Optimal Maternity Care

The book Pushed was published in 2007 and in it Jennifer Block writes about “the painful truth about Childbirth and Modern Maternity Care” in the United States of America. I wish I could say that in the USA today, in 2018, her book is outdated and things just aren’t like that anymore.

Instead her book is still disturbingly relevant. I often found myself turning to Google thinking that can’t possibly still be true— hoping things had changed, with fresh statistics, better policies, better care.

Eleven years may have passed but “modern” maternity care seems stuck, often going from bad to worse. The following statistics are national averages for the United States of America. The numbers from 2007 come from Pushed and the numbers from 2018 come from Evidence Based Birth, mostly, I had to outsource a few.

In 2007 the cesarean rate was 30% in 2018 it is 32%.

In 2007 the VBAC rate was 11% in 2018 it is 9.2%.

In 2007 labor was artificially induced approximately 40% of the time in 2018 it is 42.9%.

In 2007 (Listening to Mothers ii) 75% of women once admitted to hospital report not moving around in 2018 it is still 57%.

In 2007 (same report) more than 50% of the respondents pushed laying on their backs in 2018 68% did the same.

These numbers can be a little misleading and are probably even higher because of the rampant use of epidurals in American hospitals. Once you get an epidural you are confined to bed, have an IV, a catheter, and continuous EFM.

In 2007 the epidural rate was approximately 80% and it still hovers around 70% in 2018.

This number can fluctuate from hospital to hospital. I feel safe saying that the majority of women in hospitals get an epidural at some point during their birth experience.

In 2007 only 3% of women contracted a doula in 2018 it is 6%. (Still single digits but progress is progress and that is twice as many women)

99% of pregnant women gave birth in hospitals in 2007 and while planned home/Birth Center births are starting to rise again these births still account for less than 2% of the total in 2018.

The scary one is that the Maternal Mortality Rate was 12.7% in 2007 but it was 26.4% in 2017. Yes you read that correctly.

These numbers mostly hold true for Pittsburgh as well. As a practicing doula, I’ve seen it for myself. The following numbers for Cesarean and Vaginal Birth After Cesarean (VBAC) are from 2016 for local Pittsburgh hospitals and I wouldn’t be surprised if they are still holding to the same.

Magee 30% (C rate) 15% (VBAC)

West Penn 37% 10-15%

Mercy 31.4% 10-15%

St. Clair 34.6% <5%

Midwife Center 12.5% 80% of VBAC attempts resulted in vaginal births.

That this is still true- is frustrating and hard to believe, plus there seems there is a gap between reality and perception.

As Christiane Northrup, MD, author of Women’s Bodies, Women’s Wisdom, remarked in 2006, “Why are women willing to put up with so little?” 

Here’s that gap—83% of the women surveyed by Childbirth Connection in 2005 rated their experience good or excellent, regardless of how they gave birth. If you would apply the Optimality Index (see below) to their actual experiences, just 2% had an optimal experience.

Is the gap the lack of quality information, not being fully informed, or are women simply not given all their options, letting the doctor/staff make the decisions? Or is it something else?

As Jennifer Block puts it: “women are getting pressure from medical providers to go against instinct and research—to induce labor, schedule a cesarean, lie back during labor when every cell in your body tells you to move. Virtually everyone involved in maternity care is also on the receiving end of this pushing—the hospital, the doctor, the nurse, the midwife, the doula—all are caught in a system that discourages, to some degree, their providing optimal care.

Everyone is caught on the merry-go-round, which leads to the obvious question: Why does it keep spinning?” Pushed Jennifer Block pages: xiii-xiv

Birth in America may still be far from optimal, the system as structured will not serve you well. But I say why wait for the system to catch up— there exists plenty of ways to work around, against, and with this system.

I teach plenty of alternative approaches, I counsel and I suggest, BUT I can’t do it for you, you must be your own agent of change.

Does it matter? It most certainly does. If anything is ever going to change it has to start right now with you and the choices you make.

It starts by seeing the reality for what it really is—making your decisions from that space—and then implementing your decisions. The choice to not remain clouded by misconception and misinterpretation, the decision to not caught up in the system, and most importantly, the choice to not just blindly follow the mandates of Managed Maternity Care.

If you want birth in America to change then you have to be the change. I am more than willing to help you in any way I can. It is why I teach Prenatal Yoga, and Yoga-Based Birth Skills. It is why I am a Birth Doula and why I write The Whole Way.

You have to stop saying YES when you really mean NO and vice versa.

I encourage you to stop marching to the tune set by Managed Maternity Care, whatever its source, and instead arming yourself with the information presented here, and elsewhere, giving yourself your own power— the power to take charge of your own birth experience.

And now I will step down from my soapbox.

I carefully constructed that list of statistics above to reflect what Jennifer Block refers to as a prescription for a normal birth.  In this, as in Yoga, the prescription is not the challenge, taking the medicine is the challenge.

If the prescription is the information (right knowledge) then the medicine is making it a reality. The doing. 

In the book Pushed, I came across the Optimality Index, Mother Friendly Care, and Optimal Maternity Care.

“The American College of Nurse-Midwives developed a research tool to evaluate maternity care. Like the Apgar, the Optimality Index is a score. But rather than measuring an individual outcome, the index is intended to measure the quality of care across an institution or population. The index defines optimal care as the World Health Organization does: essentially, “no interference.” Points are deducted for induction, augmentation, early vaginal exams, epidural, continuous EFM, directed pushing, flat-on-back pushing, episiotomy, and separation of mother and baby.” Jennifer Block, Pushed p.133

In 2007 she reports that only ONE US hospital met all the requirements. In 2018 while there does seem to be more hospitals, there are no Pittsburgh facilities on the websites I looked at.

What I can say is that in 2018 there is the Coalition for Improving Maternity Services Expert Work Group, the Mother Friendly Childbirth Initiative, the Citizens for Midwifery and Birthwork National whose work and research has been taken up and supported by many organizations including The Midwives Alliance, DONA, and Lamaze. There is hope and information and an effort towards change.

So—What is Optimal Maternity Care?

According to the systemic evidence reviews conducted by the Cochrane Collaboration, Optimal Maternity Care can be distilled into six characteristics.

  • Labor begins spontaneously.
  • Women have freedom of movement during labor.
  • Interventions are medically justified rather than routine.
  • Women have continuous emotional and physical support.
  • Pushing occurs in any position but flat on the back.
  • Mother and baby are not separated.

Given simplistic nature of these characteristics, and the fact that this list has been in place for eleven years now—why are women still not receiving this type of care? Why are they not demanding it? Why are they settling?

The “bitter pill” to swallow is that if you want Optimal Maternity Care for yourself then you need to do as Jennifer Block instructed either find the right provider or start demanding better practices from the one you’ve got.

Yoga presents a third option—-you do it for yourself. Use the options, approaches and the information you will find in these pages.

The Yoga Sutras advise one to stop looking to the outside for relief from suffering and find your own relief inside yourself.

That’s the prescription so here’s the medicine:

  • you must say no to offers of early induction when offered for non-medical reasons and for non-valid "medical" reasons
  • you must get up and move UNLESS it is your choice to rest periodically
  • you must know the difference between medically justified and routine for a wide variety of interventions, then YOU determine what is the best course.
  • you hire a doula, train your birth partner, assemble your team
  • you flat out refuse to go flat on your back UNLESS it is by your choice for pushing and you are prepared to accept the consequences
  • you begin immediate skin to skin contact with your baby for the very minimum of one hour after birth, immediately beginning to breastfeed UNLESS you or your baby require immediate medically justified intervention.

Not easily accomplished but the benefits to you and your baby are enormous. Let’s get started.

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