I had my first baby in a pool of water at home in Chicago, Illinois. I had my second baby in a pool of water at home in Vancouver, British Columbia. One born in the US and the other in Canada. Both babies were born big and healthy. Both births were attended by midwives. In both cases, I was well cared-for by my providers. Yet each pregnancy and birth was its own unique, beautiful, and sometimes difficult, experience. Not all of the differences were personal: the culture and politics of the places also affected my experience of each birth.
Second birth, not like the first
My first birth was hard-going and tumultuous. And so was the birthing climate in Illinois. My peers were not birthing at home. Everyone I met who was pregnant was working with the obstetrician/gynecologist they had always used, and planned on a hospital birth. Midwives and home birth doctors were being forced out of the hospitals and being dropped by malpractice insurance providers. They were taking away the right of licensed home birth providers to make use of life-saving tools like Pitocin to help the uterus expel a retained placenta, and IV fluids to replenish a dehydrated or post-hemorrhaging mother (both of which I required after my birth). It got to the point in that state where a taxi driver could attend your birth, but if a midwife was there, she could end up in jail.
Second births are almost always the easiest according to birthing lore. Indeed, my second birth was easy, and made all the better by the birth climate of Western Canada. The hardest part of the second birth experience was finding a midwife because there was (and is) a shortage. Everyone I knew in Vancouver was working with midwives, most of them planning home births. There was never any question about whether I would be allowed to transfer to a hospital if things went wrong; indeed, they keep a special ambulance just for that purpose. (In Illinois, women were often forced to transfer to a hospital alone, or their birth attendant could be arrested and jailed.) And, to further add to the ease, nobody ever asked about money or insurance coverage. In Canada, I wasn’t pressured into prenatal tests I didn’t want, nor was I told to weigh myself at every visit. I got only one ultrasound with my second pregnancy, a far cry from the three ultrasounds with my first, and I wasn’t forced to look outside of the midwifery practice to get those ultrasounds from a doctor who would end each visit with dire warnings about all the things that could go wrong when birthing outside the hospital.
Birth experience matters
While preparing for my first birth in the US, I had an instinct that my experience of birth mattered, and by the time I had my second child – this time in Canada – I knew it was true. A physiological birth – defined by the American College of Nurse-Midwives as “one that is powered by the innate human capacity of the woman and fetus”, or, at least, an attempt at such, is an empowering start to motherhood, both physiologically and neurologically.
“The research is very clear that the optimal birth is a well-supported vaginal birth with the least amount of medical intervention necessary,” says Jennifer Block, author of Pushed: The Painful Truth About Childbirth and Modern Maternity Care. And the research all indicates that a woman is most likely to get that if her experience of birth is valued.
While natural birth is the most likely to result in providing the optimal birth outcome for mother and baby, it’s not always easy to get what’s “natural.” As soon as one intervention happens, it starts a cascading effect of additional interventions, all of which decrease the chance of a vaginal birth. According to Block, “Many of the routine interventions that are still required in hospital maternity wards across the US and Canada, such as continuous fetal monitoring, restriction of food and drink, IV fluids, manual rupture of the amniotic sac, Pitocin augmentation, and epidural, are not evidence-based and do not improve outcomes for the baby.”
The price of less access
She also says that having a choice of where to birth is very important for optimal outcomes because “not only is hospital care largely not evidence-based [as being better] and sometimes downright harmful, it is very expensive. An uncomplicated vaginal birth [in hospital] is three times the cost of a home birth and a cesarean is four to five times the cost of a home birth, and if there are any complications that require the baby to go to the NICU, multiply that another five times.”
Despite the cost differential between hospital births and home births, in the US the financial burden of a home birth usually falls on the family, as they are rarely covered by insurance. In Canada, though most of those costs are covered by the healthcare system (the same system that hasn’t raised the salaries of midwives in years), midwife shortages leave many families without access. This shortage is costing Canada, writes Ivy Lynn Bourgeault, a Professor in the Telfer School of Management and the Institute of Population Health at the University of Ottawa, and consultant with Health Canada, the Pan American Health Organization, and the World Health Organization (WHO). She points out that even in low risk births with family physicians (who are handling fewer and fewer births in Canada), the difference in provider alone translates to costs of anywhere from $800 more than a midwifery birth in a hospital, to $1800 more than a midwifery birth at home. The very significant shortage of Canadian midwives means that many of the most vulnerable Canadians—those living rurally, the economically disadvantaged, or minorities—have the least access. And Canada’s lower-income communities tend to have more birth interventions and, thus, more complicated and expensive births. Even in Canada, where birth is typically covered by government health insurance, much, if not all, of the postpartum recovery cost is left to the family.
“Midwives as providers, and home birth for women who want it, make sense for health and economic reasons,” says Block. She points to what many consider the seminal study on the safety of home birth, published in the British Medical Journal (BMJ) in 2005, as proof that planned home birth with midwives is safer, even superior for low risk births, than birthing in a hospital with a physician. "It showed that women with the best outcomes were the ones that gave birth at home with midwives."
Birth intervention incentives
Block says one of the big hurdles in the US is that for-profit medicine incentivizes medical intervention which “puts women right into the middle of a conflict of interest in a maternity ward,” where the hospital and the physicians are potentially financially impelled to intervene in ways that the woman doesn’t want, or that aren’t in her, or even the baby’s, best interest. The problem hasn’t been solved, even where for-profit medicine isn’t the primary factor: "In Canada and the UK, cesarean section rates have been rising in proportion to the US cesarean section rates," says Block.
The rise in C-section rates may be due to the attitudes of a “new generation of Canadian obstetricians” according to a 2011 Canadian National Maternity Care Attitudes Survey that collected information from nearly 70% of Canadian obstetricians doing births. This survey found that the younger generation of obstetricians, defined as those under the age of forty, was more likely to favour the use of routine epidural, believing it does not interfere with labor, despite the evidence suggesting otherwise. Similarly, despite evidence that it is pregnancy itself, not vaginal birth, that results in damage to the pelvic floor, younger obstetricians believed the opposite. They also were less supportive of vaginal birth after C-section (VBAC), home birth, and birth plans. Furthermore, they were less inclined to think that peer review mattered in reducing the C-section rate. Perhaps most disturbingly, they were less likely than their older peers to value the role of maternal choice in the birth process.
“We still seem to have a cultural problem in the culture of medicine, and our culture at large, that medicalizes women’s physiological processes,” says Block. Forcing certain practices, such as not letting women move freely, eat and drink, or push in the position of their choice during labour, perpetuates a type of violence against women and “goes against medical ethics and a woman’s constitutional or charter rights.” Block adds, “Many women still culturally accept this standard of care, that ‘doctor knows best’” and thus discount the importance of their own role in the birth.
Midwife protection vs autonomy
There is an irony in my birth experiences. In the US, I was left to my own devices to seek and find a birth provider that would value my role and experience. In Canada, I was actively empowered to do just that. Yet, if my first, somewhat complicated, birth had happened in Canada, I wouldn’t have been allowed to complete the process at home. I know this because soon after I immigrated to Canada, so did my first midwife, Jennifer Gagnon, CNM, RN (US), RM (Canada) who has been practicing midwifery for 17 years. When she compares her practice in Canada to that in the US, she sums it up as, “Here (in Canada) I have more protection, but less autonomy.” She goes on to say that I would most likely have ended up being required to transfer to the hospital in the first labour if I had been in Canada. The guidelines for practicing in BC are very specific, including when one must consult with a doctor, transfer to a hospital, and exactly which medicines can be prescribed, and what labs and testing can be ordered.
Midwifery as a recognized and certified profession began in 1993 in Ontario and 1998 in British Columbia. The midwifery profession has worked hard to get institutional establishment in these provinces, and now it’s “time to get rid of the training wheels,” says Gagnon. She believes there is much to be proud of in the deliberate growth of midwifery in Canada. Yet, she also believes that as midwifery grows up in Canada and prepares to innovate, there is much to learn from the US; though she differentiates between learning from the US and simply following in their footsteps. Gagnon characterizes the politics and bureaucracy surrounding the practice of midwifery in the US as "a giant, hot mess," with huge variation from state to state in aspects as fundamental as who can be considered a midwife and what is covered in their scope of practice.
As models worth emulating, she points specifically to a number of collaborative care group pilot projects in British Columbia that grew out of similar projects in the US. Many of these programs aim to provide the best of the midwifery model of care, with its focus on empowering and engaging the woman in her care during pregnancy and birth in a way that is also culturally accessible to and appropriate for the most vulnerable communities. These practices help to serve a "different population than the white, middle class women that make up most of the midwifery clientele," says Gagnon.
A culture of risk avoidance in birth
Jeramie Peacock is a mother of four and a traditional birth attendant. She herself has birthed in both the US and Canada, and attended births throughout North America. Her last two births were unassisted, which means she didn’t have a birth professional accompany her. Peacock points out that the culture of birth is not just about the country where a person births, but also about community values.
She points to the Amish, where she has spent many of her practicum hours delivering babies. “Their culture is that birth is normal,” Peacock states. As such, they have few interventions, very few transfers, and very good outcomes as far as healthy babies and healthy mothers are concerned. In contrast, Peacock refers to midwives she knows practicing in affluent areas of California, where the typical birth lasts three days, many of their patients transfer to the hospital, and the intervention rates, including C-sections, are much higher. And “these are good, competent midwives,” she says.
The difference is perhaps best explained as cultural, and is fundamental to how these communities view life and death. Peacock asserts, “The Amish families know and accept that death is part of birth.” Many of these women will have ten babies. Many of them will lose a child at some point. However, according to Peacock, most North Americans have a deeply held belief that babies must not die during birth. The result is a low tolerance for much of the risk of birth, and an expectation that the birth provider will ensure that this doesn’t happen. It’s a lot of pressure on a birth provider, and that pressure doesn’t necessarily translate to better outcomes.
“I had a mentor who said a good obstetrician has a fat ass and a long cigar. About the time you think you need to intervene and do something, go smoke a cigar, leave it alone for another hour and see what happens,” says Dr. Bethany Hays. She has spent 34 years practicing obstetrics in the US. “I trained as a perinatologist,” (a doctor who specializes in high-risk deliveries) she says, and, “I thought that the person with the most information won.” Despite all her training, when she first started out as a doctor she found she had sick moms and dying babies and she figured somebody, somewhere, must be doing a better job, so she apprenticed herself to some local home birth midwives. She describes it as the first big turning point in her career. It is how she learned to sit back and to believe in the power of birth; to trust it would work out. “You can afford to do that if you can walk closer to the edge of the cliff ... if the mom falls off the edge of the cliff you need to be able to get a baby out in 12 minutes. Which I could. It’s dramatic, but I [could] do it.”
While an Amish mother may intuitively be at peace with risk in birth, the way Dr. Hays thinks about risk is a logical process: "How much risk are you willing to take and where are you willing to put the risk?” She says that our culture has a collective story that the baby should take no risk, and that story can lead to decision making that actually increases the overall risk for future babies, and for the mother. Hays believes there is a common misconception that “if you don’t want your baby to take any risk: have a c-section.” But, she says, what about the next baby? A c-section will increase the subsequent baby’s chance of being born preterm, being small for gestational age, and even of dying. And, what about the mother? The c-section will increase her chances of hemorrhage, uterine rupture, hysterectomy, and even of dying. Then there are the risks beyond birth: a baby born via c-section is less likely to successfully breastfeed and doesn’t get exposed to the same bacterial flora needed for the healthiest start, nor the other benefits that come from passage through the birth canal. Dr. Hays encourages people to look at the big picture when it comes to risk: “If you don’t want your baby to take any risk, how are you going to get him home from the hospital? Cars are risky.”
The price of risk avoidance at all costs
We are lucky to live in a time and place where death is not a common occurrence at birth. Unfortunately, both where a woman lives and her societal status still influences this rate dramatically. The US, with all of its medical advances, still has one of the worst maternal death rates in the developed world, and it's getting worse. Canada has half that rate, with seven out of every 100,000 women dying from birth-related causes, yet it hasn't improved in 15 years. Meanwhile, many countries, including Austria, Czech Republic, Finland, Iceland, Italy, Kuwait, Poland, Sweden, and Greece, have managed to get their rates down to four deaths or under in that same time period. The US and Canada also fare far worse in rates of infant mortality related to birth. They are number one and two in the ranking of the highest rates of first-day infant mortality in the industrialized world, according to the 2013 Save the Children survey. In Canada, that's approximately 2.4 deaths per 1,000 live births, or 900 deaths annually. In the US, roughly 11,300 newborn babies die every year on the day they were born. This is 50% more than all other industrialized countries combined. Infant mortality is up to four times higher than the US average in some Canadian First Nations populations and certain African American communities in the US. In contrast, the best performing countries are closer to a 0.5% first-day mortality rate.
The high rate of c-sections
Many birth researchers believe that one of the reasons Canada and the US have relatively high rates of maternal and infant death associated with birth is that our c-section rates are so comparatively high. The WHO recommends a rate between 5% and 15% as ideal for the healthiest outcomes of mothers and babies. It's not zero, because even with everything done 'right', situations will still occur where a c-section will be necessary to save a life. The US rate, however, is more than double the recommended upper threshold, with about 33% of births ending in c-section. State variation ranges from approximately 25% in Minnesota to 35% in Texas. The Canadian average is also nearly double the WHO's upper limit at 27%. This rate varies among provinces, from 8% in Nunavut to 33% in Prince Edward Island. British Columbia has the second highest rate in Canada at 30%. Rates also vary from community to community. Not too far from my island home, is the Matraea Centre, a midwifery group which attends almost half of the births in their area, and claims a cesarean section rate of around 8%. Yet, they are part of the Vancouver Island Health Authority whose c-section rates average over 30%.
Similarly, in the US, the consumer research nonprofit Consumer Reports notes that even in the same community, it is hospital choice that may be your biggest c-section risk, with enormous variation occurring even in the same community of hospitals. Unfortunately, for many in both the US and Canada, hospital and birth attendant access can be limited by poverty, insurance regulations, and location.
The empowering journey into parenthood
Agency—when a woman feels like she is an integral part of the birth experience, rather than it being something done to her—plays a big role in whether a woman walks away empowered or traumatized by her birth experience. Yet Peacock reminds women that birth is subjective, not objective, and it’s the mother and baby’s experience that matters; what may seem like a traumatic birth to one person, might not to another. Ultimately, she advises women to be open to receiving what the birth brings; the “medicine” of birth as she says. It’s ultimately about making a person ready for parenthood and, as Peacock says, “Becoming a parent is a humbling, painful experience at times.”
I was one of those women who desperately wanted the home birth experience. And I got it. And I never regretted it; not ever. Yet, getting it took every ounce of will and skill that I had, and that my provider offered. I had to go against the norm. I had to pay out of pocket. I had to research the heck out of my options. I had to stand up to doctors and refuse interventions and fight a lot more than I would normally choose. But I got it. My reward was an empowering birth that brought with it a child and transformed me into a mother.
On the other hand, my second birth in Canada made everything easy. That birth was a delight, and so was that child. Yet, that ease came at a cost. I wouldn’t have traded my first birth for the ease, or the safety, of a little less risk. But, then again, I was (am) an American first. As I move forward now, raising my two children in our new homeland, I find that I am always walking that line. I love the ease, the vast sky, the gentle spirit of the people, yet I also miss the fight, the freedom, the fierce determination of the land I left.
Indeed, my greatest take-away from birth is that they were almost magical glimpses into what was in store for me as a parent. And being a parent is similarly both incredibly personal and also hugely shaped by culture and country. Birth is just another rift in the fabric of life, where a bit of the light comes through and we see a little more of the thread that holds it all together: the pulls of culture, the proximity of life and death, and our own will through it all.
