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Today there is a wide range of birthing options available. A woman can choose a birth setting, the type of assistance she receives, and a birthing technique. Which options are best depends on her personal preferences and medical condition, but she also needs to consider both the risks and the benefits of each alternative. Increasingly, pregnant women are getting their information about childbirth options from electronic sources. In a nationally representative sample of over 2,400 mothers, pregnancy and child-related blogs were the most widely used source of information, followed by online forums and discussion boards (Declercq, Sakala, Corry, Applebaum, & Herrlich, 2013). A majority of first-time mothers (59%) also reported taking a childbirth education class, most often at a hospital site.

When a woman decides to give birth in a hospital, she has access to medical professionals and medical technology, including pain medications, but hospitals are sometimes seen as impersonal settings in which the woman gives up much control over the circumstances of the birth. There also has been concern that medical interventions, such as labor induction or cesarean births, are overused when births occur in a hospital setting (Coxon, Sandall, & Fulop, 2014). As an alternative, birth centers provide a home-like atmosphere and give the woman greater autonomy during her labor. They are staffed by certified nurse-midwives rather than obstetricians. While they will have standard medical equipment, the staff does not perform surgical procedures and does not induce labor or administer drugs. For that reason, a woman might choose a hospital birth center rather than a freestanding center because pain relief, fetal monitoring, and surgery are all close at hand at a hospital birth center, if they are needed (Conaway, 2012).

Birthing options. Women have a choice about where and how they give birth. The birth can take place in a hospital, in a birthing center, or at home. The birth can be attended by a physician or midwife. What do you see as the advantages or disadvantages of each of these alternatives?

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The number of U.S. women who choose to give birth outside of a hospital has increased in recent years, but still only represents about 1.5% of births (Hamilton, Martin, Osterman, Curtin, & Mathews, 2015). While home births are generally considered safe, their safety is in large part attributable to the fact that only women with low-risk pregnancies tend to choose this option. When a woman plans a home birth, it is important that the midwife who attends the birth is a certified nurse-midwife who has the professional training required to safely oversee the delivery and who knows when it is necessary to transport the woman to a medical center. Being attended by someone who lacks such credentials could put both mother and newborn at risk (Tuteur, 2016).

In the United States, 90% of births are attended by a physician, who has most often been trained in obstetrics and gynecology. About 8% of hospital births and 31.4% of out-of-hospital births are attended by midwives (Martin, Hamilton, Osterman, Curtin, & Mathews, 2015). Although the number of births attended by midwives in the United States has risen every year since 1989, it still significantly lags behind the number in other parts of the world.

In addition to physicians and midwives, doulas and birth coaches may support a woman during her labor. Unlike a physician or midwife, a doula does not directly assist in the birth process but rather is a trained, knowledgeable companion who is present to support the woman through her labor and delivery. The support a doula provides has been associated with lower rates of cesarean section and forceps deliveries, less use of epidurals and other pain medications, shorter labors, greater satisfaction with birth experiences, and fewer low birth weight babies (Green & Hotelling, 2014; Gruber, Cupito, & Dobson, 2013). One explanation for these results is that when the doula reassures a woman that what she is experiencing is normal, it reduces the amount of stress hormones she produces during her labor. A husband, partner, relative, or close friend who has attended childbirth preparation classes with the woman can act as a birth coach who can help the woman relax, make her more comfortable during her labor, and provide emotional support.

Doula: A trained, knowledgeable companion who supports a woman during her labor and delivery.

One of the most dramatic changes in American childbirth in recent years is the number of children born by cesarean delivery, in which the baby is delivered through an incision made in the woman’s lower abdomen. In 2014, almost one third of all U.S. births were cesarean births (see Figure 4.8) (Hamilton et al., 2015). While cesarean deliveries were once the result of medical necessity, at least part of the recent increase has been attributed to nonmedical reasons that include maternal choice, more conservative medical practice guidelines that call for surgical intervention sooner, and physicians’ fear of litigation. In an evaluation of the benefits and risks of an elective cesarean compared to a vaginal delivery, the American Congress of Obstetricians and Gynecologists (2013, reaffirmed 2015) came to the conclusion that vaginal birth should be recommended whenever possible and cesarean birth not be recommended if the woman is planning to have several children because of the increased risks associated with subsequent births after an earlier cesarean.

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Figure 4.8 Rates of Cesarean births, 2009, 2013, 2014.

Source: Martin, Hamilton, and Osterman (2015).

Although giving birth is universal, the birth process itself may be quite different from one culture to another, as these few examples illustrate:

 An Ifaluk woman, who lives in Micronesia on one of two tiny islands in the Pacific Ocean, gives birth in a birth house, accompanied by a midwife and her female relatives (Le, 2000). When the baby is ready to be born, the woman kneels on a mat and helps the baby out by herself. She must try not to show distress or pain, in accord with the Ifaluk value of remaining calm at all times. If there are complications, the other women will help. After the baby is born, the woman’s mother helps by holding the baby and then bathes the baby in the ocean.

 In the Netherlands, most expectant women are referred by their family doctor to a local midwife practice (Christiaens, Nieuwenhuijze, & de Vries, 2013). Doctors only intervene if there are complications or it is a high-risk delivery. All expectant mothers are required to pick up a packet containing the medical supplies necessary for a home birth. If a woman chooses to give birth in a hospital rather than at home, her midwife makes a home visit to determine when it is time to go to the hospital. If a hospital birth occurs early in the day and without complications, mother and baby may go home in as little as two hours (Schalken, n.d.).

 In remote rural areas of Nepal, many women prefer to give birth in a goth, a small outbuilding near the main house or in the lower section of the house used for animals. In preparation, the floor of the goth is covered with clean straw. Giving birth there avoids bringing birth pollution into the house which would offend the God in the house. It is meant to ensure the health and safety of the mother and the newborn, and also allows the woman to manage and control her own birth process (Kaphle, Hancock, & Newman, 2013).

Despite the availability of trained medical specialists and an array of medical technology in modern hospitals, maternal mortality rates have actually increased in the United States in recent years, a trend that is counter to what is happening in most countries around the world (Tavernise, 2016). In 2013, the rate in the United States was 28 maternal deaths per 100,000 births, an increase from 17 deaths per 100,000 births in 2005 (World Health Organization, 2014). Failure to receive adequate prenatal care, the greater number of pregnant women who suffer from chronic conditions, increased maternal age, and higher rates of obesity among U.S. women all may contribute to this disturbing trend. Some critics have charged that another contributing factor may be our focus on fetal and infant safety in recent years, which diverts attention from the medical needs of the mother and places her at an increased risk (Hogan, 2017; National Public Radio, 2017).

T/F #7

The rate of maternal mortality in the United States is increasing. True

Within the United States, disturbing disparities exist in the rates of maternal mortality during pregnancy or within one year of the birth. Between 2011 and 2013, the rate for Black women (43.5 per 100,000 pregnancies) was more than 3 times as high as the rate for White women (12.7 per 100,000 pregnancies; CDC, 2017p). And although Black women develop life-threatening conditions such as hemorrhage at the same rate as White women, they are two to three times as likely to die from them (Tucker, Berg, Callaghan, & Hsia, 2007). The reasons for the extreme racial disparities in maternal mortality have not yet been explained.