Birth in the United States What your mother didn’t teach you about pregnancy and childbirth

What are an American woman’s options?

Questions  Can you name the places where women in the United States are able to give birth?  About what percentage of women in the United States give birth in the hospital?  Why do you think this is the case?

Some Characteristics of U.S. Childbirth  99.1% give birth in hospital (2006)  80% receive epidural anesthesia (2005)  about 50% births augmented with pitocin (2005)  13.3 maternal deaths/100,000 live births (2006)  31.8% cesarean delivery rate (2007) [Source:

Midwifery

Questions  Can someone describe what a midwife’s role is?  Why might a woman choose to hire a midwife instead of a doctor for her birth?

Midwifery Model of Care Overall theme: Pregnancy and birth are normal life events.  The tenets of the model include:  Monitoring the physical, psychological and social well being of the mother throughout the childbearing cycle  Providing individualized education, counseling and prenatal care, continuous hands on assistance during labor and birth and post partum support  Minimizing technological interventions  Identifying and referring women who require specialized obstetrical services

Midwifery Model of Care  Birth is a social event, a normal part of a woman's life.  Birth is the work of the woman and her family.  The woman is a person experiencing a life-transforming event.  Longer, more in-depth prenatal visits  Information shared with an attitude of personal caring  Familiar language and imagery used

Midwifery Model of Care  Shared decision-making between caregivers and birthing woman  No class distinction between birthing women and caregivers  Awareness of spiritual significance of birth

Medical Model of Care  Pregnancy is viewed as a potentially threatening condition requiring close surveillance and monitoring  The role of technology is highly valued in the process of monitoring the status of women during the childbearing year  The goal is a healthy mother and healthy newborn as the outcome of the labor and delivery process.

Medical Model of Care  Information about health, disease and degree of risk not shared with the patient adequately.  Brief, depersonalized care  Little emotional support  Use of medical language  Spiritual aspects of birth are often ignored

Medical Model of Care  Birth is the work of doctors, nurses, and other experts.  The woman is a patient  "Professional" care that is authoritarian  Dominant-subordinate relationship

U.S. Care Providers  Obstetricians  Family Practitioners  Midwives

Midwives in the United States  There are two main categories of midwives in the U.S.:  Nurse-midwives, who are trained in both nursing and midwifery  Direct entry midwives, who are trained in midwifery only.  Regulation varies from state to state, including licensure, certification, registration and documentation. Only 9 states and the District of Columbia actually prohibit the practice of direct entry midwives

Certified Nurse Midwives (CNMs)  Educated in both nursing and midwifery, primarily work in a hospital setting  Must have at least a Bachelors Degree when training is complete.  Have successfully completed a university-affiliated nurse-midwifery program accredited by the American College of Nurse-Midwives, and passed the exam.  Out-of-hospital clinical experience is not required.  Are legal and can be licensed in all states.  Most practice in hospitals and birth centers.  May legally assist home births in any state. But most of them work in hospitals.  In most states must have some kind of agreement with a doctor for consultation and referral; practicing without such an agreement can lead to loss of license.

Direct-Entry Midwives  Multiple routes of education (apprenticeship, workshops, formal classes or programs, etc., usually a combination).  May or may not have a college degree.  May or may not be certified by a state or national organization.  Legal status varies according to state.  Licensed or regulated in 21 states.  In most states licensed midwives are not required to have any practice agreement with a doctor.  Educational background requirements and licensing requirements vary by state.  Mostly maintain autonomous practices outside of institutions.  Train and practice most often in home or out-of-hospital birth center settings.

Certified Professional Midwife (CPM) Designation  Not required to be nurses.  Multiple routes of education recognized; direct entry midwives and certified nurse midwives can qualify for this credential.  Accredited education programs prepare students to meet the requirements for the CPM.  Out-of-hospital birthing experience is required.  Have met rigorous requirements and passed written exam and hands-on skills evaluation.  Administered by the North American Registry of Midwives.  Legal status varies according to state.  Practice most often in homes and birth centers.

Doulas  Dr. Marshal Klaus says, "If a Doula were a drug, it would be unethical not to use it."  His research shows that having a trained labor companion present during labor reduces the cesarean rate by 50% and the amount women ask for pain medication by 60%.  After birth, mothers who had a trained labor companion believed their babies cried less often than other babies and were more confident that they could care for their babies better than anyone else (Klaus, Kennel, & Klaus, 1993).

Questions  Can anyone describe what a doula is?

Labor/Birth Doula  Someone who provides non-medical and non-midwifery support to a woman leading up to and during her labor and delivery.  They do not perform clinical duties such as heart rate checks or vaginal exams, or give medical advice.  Use techniques like massage, positive positioning, emotional support, encouragement, and nurturing to help women through labor.

Postpartum/Postnatal Doula  Provides support to the mother and family following the birth and immediate postpartum period. This can be up to and beyond six weeks.  May include breastfeeding support, newborn care assistance, cooking, light housekeeping and errands as well as education, companionship and support.

Childbirth Educators  Teach about labor and delivery and different aspects of pregnancy, such as nutrition.  There is no set program for childbirth educators in the United States  Most of the associations center on natural childbirth  The requirements of each program are similar: workshops, evaluated teaching experience, observation of a number of labors and births, and an examination.

Popular American Birth Education Organizations  Most claim to be in place to promote, support and protect natural, safe and healthy birth through education and advocacy

Where Americans Give Birth  Hospital  Birth Center  Home

Birth Centers  Offer excellent care at half the cost of conventional hospital birth  Licensure regulation varies depending on the state so it meets safety and health standards for medical facilities  Center should be accredited by the Commission for the Accreditation of Birth Centers. This requires that the center follows the national standards for birth centers, which for example means the center is prepared to handle emergencies  Generally have arrangements with a hospital, so hassle for transfer to hospital in case of emergency is less likely for transferees than for home birthers  Accreditation criteria specify that no mother should be left by herself  Narcotics rarely available and epidurals never available. A wide variety of nondrug techniques used.

Questions  What are your general thoughts about childbirth in the United States?  Do you notice any clear differences between birth in the United States and birth in Hungary?

A Final Question to Consider  How can a better understanding of both models of childbirth improve the current state of pregnancy and childbirth in Hungary?

Questions or Comments?

Thank you! Köszönöm szépen!

References  American Pregnancy Association  Campbell, D. A., Lake, M. F., Falk, M., & Backstrand, J. R., (2006). A randomized trial of continuous support in labor by a lay doula. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(4), 456–464.  Coalition for Improving Maternity Service (CIMS)  G. Carroli and J. Belizan, Episiotomy for vaginal birth, Cochrane Database Syst Rev (1999) CD  Goer, H. (1999). The Thinking Woman’s Guide to a Better Birth. Berkeley Publishing Group.  Feminist Theory in the Study of Folklore, eds. Susan Tower Hollis, Linda Pershing, and M. Jane Young, U. of Illinois Press, pp ,  Morning Star Birth Services, LLC.