A Better Birth

Have the delivery experience you want


Over the past century, childbirth has become safer for mothers and babies in the United States. From 1900 to 1999, the risk of a baby dying during birth or in the first year of life plummeted from 1 in 10 to less than 1 in 100. The risk of a mother dying from pregnancy-related complications or childbirth decreased even more dramatically, from 850 deaths to less than 8 in every 100,000 births.

In addition, changes in the later 20th century, such as childbirth education and encouraging women's partners or other close friends and family members to be present during labor and birth, have helped many women better understand the process of childbirth and enjoy more support through it.

Yet despite this progress, mothers and babies still face many challenges. Unlike most other industrialized countries, the U.S. has no guaranteed paid family leave, no guaranteed health care and little affordable high-quality child care. Our country has the highest infant mortality rate among affluent nations, and higher maternal mortality rates than all but five economically industrialized countries. Mothers and babies of color, especially African-Americans and Native Americans, are at higher risk.

The health care that is provided to women during pregnancy, childbirth and the early postpartum period—what is known as maternity care—is also in need of improvement. Far too often, maternity care practices are not based on the best scientific research on safety and effectiveness. Procedures that are useful—and sometimes even lifesaving—when applied to women and babies with specific high-risk conditions are often extended liberally to other women and babies, "just in case." Such unnecessary medical interventions are not helpful and can even be harmful.

Too much or too little A national survey of mothers who gave birth in hospitals in 2005 found that nearly all women experienced some combination of interventions that can interfere with the normal progression of birth. Most of the women surveyed had continuous electronic fetal heart rate monitoring, urinary catheterization, administration of intravenous fluids, and epidural or spinal analgesia. One in two received synthetic oxytocin to either start her labor or make her contractions stronger and more frequent, and slightly more than three in 10 had a Cesarean section.

The United States' C-section rate (31 percent) is more than twice the maximum rate recommended by the World Health Organization; this means that more mothers and babies are exposed to the negative effects of surgical birth. Most women also experienced practices that may do more harm than good, such as not eating or drinking anything during labor and lying on their backs during labor and while giving birth.

Other practices that have been shown to improve birth outcomes and increase women's satisfaction are widely underused. These include receiving continuous one-on-one support during labor; being able to change positions, get out of bed and walk during labor; and using comfort measures such as massage, warm baths and birthing balls.

Advocates for improving maternity care in this country point to the following roadblocks to change:

Obstetrical training Obstetrics is a surgical specialty, and doctors training to become obstetricians learn, among other things, to perform Cesarean sections, apply forceps, and cut and repair episiotomies. They generally receive less instruction in the natural progression of childbirth or in birth techniques that minimize perineal tearing. In many training programs, obstetricians are not even required to sit with a healthy woman throughout her entire labor or observe one birth without any interventions.

The widespread use of epidurals A woman who has an epidural is usually restricted in her movements and for safety reasons must be monitored continuously by electronic fetal monitoring (EFM). The resulting restricted movement and muscle relaxation can cause babies who are facing backward to stay that way, which results in a longer second stage of labor and a higher incidence of forceps and vacuum deliveries. Use of epidurals also can lead to less effective pushing.

Continuous fetal monitoring Because the fetal heart rate patterns seen when the heart rate is continuously recorded are sometimes difficult to interpret, EFM has increased the number of labors considered "complicated" or "risky." For women who do not have labor interventions such as epidurals that make continuous monitoring necessary, intermittent monitoring appears to be as effective as continuous monitoring at detecting true problems, and is not associated with an increased risk of Cesarean birth or of vaginal birth assisted by vacuum extraction or forceps.

Changes in nursing care In the past, personal one-on-one care was the hallmark of obstetrical nursing. Today, for a variety of reasons, including nursing shortages, budgetary constraints and less training in the natural progression of birth, labor nurses increasingly rely on continuous EFM to help them care for more than one woman at a time.

Economic incentives Many payment systems offer a single or fixed fee to doctors regardless of whether a baby is born vaginally or by Cesarean, and others offer a larger fee for a Cesarean. Doctors who patiently support natural labor, which starts at unpredictable hours and generally requires more time, are penalized financially. Inducing labor instead of waiting for it to start on its own also helps doctors control their hours. Elective Cesarean sections and scheduled induction of labor help hospitals make nursing staff schedules more predictable and shift more of health care providers' work to convenient weekday hours.

Fear of lawsuits If something goes wrong, doctors may be blamed for not doing something, but rarely are they blamed for doing something that is not necessary. For example, malpractice lawsuits for not performing a Cesarean section are much more common than lawsuits for doing one when it wasn't necessary. To avoid litigation, many doctors and some midwives feel compelled to do "too much" rather than be accused of doing "too little."

A rushed, risk-averse society U.S. society today has an aversion to risk that contributes to a climate of doubt in which all labors are treated as potential problems and women with low-risk pregnancies receive treatments designed for use by women with very high-risk ones. In addition, women sometimes are not allowed sufficient time for labor to progress and a vaginal birth to occur. Women's own expectations can contribute to rushing labor.

Often motivated by personal experiences, some of us have become involved in groups working to change birth practices (for one patient-turned-activist's story, see "Not in My State!"). If you are healthy and have no medical complications that call for a "high-risk" approach to your care during pregnancy and birth, you can increase your chances of having a safe and satisfying vaginal birth by trying the following strategies:

- Find a doctor or midwife and a birth setting with low rates of intervention. - Create your own birth plan and discuss it with your caregivers. - Arrange for continuous labor support from someone with experience. - Explore all your pain-relief options. - Avoid continuous electronic fetal monitoring and other medically unnecessary interventions when possible.