Not All Vaginal Birth is ‘Natural Childbirth’

I recently came across a post on Facebook that included a clip of a news program talking about birth in which instrumental deliveries were described as ‘natural childbirth’. There seems to be some confusion as to what natural childbirth is, and anything that is not a cesarean section is now labeled natural childbirth. And this is not new. Back in 1986, there was an article in the Wall Street Journal that made the same error. A colleague and I wrote a letter to the editor challenging that assumption. Thirty years on, the media around the globe are confusing, or conflating, any birth that happens through the vaginal route as natural childbirth. This ignores the increasingly medicalized experience that most women giving birth in hospitals endure. Births that are obstetrically driven, whether in the US where doctors dominate in nearly 90% of births, or in ‘consultant’ units in the UK where midwives are practicing according to obstetric protocols, will reflect the attitude of an emergency waiting to happen. The adage that ‘birth can only be called normal in retrospect’ is the guiding principle of obstetric care and is completely at odds with what natural childbirth is.

What is natural childbirth?

I was a certified childbirth educator for twenty years in the United States before immigrating to the UK in 1998. In my classes we talked about how natural childbirth means different things to different people: for some it means being conscious during birth; for some it means not taking medication during birth; for some it means a noninterventionistic birth – without all the technological trappings that exist; and for some it means birthing outside a hospital.  Hospital birth is always an institutional experience, even when women succeed in giving birth without all the medical accoutrements on offer. For me the obvious, yet unacknowledged, meaning to this phrase is that it puts us back in touch with NATURE, being in tune with the natural cycles of life, of which birth is just one, with less dependence on the mechanical nature of technological birth, and more in tune with the earth matrix, our bodies and our sexuality.

My definition of natural childbirth is to move through the experience of labor and delivery on our own power, our own steam, spontaneously, instinctively, and completely uninhibited by others or policies. It requires a wealth of information to compensate for what we have not learned all our lives – there is a real gap in what women grow up knowing about childbirth. It must be grounded in physical reality and not just theoretically presented, and when this happens the body has a memory of what to expect. It must respect that each of us brings our own interpretation into the birth process, so that even though my reality will be different from yours, WE ALL BIRTH IN ACCORDANCE WITH THE WAY WE LIVE. We often play out our issues during the grand drama called birth. It exemplifies birth as a personal expression of power, while incorporating trust in the process and in our bodies, as birth is an unknown territory in life, especially for first time mothers.

The value of good preparation for childbirth

I believe that childbirth education needs to address the woman as a whole person giving birth, and not just focus on particular body parts, and that the mother brings many levels of experience into birth – physical, mental, emotional and spiritual. She does this within the context of her relationship with her partner, the social context of her life, within a family and within a culture. This is a holistic framework for preparing for birth which I taught through my Birth Empowerment^® Childbirth Preparation, and The Birth Empowerment Workshop^®, which added the emotional and spiritual components for the journey into parenthood. One emphasis of my teaching was birth as an initiation into parenthood, and that the quality of our birth experience will affect how we accept our role as parents and how we receive our child into our loving arms. This rite of passage is often forgotten in the institutional experience of birth in hospitals, and may be one of the contributing factors in the increased incidence of women being traumatized by birth.

Traumatic birth is happening to women all over the world, due to the intensified medicalization of childbirth, and the numbers are staggering – between 33 – 45 % of women perceive their birth to be traumatic (Beck, Driscoll & Watson, 2013). These figures include studies from the US, Australia and the UK, as well as other countries. Although they might not meet the full criteria of post-traumatic stress disorder (PTSD), which is approximately 3% and rises to 15% for women at high risk, mothers are coming away from their births feeling traumatized, which is not a good way to start family life. What happened? When I was actively teaching, the incidence of traumatic birth was relatively rare, but today women are often deeply disturbed by the experience that they’ve had, and the uncaring treatment they have received at the hands of health care professionals. I like to think that the comprehensive education that I provided for my couples helped them to meet the challenge of birth knowing what to expect and what they could do to make themselves as comfortable as possible, and to move through the process powerfully. When women feel out of control and powerless, their perception of birth can be traumatic.

Normal birth and the cascade of interventions

Definitions of normal birth can be as varied as those for natural childbirth. But what’s normal about having a baby in a hospital, with protocols and policies that are there to protect the institution, and not in the best interests of the parents – no matter what the professionals claim? Is a birth where the baby is removed by forceps or ventouse (vacuum) normal? Is a woman tethered to an electronica fetal monitor throughout labor normal? Is induction of birth before the baby is ready to be born normal? Is anesthetized birth normal? Is the administration of synthetic oxytocin to start or augment labor normal? What’s normal about the proliferation of interventions that women are subjected to when they enter a hospital? And what about the pressure to consent, not always informed, to the use of these interventions that can cascade into an onslaught of additional interference when the effects of one cause the need for others?

Failed inductions are known to increase the rate of cesarean sections up to 65% (Arulkumaran, et al, 1985; a statistic that is 30 years old), but even if we don’t end up with a surgical delivery, one thing leads to another. Let’s see how that might unfold, starting with a prostaglandins gel, like misoprostol, that is meant to efface (thin out) the cervix so it can start dilating. This can take hours to happen, tiring out the mother before things even get started. If that doesn’t work, then we add in amniotomy – artificial rupture of membranes (AROM), to see if that will do the trick. If not, then we add in the administration of pitocin/syntocinon, artificial oxytocin, through an IV to start the contractions. When this isn’t monitored properly, and too much is given, the contractions become very painful, which then leads to the use of epidurals to numb the pain. The side effects of epiduals include a transient slowing of the intensity and frequency of contractions, prolonging the total length of labor, which could then lead to more artificial hormones in a vicious cycle. Of course epidurals come as a package deal, so there’s also an IV and electronic fetal monitoring (plus the hormones) to make sure the effects of all these interventions are not compromising the fetus. Epidurals can be incomplete and only work on one side (sometimes called ‘flunking your epidural’), or they can become unintentional spinal anesthesia when the catheter enters the spinal cord instead of the epidural space surrounding it. Blood pressure drops in about 15% of women and they change the normal pattern of oxytocin surges that occur at the end of the first and second stages. However, the main issue is the loss of tone in the pelvic musculature and the loss of counteractive pressure from the pelvic muscles that helps the baby rotate into the proper position for delivery. Without that tone epidurals can cause malrotation of the baby’s head during expulsive efforts and a diminished urge to push, resulting in instrumental deliveries, which happen in 20% of births with epidurals. Whether it’s a ventouse (where a suction cup is attached to the baby’s head) or forceps (steel devices that resemble salad spoons), these require an episiotomy and apply a lot of pressure to the baby’s head while being pulled out of the body. If all these interventions are done without proper informed consent, it can leave the mother and her partner reeling from the overload of medicalization. It’s no wonder they feel traumatized. None of this is normal birth, though hospital staff might view it as such, mainly because that’s what is familiar to them. It may be vaginal birth, but it’s not natural childbirth.

Midwives and out of hospital birth

Natural and normal births are more likely to happen in out of hospital births – in birth centers and at home. Because these locations are not equipped with all the paraphernalia, a woman is encouraged to find non-pharmacological ways to manage the intensity and pain of her labor and to draw on her own inner resources. She is more likely to be attended by a midwife, who in the UK is the autonomous professional who leads on normal birth and only makes referrals to an obstetrician when there are complications. This model is used in Australia as well, but in the US only about 12% of births are attended by midwives, and usually with the requirement that an obstetrician is available for back up. What an American midwife has over a Commonwealth midwife is continuity of care. Midwifery care in the UK is fragmented, and community midwives see women before and after the birth, but a hospital midwife, usually unknown to the laboring woman, is the one who managing parturition (labor and delivery). Only if a woman chooses a home birth is she able to see the same midwives for the duration of pregnancy, birth and the postnatal period. A woman needs to feel a deep sense of confidence in herself as a birthing woman to choose to give birth outside a hospital because she can be bombarded with people asking ‘what if’ questions challenging her decision. Even though the advent of hospital birth is still less than a century old, the hegemony of ‘birth as a medical event’ is overpowering. And let’s face it – the decision to hospitalize women for childbirth was made for the convenience of the doctors, not the mothers. Women are naturally out of power in hospitals, unless they work there, and that contributes to a heightened sense of fear in women approaching birth.

After some time away from birth when I was working as an academic health researcher, when I returned to birth work I was shocked to see the level of fear that had permeated the consciousness of women having babies. Why was this? I believe they are not getting the kind of preparation that they need in order to reduce the fearful aspects of birth – fear of the unknown, fear of the pain, or fear of the power of birth. Knowledge is power, and never was that slogan more appropriate as when applied to birth preparation. And it’s also the practical application of that knowledge that empowers women to step over that threshold feeling in charge of what happens to her, and able to negotiate with her attendants. I’m not saying that women should never have the interventions that I’ve mentioned above.  Women need to be part of the decision making process when these interventions are needed, and they are necessary sometimes.  When women feel listened to and part of the process, they can accept the necessity because they’ve asked the questions and received the answers. This is what minimizes the experience of trauma during birth, as being out of control is one of the biggest contributors to women feeling traumatized.

Conclusion

I hope the media will take note that natural childbirth is a very different phenomenon to vaginal birth, which can be loaded with any number of interventions that make it wholly unnatural. The media like to create catchy headlines and often focus on the wrong thing. Recently the UK National Maternity Review came up with a number of positive strategies to make birth better, but the media chose to single out the suggestion that women receive a £3000 personal budget to use towards the planning of their pregnancy and birth. All the many headlines stirred up the public about the £3000 for women instead of all the other valuable approaches for making birth healthier for British women, reflecting a national consultation around the UK in which all stakeholders had the chance to input into the results. In most cases, vaginal birth is preferred over cesarean sections because the risks of surgical deliveries are much higher for baby and mother. Going back to the original media hype I mentioned at the start, the news clip was highlighting the incidence of birth injuries caused to babies by botched up forceps deliveries, done to reduce the rates of cesarean sections. We don’t want to trade in one set of risks for another. We also don’t want to misconstrue what true natural childbirth is. Let’s get back to nature – there’s great power there!

References:

Beck, Cheryl Tatano, Jeanne Watson Driscoll and Sue Watson (2013) Traumatic Childbirth, London and New York, Routledge.

Arulkumaran S, Gibb DM, TambyRaja RL, Heng SH, Ratnam SS (1985) ‘Failed Induction of Labour’, Australia and New Zealand Journal of Obstetrics and Gynaecology, August, 25:3, pp. 190-3.

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