Your Pregnancy, Your Way

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WHAT DOES A "NATURAL" BIRTH MEAN, ANYWAY?

WOMEN HAVE BEEN GIVING BIRTH FOR CENTURIES; WHAT CAN BE more natural than that? Well, it is not quite so simple. For each and every woman, natural means something different. The definition depends on where you live, the customs in your family, and, most important, whether you view pregnancy as inherently safe or inherently risky.

In recent times, the word natural is often used to characterize things we assume to be healthier, safer, and better for us. For some women, having a natural birth simply means that they want to deliver vaginally instead of by cesarean section. To others, it means not using pain medication, although an IV and fetal monitoring are welcome. Some believe that all births are natural as long as what is done is best for the mom and the baby. Others think natural implies avoiding the hospital altogether and trusting their body to give birth the way women have done for generations, delivering in the familiar setting of their own home or in a peaceful birthing center without beeping machines and rushed medical personnel.

Calling a birth "natural" brings up the question of what would constitute an "unnatural" birth. For those of us in the medical field, the opposite of a natural birth is one with interventions. Yet, in lay terms, to say that a birth is not "natural" implies that the event is not as good, or even harmful. Is a birth experience artificial or abnormal when medical interventions are chosen, or become necessary?

Influences on Our View of Childbirth

Thanks to Hollywood, when most of us picture labor, we think of a woman on her back in a hospital bed, surrounded by machines, screaming and sweating, perhaps yelling a string of curse words as she bears down with each contraction. The father-to-be grips her hand, white-faced and helpless, feeling faint. A tense nurse shouts instructions as a doctor catches the baby's emerging head. Labor is fast, furious, and intense.

We almost never see labor depicted as a relaxed, peaceful experience. Watching the process play out in its slow, methodical way, sometimes lasting for days, wouldn't make for a dramatic moment in a movie. It is no surprise that many women approach labor fearfully, focusing on the pain, rather than anticipating it as the extraordinary event it can be.

Our view of pregnancy and childbirth is also influenced by the experiences of women who have gone before us—the well-meaning family and friends who, with good intentions, want to prepare us for the worst, and explain the labor process in frightening detail. Women freely discuss their emergency cesareans and the unforeseen twists and turns, and all of it seems commonplace. As "survivors," they feel obligated to share their words of wisdom. Even if their stories are reassuring, the birth you want, or that will be best for you and your baby, may not be the same as your friend's, sister's, or mother's. Unfortunately, you may hear more negatives than positives. A woman with an unfavorable birth experience will frequently share her horror story with anyone who will listen, whereas a woman with a positive experience will hold the memory privately with just a few friends and family.

The shared experience of pregnancy should bond women together and encourage them to be supportive of one another at this important time. Finding a group of women who share your views and beliefs can be invaluable. Childbirth is not a competition in which prizes are awarded to the mother who was able to give birth without an epidural or who pushed out the biggest baby. Sometimes, you may feel that any decision you make about your pregnancy can lead to a conversation loaded with judgment. Are you going to have a natural birth? Will you use an epidural? How long are you planning to breastfeed? No matter how you answer, or how well thought-out your decision, someone, somewhere, will tell you that you're doing it wrong. Remember, your choices are ultimately between you, your partner, and your provider. Identify a few close friends to confide in, who want the best for you and will support you in your decisions.

Childbirth from the Home to the Hospital

Until the 1900s, childbirth took place in the home. Women commonly labored in an area that was closed off from the rest of the house, surrounded by female family members and friends. They used herbs and drank caudle, a spiced wine, for pain relief and relaxation. As active labor got under way, they were kept warm with the windows closed and candles burning in the room. Once the baby was born, they would remain in this room for a month, being attended by their families. Despite the comfortable environment, childbirth was regarded as dangerous because, in those days, many women did not survive. In the United States, prior to 1900, 1 in 1,000 women and 40 in 1,000 babies died during birth.

In 1531, an innovative military surgeon, Dr. Ambroise Paré, started a school for midwives in Paris. One of his pupil's wives, Louise Bourgeois, became a well-known midwife to the royal court of France, and in 1609, published an influential book on how to practice the craft. She promoted the idea of letting nature take its course: "The time of the birth having arrived, they [midwives] did what their art demanded, which was, the child coming nicely, to reassure friends and family, keep her in a good position, have her eat as appropriate, keep her moderately warm, then help her to use her labor pains to bring everything to a happy conclusion."¹

In the late-1800s, there was a shift in philosophy about childbirth as more men became trained in obstetrics. It wasn't just a field for midwives who had learned their skills as apprentices; it was a science that attracted surgeons. "Lying-in" hospitals were founded in urban areas, and women would travel there to have their babies delivered by male midwives, or accoucheurs. Birth became separate from family life. The use of lifesaving antibiotics and antiseptic solutions became more common. Pain medication was available, and cesareans were a viable option.

Dr. Joseph DeLee, who founded the Chicago Lying-In Hospital in 1899, is considered the father of modern obstetrics. Because of the high complication rates in childbirth, he wondered "if nature did not intend for women to be used up in the process of reproduction, in a manner analogous to salmon, which die after spawning." He believed that labor should be actively managed so as to protect the life of the mother and baby. He suggested that a laboring woman should be heavily sedated to the point of being unconscious, to allow the cervix to dilate. A generous episiotomy should be made and the baby pulled out with forceps. Birth became a completely passive process and family members were not involved.

Dr. DeLee's philosophy influenced generations of obstetricians. By the 1950s, 90 percent of babies in the United States were born in hospitals, and 70 percent of those were delivered with forceps. Hospital staff performed the duties previously delegated to family members. Most women were sedated with ether, giving birth in beds that had rails like a crib and wearing helmets so they wouldn't injure themselves while they were medicated. As technology advanced, medical interventions, such as electronic fetal monitoring, ultrasounds, and epidurals, became the norm.

Today, doctors have replaced midwives, now attending 92 percent of births in the United States. Cesarean sections account for 33 percent of births. Instead of expecting something to go wrong, many women assume that the advantages of modern medicine will guarantee a perfect outcome. They want the latest technology to be available and to have the option to deliver their baby pain-free.

Natural Versus Medicated: The Debate

Women want their birth to be safe. But what safety means is open to discussion. Should you receive medication to speed up the labor or to reduce its pain? Is it better to let nature take its course or undergo an intervention that has its own risks? In the debate over natural or medicated, is there a right answer? The controversy can turn as heated as a political argument! People on both sides of this issue firmly believe that they are doing what is best for themselves and their babies.

Medications to prevent infections, drugs to reduce bleeding, cesareans—these advances in medicine have saved the life of numerous mothers and babies. However, interventions have become the norm, even in low-risk pregnancies. Some of these have undoubtedly benefited families. Others have little evidence to support their use, and a few may actually be harmful. These days, finding the balance between the natural experience and medical interventions is particularly challenging.

Natural childbirth advocates believe that using interventions during labor diminishes the birthing experience, puts women at increased risk, and may have long-term consequences for both mother and baby. They see the pain of labor as "good" and even necessary. Medical interventions are viewed as dangerous and overused, and employed for the convenience of the doctor. They believe that the more we know about pregnancy and birth, the more we lose sight of how perfectly designed it is. They feel safer away from a hospital than in one. They contend that women who have a natural childbirth recover faster and breastfeed more easily. They want to connect intimately to the birth experience, which they believe will allow them to bond with their baby in an enhanced way. They believe a baby born without medical intervention will be calmer and more relaxed. The rediscovered enthusiasm for home births has accelerated in recent years as some women worry that they won't be able to achieve a peaceful birth experience on a maternity ward. With strangers running in and out of the rooms, nurses asking one another about other patients, and a multitude of intrusive machines, the ability to create an intimate, personalized environment in a hospital setting is difficult.

Other moms believe that pregnancy and labor need to be monitored carefully. They recognize that things can go wrong despite the best-laid plans and don't want to take any chances. They admit that labor is too painful to go through it without an epidural and appreciate being able to rest and save their strength for taking care of their newborn. They feel reassured that an operating room is right around the corner. They find comfort in knowing that a pediatrician is readily available if their baby needs any assistance. They know they will have the energy to focus on their baby after the less stressful experience of a medicated birth. They recognize that what feels good may not always be what is safest.

The conflict between natural and interventional birth extends to doctors and midwives as well, who philosophically look at childbirth differently. A doctor is trained to view pregnancy as a medical event and to look for the smallest deviations from the norm that could signal something is wrong. Doctors try to eliminate or at least minimize risks by performing tests, monitoring the mother regularly, and utilizing all of the latest technology.

A midwife views birth as a normal process that women's bodies are designed to undertake without difficulty. She believes that patience will allow nature to take its course. Although these philosophies are different, the goal is the same: to manage the unpredictability of birth.

Deciding What Is Right for You

How do you decide which type of birth is right for you? Some women have a clear vision even before they get pregnant. Others aren't so sure. Natural sounds great but they fear that the pain will be more than they can handle. Some women know they want an epidural as soon as they get to the hospital. Still others plan to do whatever their doctor suggests in the moment.

When considering your options, you must think realistically about your health, your personal risk factors, and your fitness. Do you have a low-risk pregnancy, or do you have a medical condition that cannot be ignored? Has your blood pressure been slowly climbing upward from week to week? Has your baby suddenly done a somersault and is now breech with only a month left in the pregnancy? Are you significantly overweight? When you've spent months preparing for a certain type of birth and you have your heart set on a particular outcome, it's tempting to continue in that direction although it may not be safe.

Whereas some risk factors develop during pregnancy, others appear only once you are in the delivery room in labor. Everything has been going along smoothly, until you find out that your baby is stuck in one position and can't rotate through the birth canal. Or that every time you have a contraction, the baby's heart rate dips because it has inadvertently tied a knot in the umbilical cord. There is no way to predict how a pregnancy will conclude. For this reason, doctors categorize pregnancies as low risk or high risk—there's no such thing as a "no-risk" pregnancy.

Women with low-risk pregnancies have many options for childbirth. If you and your doctor or midwife have determined that you are truly low risk, you can choose a noninterventional birth. You should fully commit to preparing for this during pregnancy. It means intensive education, reading, classes, and reflection. You can't just arrive in the delivery room and say, "I don't want this, I don't want that," without preparing yourself for how you will deal with the realities of labor. Most women who plan for an unmedicated birth attend childbirth classes for at least a few months. They may hire a doula to provide them with continuous emotional support during labor. They eat well and they stay fit. They consider what helps them to relax and prepare accordingly.

Planning for the birthing style you want is where your relationship with your doctor or midwife really counts. Your provider can help you determine what is safest for your individual situation. Hopefully, you will work with someone whom you trust, someone who will listen to your concerns and not dismiss what is important to you. When a mother feels supported, rather than managed, she will have an easier birth. Your labor may take an unexpected turn but your doctor can help you stay on the track you have chosen.

Ultimately, childbirth can be anything: overwhelming, guilt-ridden, beautiful, agonizing, calm, enlightening. I can think of no other life experience that brings out such diametrically opposite emotions—sometimes at the same time. As you think about what you want your birth to be like, you may find yourself overcome with fear or doubt. Remember that every woman has felt the same way at some point in her pregnancy. Odds are you're a lot more capable than you give yourself credit for. Frame your own narrative by listening to the positive stories. Focus on bringing your baby into the world with your loving family cheering you on. And support other women in their choices, whether or not they mirror yours. Stay clear-eyed, with an open mind and an open heart: you're on your way to becoming a mother.