Debra Bingham: Taking Birth Back

Debra Bingham, DrPH, RN, is the Executive Director of the California Maternal Quality Care Collaborative (www.cmqcc.org) at Stanford University School of Medicine. CMQCC is a state-wide California initiative to support physicians and nurses to improve maternity care.  She was formerly the director of Maternal Child Health Nursing at two hospitals in New York City.  Throughout her career, Debra worked to support safe and healthy births for both mothers and infants.  She is the mother/stepmother of 4 children, grandmother of 7.

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I am a nurse with over 30 years of high-risk perinatal experience.  I became a high-risk perinatal nurse because I find it an honor to support families through the miracle of bringing new life into the world.  I never tire of learning and discovering as much as I can about the 'simplexity' of such a universal yet personal life-transforming event. 

 

Source:  istockphoto

Lately there are many troubling trends.  Rates of maternal deaths and maternal childbirth-related injuries are rising in the United States.  In fact, we have not seen maternal mortality rates this high since the early 1970’s.  In addition, in 2007 the United States was ranked 41st among developed countries for maternal mortality rates.  These negative trends and worsening outcomes do not make sense in a country with so many resources.  (Click on this link to hear Debra elaborate).  The key questions behind this statistics are:

Why has maternity care become less mother and newborn-centric, and more hospital, nurse and physician- centric?

Why is maternity care costing so much and yet bringing about such poor outcomes?

Last night when I vegged out and watched Father of the Bride, Part II the movie helped me see the answers to the questions more clearly.  It stars Steve Martin as the father and husband – so you know that the movie is meant to be fun and over the top.   However, in watching Hollywood's caricature of both mother and daughter going through a pregnancy and giving birth together reminded me how ingrained certain cultural rituals around childbirth have become.

 

This movie and most every sitcom or movie in the general cultural landscape unquestioningly portrays what are common, but often not scientifically based maternity practices.  For example, (and this is just one of many possible examples), it is now common for a laboring woman to expect to be in bed tethered to an electronic fetal monitor when in labor. 

While there is no evidence to suggest that constant fetal monitoring improves the health of the baby, there is a negative consequence to women being in a bed -- a seemingly innocuous change in how women had previously given birth for centuries.  Being in bed has been shown to slow labor down, lead to more pain in labor, and to more dysfunctional labors – all of which cause more harm to both unborn babies and their mothers and increase the pain of labor. (For more information, I recommend Evidence-Based Maternity Care.)

Cultural norms affect beliefs and expectations.  Beliefs and expectations affect cultural norms.  It is a difficult cycle to alter.  You have probably heard of the placebo effect, where someone thinks they are getting medicine, but they are not, but they get better anyway.  There is also a nocebo effect that is not as commonly discussed.  The nocebo effect is how negative expectations can also affect our physiologic responses by making us sicker.  Indeed, it is a known fact that beliefs and expectations affect the cellular function of our bodies, our very biology.  (see The Biology of Belief by Dr. Bruce Lipton for further reading.)

What does this have to do with maternity care?

Since beliefs affect physiologic functions, how women and men discuss the process of pregnancy and birth can have a negative or positive effect on the women that are involved in the discussion.  Our words are powerful and either reinforce or undermine the power of women and their bodies.  The next time you talk about pregnancy or birth, think about how your basic assumptions affect your discourse. 

1. Does your discourse include stories about the power of women?
2. Or do the stories shift the locus of control away from women and their bodies to other authority figures such as nurses, physicians, or machines?
3. Does your discourse assume that women are physiologically capable of giving birth and nourishing their own children?
4. Or does your discourse assume that women’s bodies are fundamentally flawed and in need of medical attention and intervention? 

In order for women to fully grasp the power of our bodies, we will need to become better informed.  Great options for finding out more information are on the Lamaze International website.  In particular, there is a blog led by my colleague, Amy Romano, CNM.  There are also pregnancy emails that send weekly empowering messages to pregnant women and there are six evidence-based steps to having a healthy and safe birth. 

There are also films that provide a contrast to commonly seen Hollywood images of childbearing and are helpful steps in moving us toward more meaningful discourse about maternity care practices in the U.S.  I recommend them, not as depicting the ultimate solution to improving maternity care, but to provide another point of view:

1) A documentary film by Ricki Lake entitled the Business of Being Born (you can see a short clip here);

Some of the action in the movie takes place at Roosevelt Hospital where I was the Director of Maternity Care Nursing.  I either supervised or was a colleague with the clinicians interviewed or shown in this movie at this hospital.  I also worked closely with Cara, the midwife in Ricki Lake's movie, before she became a midwife.

2) A movie by a colleague of mine, Debra Pascali-Bonaro entitled Orgasmic Birth.  Debra's movie title is a bit provocative, but if you go to her link and hear her speak about her movie you will learn more about why she chose the title she did.  It is worth checking out.

Both movies raise important issues about how maternity care is practiced in the United States and explore these issues in different, interesting, and provocative ways. 

What are your thoughts?

How do we shift the public discourse around maternity care?

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It would be fascinating to catalog stories around the birth of our children, or hear our mothers' tell of stories around our own birth.   Would they illustrate the power of women?  Or shift the  locus of control away from us or our mothers?

Author Diane Setterfield wrote "All children mythologize their birth.  It is a universal trait.  You want to know someone?  Heart, mind and soul?  Ask [her] to tell you about when she was born".  What is the story around your birth?  Your children's birth?   

And our dreams -- do they illustrate our power?  Or do we give away all our dreams -- and their fulfillment to others, whether husbands, children, colleagues?

What of policy shifts?  How would you move the conversation forward?

Comments

[Janna]

Comment #1 (there will be more from me on this post!): My birth story always sounded like a tragedy to me. I'm just realizing as I write this how guilty I feel about it: "I should've been easier to birth" is the central thought. Oh, wow. That just opened up a can of worms in my psyche...

[JBB]

AMEN! I have 6 kids and I LOVE childbirth. I could go on and on, but let's leave it at this: I cannot STAND to be lying down on my back at the end of my pregnancies and certainly not during labor. Walking around and squatting are far superior. Women should go into birth with a plan for what they want from their nurse, midwife and/or doctor.

[erinn]

Even before my husband and I decided to start trying to conceive I had thought to myself that there has to be something better out there for women's care than what I was experiencing at the half dozen or so OB/GYN offices that I had been to since my teens. The last one rushed me out the door after 4 and a half minutes and had me so flustered I couldn't remember the questions I wanted to ask her. At the recommendation of a couple of friends I had decided to look into the well-woman care at a local birth center staffed by mostly midwives but also an OB/GYN and pediatrician. I am healthy and in my early 30's so I ideally come to have this care with no risks or complications and so far it has been wonderful. I lost an early pregnancy in May and am now pg again and they have been so supportive both medically and emotionally spending as much time with me at appts. or on the phone as I need. We are hoping that all goes well with this new little bean and that we'll deliver at the birth center in April.

Prior to my pregnancy early this year, my husband and I watched TBOBB together (I prescreened it just to be sure he wouldn't be freaked out) and had decided that a natural birth is what feels best for us and our baby. I am not a fan of hospitals. I equate hospitals with serious illness and death since the only time I ever go to one is pretty much due to horrible situations. It never made sense to me that I would have to be a patient and deliver at a hospital and to begin to find out that I had other choices was such a relief. I told a couple of my close girlfriends when I was first pg what we had decided and I got mixed reactions but mostly I have kept my feelings to myself in fear of real negative reactions. But I have come to realize that as my pregnancy progresses I will probably have more and more opportunities to mention the choices that we have and not to just be satisfied with the status quo. When it comes down to it some people just can't handle doing anything differently than their peers and I find this so much within the group of women that I know. They sit around and compare epi experiences, how many machines they were tethered to, what drugs they were given (cervadil, pitocin) almost like a the more intervention they received the better care they were given by their doctor.

I'll never criticize any one's decision on how to bring their child into the world. It's personal and one size does not fit all. I feel as though the medical community pounds into our heads how many things can wrong during birth and how risky it is but they never tell you how risky and epidural is or what side effects you'll have from the drugs they use. Someone said we as Americans will spend more time researching what kind of flat screen TV to buy than anything regarding pregnancy.

I need to not keep my mouth shut and need to speak gently and encouraging to let women know they have choices and need to be courageous in seeing that their decisions are respected.

That's how we shift the public discourse. Between us and our friends and the women we know and love.

Sorry this is so long. Whitney, thanks for having Debra here.

[Cindy Coletti]

Excellent information. Very interesting. I wonder if you have considered the role that vaccinations play in maternal deaths. That is a real factor also. I'm sure it plays a role and should be examined. Thanks for your work in this area.

[Janna]

Comment #2: To your question about whether our dreams illustrate our power: Fulfilling our dreams makes us responsible for the power we gain through the process - and it's scary to stop being the victim, to stop having an excuse, to stop saying, "I can't." We become accountable. Power makes you accountable.

Recently, I witnessed a woman's dream coming true. It was so beautiful. We all felt her power and humility as we watched it happen. As we joined in the celebration, I couldn't help but yell out several times in joy.

As she continues on in her dream, she will be faced with many more decisions in which she will need to assert her power - and then she will take responsibility for those decisions.

It's easier to simply allow life to happen to you. To let others make the decisions. To follow another person's dream. How grateful I am to have seen someone assert her dream, and in this woman's case, reject her cultural inheritance in the process - and claim the power that is and was always hers to be had.

[Maria]

Debra's post made me want to cheer! I am a former childbirth educator and birth attendant, this is one of my passions. Bringing children into the world is one of the most effective ways to claim (or give away) our power as women. It carries over to the rest of our life. Thanks Whitney for this post!

[Diane Sampson]

I love this post. My first two kids were born in Ann Arbor, MI where "natural" childbirth (meaning moving around until the last seconds, no medication, massage as pain therapy, etc) were the norm rather than the exception. I had a very unhappy awakening when I tried to find a similar ethos after we left Ann Arbor. In fact, in Chicago an OB-Gyn and I came to sharp words as she insisted that I just didn't remember my IVs during childbirth, and I insisted that I had never had an IV. My more medically-managed third birth was by far my most uncomfortable and least joyful.

Great post! Good luck to you in your mission to educate and encourage women in their decision-making.

[Diane Sampson]

Ok, that was a romanticization of the process--it wasn't that I could "move around until the last seconds" but I moved until moving around was impossible. Sorry.

[Chrysula Winegar]

I have always received wonderful pre-natal care from a marvelous OB who I respect enormously and most recently a great team of midwives. But birthing itself has been a little more complex - my carer having not been present at crucial moments and others therefore being involved in the process. Having birthed once with heavy handed medical intervention and also completely naturally three times, I feel the gift of both perspectives.

With my first child, I did not realize my power and certainly lost my voice at the crucial moment. With the subsequent deliveries, I fought with the medical establishment EVERY time, although much less with the last birth which was attended for 5 mins by a midwife for the catch. The crux - not being believed that I knew what was happening, that I understood my body's patterns.

Women have been taught to fear their bodies in recent generations. And taught that they do not really understand them. There has never been a time when I have felt more powerful than that crucial moment of delivering a child. It's time we took our bodies back. Thank you Debbie. You have taught me so much over the years, and been there to catch at least one of my special babies. Wish you could have delivered them all. And got to me before Dr M that first time!

[David Jones]

Great post, thank you. I'm glad that I had been taught this perspective before my wife gave birth to our first child. The midwives were fantastic, helping my wife labor in whatever position she found most comfortable, which turned out to be on her hands and knees the whole time. We've just moved to Ann Arbor and as we contemplate our second child I'm glad to hear there is a culture here supportive of natural birth.

In a recent debate over the public option in health reform I heard a left-leaning politician cite these mortality statistics as evidence that our health care system is not as effective or efficient as it could be. The right-leaning politician rebutted by arguing this was actually evidence of the inability of government run programs like Medicaid to improve quality of care compared to private insurance companies. This seemed like a weak counter-argument to me. This has post has me thinking that perhaps the real culprit is the culture around childbirth. If poor women of racial minorities tend to have worse outcomes (which I believe they do), it's not because they're on Medicaid, but because they have less access to educational materials and fewer peers who have experienced natural childbirth than I did, not to say anything of the medical professionals they interact with and the financial structures influencing how these doctors are paid.

Am I way off base?

[Mary Carstens]

Thank you for posting this!! I had my son almost 3 years ago and did it the "old fashioned way," (labored at home until an hour before he came out and no meds, at all). I took Bradley Childbirth classes for 12 weeks with my husband and the more we learned about our culture and birth, the more we were turned off. The stats are alarming, too. A lot of women do not make informed decisions. They go to their docs and trust everything they say, without sitting down to do any research or ask any questions. It's scary. Because how many times do women run to their computer to look up a recipe or read a blog, but they never think to look up what their doctor has told them. Of my mom friends, about 85% of them ended up with a c-section. Yes, a few might have been medically necessary, but the reasons I heard were definitely questionable for the others. Most of them seemed to stem from an induction. Once the pitocin starts, you're on the hospital's clock and it all seems to snowball...mom is laying in a bed, on her back (cervix can't open like that), baby's heart rate starts to drop (yeah, duh.), c-section ensues.

I rarely talk about childbirth because I find it to be akin to talking about politics; it's very personal and unless you're talking with someone who really knows their stuff (and the facts, trends, etc.), it's kind of pointless. You can't have an intelligent debate with someone who hasn't taken the time to research childbirth.

Obviously, I respect the decisions my friends have made about their bodies, but when I decided to have a natural childbirth, I was called all kinds of things and "you don't have anything to prove to anyone, you don't have to be a hero." came up quit often.

I was like, "Dude, our bodies were made for this." Unfortunately, I think a lot of women have forgotten that.

[Whitney Smith Cripe]

Debra,

I'm Whitney. Another Whitney. A friend of Whitney's...and a happy reader of her blog.
Beyond one's salary, one's late night diet, and one's sex life, perhaps nothing is more personal to a woman that her birthing experience. A had an astoundingly amazing lactation nurse who came to my aid after my first son was born and before she even discussed my breastfeeding "issues" she asked me to tell her my birth story. She said she (and more importantly I) had "get that straight" before she would even touch me, take a look at my milk situation or talk about the baby. She wanted me to tell her about ME. I was floored. Emotionally overcome I recounted the good, bad and ugly of it. My second child birth experience felt so different because I went into it feeling so present. I got it straight in my head and my heart, what was about to happen to me, before it even happened. As part of my overwhelming sense of gratitude for what I have, access to amazing medical care and resources and love, I started thinking about what I could do to help other women. This December, I'm planning a fundraising event to benefit the Fistula Foundation, with the hopes that small efforts will result in dignity and a happy, clear birth story for another mother somewhere far away.

[Jennifer Knight]

Debi Bingham! I have been thinking about her a lot lately- Whitney, this post is so great! I met Debi when we lived in Manhattan prior to having kids, and I don't think she knows how much hearing little snippets she'd share at baby showers influenced my childbirth choices and experiences. I need to email her. Can't wait to keep catching up on your blog!