Good training is important, but so is the birth environment. We shouldn’t separate the mother from the child, literally or figuratively, without attention to stress. Stress is a normal part of birth, but there is such a thing as too much. Read birth stories on parenting and pregnancy websites, and you’ll find women describing lingering mental trauma from hospital experiences, trauma that clinicians may not have even registered. Women may undergo an unfamiliar humiliation, a loss of all control at a transformative moment in their lives when that sort of stress can have lasting effects. If they’re like me, they turn to home birth with the hope that it will limit stress for everyone involved, in part because of familiar surroundings and the very personal care a midwife provides for her and the baby.
Obviously, a healthy child is paramount, but the woman is important, too, and safety and a reduced-stress environment are not mutually exclusive in a country where medical care should be exceptional. There are important reasons to consider a birthing woman’s needs. Some studies indicate that anxiety is no friend to labor progression. And then there are the longer-term outcomes. For example, experiencing “pressure to have an induction and epidural anesthesia” has been linked to post-traumatic stress disorder in women. Another large analysis of several PTSD and childbirth studies found that risk factors for PTSD included “obstetric procedures, negative aspects in staff-mother contact, [and] feelings of loss of control over the situation.” Maternal distress may be a risk factor for PTSD later in the child, and those early experiences between mother and child may matter for a lifetime. In other words, maternal stress is relevant, and having some say in this transformative experience is important to reducing that strain so that a mother can parent her new baby effectively.
What choices do women in the U.S. have that empower the woman and offer a safe, stress-reduced birthing environment? Harriet Hall, a doctor who is a considerate and calm proponent of hospital birth, has noted that integrating a “kinder, gentler, less-interventionist midwife approach into a home-like hospital birthing facility” would increase patient satisfaction without sacrificing safety. Indeed, the hospital where we had our third son offered such a setting, the elusive “just-right” balance for us. Hall also has said, “We need to figure out (with science)” what is “beneficial, to improve the safety of both homebirths and hospital births.”
True. But many women in the United States who don’t live in “progressive” areas continue to have little more than a binary choice between a heavily medicalized hospital experience and whatever limited midwifery option is available near them, which can range from lay midwives with little formal medical training to well-trained, experienced certified nurse midwives with hospital backup. Science-based conclusions about what really constitutes “safe” homebirth remain unobtainable without an infrastructure of certified nurse midwives available across the United States. Non-U.S. data tell us that birth attendant training and experience carry considerable weight, regardless of location, and that with a well-trained attendant, nonhospital births can provide a lower-stress environment and still be safe.
The obvious solution to the controversy is to offer choices that reduce perinatal stress, minimize interventions, and personalize birth—the great appeal of home birth and midwives—while ensuring a safe outcome with well-trained attendants and access to emergency facilities. The absence of options in the United States leaves this solution elusive, especially where hospitals lack a homey, low-stress environment and local midwifery care fails to meet the gold standard. Strange, isn’t it, that our nation, in the 21st century, can’t offer more uniformly safe choices for a low-risk pregnant woman seeking a healthy, low-stress birth for her child … and herself?