Saturday, May 14, 2011

Should we trust birth?

"Trust birth" is a phrase that I've commonly heard among those in the natural or home birth advocacy movement. There are even Trust Birth groups springing up advocating this. Such groups may state that trusting birth is natural, and fearing or distrusting birth is unnatural and has simply been taught through our culture. Is this correct? Fear of childbirth has in fact been common throughout history, in all times and cultures. Why? Because while birth is a natural process, it is also naturally a dangerous process. Childbirth in humans is an evolutionary bottle neck, where the advantageous feature of large, well developed brains conflicts with the advantageous feature of narrow pelvises, to aid bipedalism. It is also a complex process, to which no other natural process can be an adequate comparison. Pregnancy itself precariously balances the needs and health of the fetus against the needs and health of the mother. The result is historically high rates of both perinatal (around the time of birth) mortality for the babies involved and maternal mortality. This has the evolutionary purpose of keeping head and pelvis size in check, yet as a human event each loss represents a tragedy. We are not willing to accept the death of a human being as simply "evolution in action."

Improved sanitation and nutrition and modern medicine -- including antibiotics, safer cesarean sections, improved ability to monitor the health of mom and baby during pregnancy and childbirth, and developments in neonatal resuscitation and life support, among many others -- have dramatically decreased the perinatal and maternal mortality rates, although attempts to further reduce it are constantly being made. We now take these improvements in mortality rates for granted. We assume that mother and child will come through birth and be fine. Ironically, it is these very improvements that allow us to assume that birth is low risk and worthy of trust.

If we cannot trust birth, should we then fear birth? Are all interventions good and necessary, with no harmful side effects? Is the best response to make birth a completely medicalized event, attempting to remove all uncertainty? This position forgets that birth, as a natural physiological process, is not fully understood by science. We know of what can go wrong, but still often do not know why it goes wrong. We don't fully understand the purposes of the natural physiology of birth -- we can't know for certain what elements in the process of birth serve a purpose in the health of the mother and child, and we don't always know the long term effects of medical interventions.

I propose the best attitude of a birth attendant is not "trust birth," nor is it "fear birth," but rather is "respect birth." That is, respect birth both as a natural physiological process which goes well much of the time, AND respect birth as a complex event with inherent and natural risks. Birth attendants need both to allow labor and birth to unfold, and to exercise vigilance and intervene when deviations from normal begin to put mother and child at risk. This balance isn't easy, it likely takes significant training both in normal births and potential complications. It means accepting and responding to the scientific evidence on birth practices and interventions without prejudiced ideology. It means abandoning simple catch phrases or black and white positions and truly grappling with what we know, and what we don't know.


  1. This is not a rant at all, Becky, but a well-thought-out opinion that I think most women share. I love your comment decrying a "black-and-white approach to childbirth (and I think breastfeeding, schooling, eating, religion, relationships, all-of-life could be waxed into this ball). Every situation is different and it is important that we trust nature AND science. Neither is perfect and both are forever intimately related. Respect is an excellent word. Great post.

  2. I admit am uncomfortable with the term "trust birth". Mainly because it begs a question that it doesn't really answer- trust birth to.... what? Work correctly most of the time? What do we mean by "most" if that is the case?

    As far as "Trust Birth" as a movement, I have less problem. The Trust Birth Initiative's beliefs are stated here: Some of them are overly simplistic, admittedly. But for *most* (there is that word again!) women, birth will work fine. For these women, any disturbance to the balance of hormones has the potential to be detrimental to her labor. Even dangerous. And since most people really aren't aware of this, I have no problem with this movement as a sharing of knowledge. I guess my problem is that I don't think the name "Trust Birth" necessarily encompasses what the belief statement conveys- I think Respect Birth or Informed Birth or Respect Birthing Women would be more appropriate.

    The (not minor) problem with this advocacy, is what about the other side of *most*? Those who are truly not low-risk? Pre-eclampsia, blood incompatibilities, serious malpositioning, placental issues. Even though it works right most of the time, pregnancy and birth are imperfect physical processes. And there is a segment of the NCB movement (I can't speak to the Trust Birth movement, just NCB in general) that tends to minimize these problems or blame them on mothers, discrediting their advocacy and making them look like zealots. Seriously troublesome. How do we talk about the "most of the times" without women blaming? Is it so much to ask for evidence-based, compassionate, holistic care for both low and high risk women?

  3. While I agree with several of their listed beliefs, I do have a significant problem with many others, because I see in many of them overemphasis on the risks of interventions and minimization of the risks inherent in birth or in birthing away from emergency medical care, just as some OBs may overemphasize the risks that THEY are uncomfortable with, while minimizing the risks of interventions. I see this movement not as sharing the truth, but in creating a fear of hospitals and interventions by overemphasizing their risks. I absolutely believe in a balanced and truthful presentation of risk and benefit, but I don't think a group that proclaims on their front page "Birth is safe, Interference is risky!" is presenting the full truth.

    For some women, and in some situations (such as back up and transfer time, available care providers), hospital birth is safer than home birth. All interventions have risks, but they also have benefits and there are times when not intervening has risks. I don't think the evidence is that birth "rarely needs medical intervention," although it usually doesn't, the times when such intervention is needed or beneficial are not rare. A balanced and truthful presentation of risk and benefit can't use oversimplified catch phrases. Perhaps, though, this can be seen as a balance to the medical establishment? I just worry about women rejecting hospital and medical care out of fear and misinformation when it would in fact be beneficial or lifesaving in their case.

  4. OH and sorry for being long winded. When talking about birth, brevity is not my strong point ;)

  5. Oh, no don't apologize! I'd really like to hear your viewpoint.

    I don't know WHAT I think anymore. After digging into further original research, there has been too often that what I thought I knew is an oversimplification, sometimes to the point of being false and misleading.

    One thing I am sure of, though, is that I don't know everything, and I don't think my "intuition" itself is sufficient. The problem comes in when I am uncertain of which expert to listen to. Sigh. So I'm making the decisions with which I'm most comfortable, now, even if they're not perfect.

  6. I think most of this comes down to general beliefs about birth. As you pointed out, there is risk minimizing and overinflating on both sides of this issue. I think you nailed it with this: "Perhaps, though, this can be seen as a balance to the medical establishment?" I think that it is exactly that- a response to the medical model of birth and the abuses that have occurred there. The pendulum swinging the other way, if you will.

    I am not sure there is an unbiased way to present the information, though we should strive to. I mean, people can look at the same statistics and come away with completely different conclusions. What constitutes reasonable risk is pretty individual.

    RE: use of the word rarely. Again, so relative. I mean, what I consider "rarely" may not be what someone else considers "rarely", right? And the birth that "rarely needs medical intervention" might cause me to feel safe at home while it might drive someone else to birth at the hospital just in case. Are both of those reasonable responses?

    My thinking is certainly less black and white about this (um, about most things, really) than it used to be. No, catchphrases don't do it justice. Because really, there are always times when interference is necessary and good. Perhaps I just assume that people understand that? Birth is Safe, Interference is Risky (Except When it Isn't) just wouldn't fit as well on a button?

    I don't know. Yes, some of the rhetoric against hospitals and doctors is alarmist, but I can't help but think, in general, they earned it. Instead of worrying about homebirth, they need to worry about improving hospital birth.

  7. "Instead of worrying about homebirth, they need to worry about improving hospital birth."

    This is absolutely true. I will say that my experiences in hospital (at St. Joe, 7 & 9 years ago, if you can believe it) were much better than some stories I've heard about. They, at least, took mother and baby togetherness for granted, my nurse stayed with me continually once I was in active labor, the nurses were great about letting me move while still doing continuous monitoring (for my induction). Still, there were some things that were were unnecessary and could be improved. And that makes me feel a bit worried about how things will go this time, though it is still the most comfortable choice available to me.

    "Because really, there are always times when interference is necessary and good. Perhaps I just assume that people understand that?"

    I think for most people this is probably true, but lurking on the birth forums has taught me that it isn't universal. I think some of those moms are at the far extreme of the natural childbirth movement, though.


What do you think? Let me know.