self-directed tactics for dealing with labor and delivery pain. He advocated the commitment by parturient women to a drug- and ­implement-free p. 138↵process, if possible. Dick-Read believed that pain was a by-product of the fear women had been trained to associate with childbirth. Proper preparation, he claimed, could dissipate fear and put women in charge of their birth experiences. Dick-Read and his popular successors such as Dr. Fernand Lamaze, have stressed that parturient women, bolstered by the confidence that follows this kind of preparation, can transcend pain, be more likely to have uncomplicated deliveries, and produce healthier babies.

Is there a maternal health care crisis in the United States?

Even though the United States spends more money on pregnancy and childbirth-related hospital services than any other country, every day two to three women die during pregnancy and childbirth in this country. Women in forty other countries have a smaller lifetime risk than American women of dying from pregnancy-related complications. For example, a woman in the United States is five times more likely to die in childbirth than a woman in Greece and four times more likely than a woman in Germany. Maternal health services are not equally accessible in the United States to all women: those living in low-income areas of the country are twice as likely to die during or very soon after their pregnancies as women living in high-income areas. According to a recent study of maternal health in the United States by Amnesty International, high maternal death rates have stemmed in part from the fact that 13 million women of childbearing age have no health insurance, a situation that should be ameliorated by the Affordable Care Act. Up to this point, however, women of color have comprised about one-third of the reproductive-age female population and over one-half of all uninsured women. About one in three pregnant African American and Native American women have not received adequate prenatal care beginning in the first trimester, and Medicaid-eligible women have often encountered delays when they try to access medical services. In addition, p. 139↵the study reports that 64 million Americans live in “shortage areas,” rural and urban locations in which there are not enough medical personnel to serve the population’s need for primary medical care, including maternal care. Many women living in these areas lack transportation to get to prenatal clinics, have jobs that don’t allow them time off for doctors’ appointments, and lack child care. The Amnesty International study reports that a majority of the maternal deaths in the United States and many pregnancy-related complications would be preventable if all pregnant women received adequate health care.⁶

What do medical authorities say about the relationship between breast-feeding and infant health?

The World Health Organization has recommended that infants be breast-fed exclusively for the first six months of life, and in 2011 the US Surgeon General Regina M. Benjamin issued a “Call to Action to Support Breastfeeding,” urging communities, employers, and health care systems to promote and facilitate breast-feeding. The call cited evidence that breast-feeding protects babies from infections and illnesses that include diarrhea, ear infections and pneumonia, asthma, and obesity, and that it decreases the risk for breast and ovarian cancers among mothers who nurse.

Some studies have associated breast-feeding with environmental health risks because various dangerous toxins in plastics, paint thinners, termite poisons, flame retardants, dry-cleaning fluids, and other common products end up in breast milk. Recent studies, however, have found that the toxic load in breast milk is less dangerous than the typical American infant’s exposure to airborne pollutants and does not significantly compromise the health benefits of nursing.⁷

Without question, many new mothers—those whose employers provide no paid maternity leave and those eligible for some limited paid leave—are unable to provide their infants with an exclusive diet of breast milk, even with extensive p. 140↵pumping. Some public health experts and other advocates of breast-feeding have noted that because the United States does not have a national paid maternity leave policy, breast-feeding as a route to infant health has become a privilege fully available only to babies whose mothers can afford to stay home during the early months.

Must employers allow employees to express milk with breast-pumps while at work?

After the passage of the Patient Protection and Affordable Care Act in 2010, the Fair Labor Standards Act of 1938 was amended to require an employer to provide reasonable break time for an employee to express breast milk as often as she needs to for her nursing child for up to one year after giving birth. The employer is not required to compensate the employee for this time but must provide a place, other than a bathroom, that can be used for this purpose. An employer with fewer than fifty employees who can show that providing these accommodations causes hardship to the business, can be exempted from these requirements.

Do states have laws about breast-feeding in public?

Forty-four states have laws that specifically allow women to breast-feed in any public or private location; about two-thirds of these exempt breast-feeding from “public indecency” laws. About a dozen states exempt breast-feeding women from jury duty, and a small number of states have launched educational programs about the benefits of breast-feeding.