Have It Your Way: Redesigning Birth

Water birth, homebirth, HypnoBirthing--when Marion McCartney started as a nurse-midwife 30 years ago, none of those were popular, and birth was just birth. Women didn't get to choose their method of labor. If they were lucky, their doctors let them choose who stayed beside them as they pushed. "It was a medical event, not a personal experience," McCartney says. "Women were chaining their husbands to the delivery table so they'd be allowed to stay in the room. They didn't have any control."

Today they've got almost more control than the doctors. From working mothers who schedule Caesarean sections around their office hours to those who insist on laboring at home on a birthing seat, expectant mothers are increasingly giving birth on their own terms. "Women are taking a bigger role in what they want from childbirth," says Dr. Mari-Paule Thiet, chief of obstetrics at the University of California, San Francisco's Birth Center. "And physicians are listening more." But how to respond? Should doctors "medicalize" birth even more, go alternative or seek out a middle ground? And how can they ensure that they give women autonomy without ceding too much of their own authority?

For many women, control means scheduling a birth the same way they'd schedule a doctor's appointment. C-sections, many of them elective, now account for one in four births in the United States. Many women with little medical need for the procedure specifically request it, in part because it may be less likely to cause pelvic-floor dysfunction (a condition resulting in incontinence and pain) postpregnancy--and in part to avoid the inconvenience of waiting for the baby to decide to come out. C-sections are invasive procedures, though, and studies are divided on how safe they are compared with vaginal deliveries. The American College of Obstetricians and Gynecologists says it's ethical for doctors to perform elective C-sections, but Dr. Laura Riley, chair of ACOG's obstetrics-practice committee, discourages her own patients from having them.

At the same time, many women are choosing to give birth at home--and they may not have a doctor present at all. Although most women today believe the hospital is the safest place to give birth, more of them are staying home or flocking to medical facilities that mimic the home environment, and many prefer doulas, who act as birth "coaches," or midwives to doctors. America's 8,000 nurse-midwives now perform about 10 percent of vaginal deliveries. Most of them are women, which may benefit mothers-to-be. Several studies have found that having another woman present during delivery, whether or not she's trained in obstetrics, lessens the need for medical intervention during labor. That's something women have instinctively known for ages: in almost all ancient cultures, labor attendants were female. Many of the other "new" home-birthing trends hark back to ancient times, too. The kneeling position, which some women prefer, was standard for ancient Hawaiians; birthing seats popular today owe their shape to stools designed by Egyptians 4,000 years ago.

But women are also seeking out less time-tested techniques like HypnoBirthing, a trademarked curriculum that trains expectant moms in visualization, relaxation and self-hypnosis techniques, which are then used during delivery in lieu of drugs. Some studies indicate that hypnosis can cut down on pain and complications and possibly even shorten labor, but the method, developed in 1989, is still poorly understood. Women who train in HypnoBirthing are often warned that their doctors may object to the technique and try to give them pain relievers instead.

Even doctors open to alternative treatments draw the line at underwater birth, in which women deliver their babies in a specially designed shallow tub. Jerold F. Lucey, M.D., editor of the journal Pediatrics, wrote in the October 2003 issue that he had "always considered underwater birth a bad joke, useless, a fad which was so idiotic it would go away. It hasn't!" Underwater birth undoubtedly soothes expectant mothers' nerves, but most doctors feel that it's unsafe for babies, who may aspirate water as they emerge from the birth canal.

Still, women may benefit from sitting in the pools during the first stages of labor. A recent article in the British Medical Journal reported that women who used the pools early in labor but actually gave birth in beds were less likely to request epidurals. That kind of compromise may be the future of birth in America. "We try not to let patients totally dictate the way their labor is managed," says Thiet, whose UCSF birth center offers pools for the early, but not late, stages of labor. "But we do want them to have a say." After all, in the last 30 years they've gotten a say in almost everything else.

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