Birth Control

Ken Orvidas

On a weekday morning, Providence’s Women and Infants’ Hospital buzzes with activity. Sliding glass doors open and shut every few seconds as people rush in and out. Hospital employees sit behind thick glass windows, directing patients and visitors through the labyrinth of corridors. In the brightly lit main lobby, white-coated medical professionals stride beside women whose coats no longer button over their pregnant bellies and men holding
toddlers’ hands.

In the labor and delivery center on the second floor, twenty hospital rooms await expectant mothers. The rooms are outfitted with adjustable hospital beds and surrounded by technology—a pole on wheels for an intravenous drip unit, a fetal heart monitor, a baby warming unit. Nurses scurry in and out of rooms. Family members spill into the hallway near one room where four mothers who have just given birth by Cesarean section operations are recovering.

Just off a basement-level hallway and through a metal door, there is no rush and hustle. Here, the Alternative Birthing Center is quiet and dimly lit. Inside each of two suites, the queen beds have no metal stirrups, wires or hand cranks. They are covered with cozy quilts. Each has a private bathroom with Jacuzzi. A bright yellow toddler-sized chair sits beside an adult-sized recliner. Monet prints decorate the walls, and children’s books, movies and toys await families in the separate living room.

Severine Degnan of North Kingstown decided this was where she wanted her baby to be born.

“There’s so much comfort and peace here,” says Degnan, thirty-three, who works as a travel agent. “I felt we had made the right decision; this was the perfect setting to welcome our baby into this world. I feared that if I was locked on a bed, I wouldn’t be free to move, and I was afraid that I would have to be cut open. I feel that the more intervention a mom gets, the more things escalate and end up in an emergency Cesarean. One thing leads to another, and many times, if you just leave it alone, it will be fine.”

Anais Degnan, born on June 20, 2006, was one of just 152 babies born in the ABC last year. Mothers seeking unmedicated, technology-free births remain a tiny minority in Rhode Island. The popularity of the ABC has remained relatively flat since it opened more than twenty years ago, hospital officials say.

The vast majority of babies are born under bright hospital lights, surrounded by a dizzying array of medical technology to mothers whose labor pains have been dulled by drugs. Most Rhode Island births occur in the regular maternity department at Women and Infants. There were 9,264 deliveries there in 2006.

Degnan chose the homelike setting of the ABC because it is a place where medical intervention is kept to a minimum and mothers can be surrounded by as many family and friends as they want (in the regular maternity ward, they are limited to two). She is part of a small, but adamant group of mothers and health professionals in the state who are more often questioning the frequent medical procedures used in the birth process.

“I am grateful that life-saving interventions, technologies and pain-relief medications exist and can be utilized when needed,” says Erin Barrette Goodman, mother of two and founder of the Rhode Island Birth Network. “What concerns me is what I see as the over-use, or ‘standard procedure’ use, of interventions, particularly on healthy, first-time mothers.”

In Rhode Island, as in the rest of the nation, medical interventions during birth have increased dramatically. According to the most recent figures available from the national Centers for Disease Control, 28.8 percent of all Rhode Island births are done by the abdominal surgery called Cesarean section, just slightly lower than the national rate of 29.1 percent. In 1994, the Cesarean rate stood at 17.3 percent in the state and 21.2
percent nationally.

Epidurals, a procedure in which medication is injected into the spine to ease labor pains, are given in as many as 90 percent of the state’s births, according to local medical professionals.

Another procedure that has increased is medical labor induction—artificially beginning or speeding labor by rupturing membranes or injecting drugs like synthetic oxytocin. According to the Lamaze Institute for Normal Birth, an international natural birth advocacy organization, medical induction rates should be no more than 10 percent, and the procedure should only be done for specific medical risks that do not occur in the vast majority of births. But currently in the United States, according to the CDC, nearly 21 percent of births are induced, more than double the rate in 1990. While induction rates in Rhode Island are hard to come by, medical professionals say that the trend here has mirrored that of the nation.

Those who advocate for natural birthing say that the more prevalent use of intervention means increased risk and decreased confidence in something that is a natural process. Cesareans require longer recoveries for mothers and increase the risk of a host of health problems ranging from blood loss and infection in mothers to premature births, breathing problems and less vigorous infants. The Lamaze Institute cites a number of medical studies concluding that labor inductions more frequently led to Cesareans. Induction can also result in premature births if the gestation period was not properly calculated, as well as longer and more intense contractions making it more likely that a mother will call for an epidural. Epidurals, though shorter lasting than they once were, put mothers at increased risk for blood pressure drops and fever, and babies at risk for abnormal heart rates and Cesarean delivery.

In 2006, Childbirth Connection, a New York City-based nonprofit that seeks to improve maternity conditions for women, surveyed nearly 1,600 mothers throughout the country about their birth experience. The survey found that most of the women experienced continuous electronic fetal monitoring, intravenous drip, epidural or spinal analgesia, and urinary catheter. More than half reported receiving either oxytocin or membrane rupture to induce or speed their labor, a figure far higher than the CDC statistics.

The vast majority of babies are born under bright hospital lights, surrounded by a dizzying array of medical technology to mothers whose labor pains have been dulled by drugs.

Some common practices, like fetal heart monitoring, may at first seem like a no-brainer. But Linda Nanni, a certified nurse-midwife with Women’s Care, a group obstetrics and gynecology practice in Providence, says continuous fetal heart monitoring may actually contribute to the increase in Cesarean rates in low-risk pregnancies. There are times, she says, when it is natural for the baby’s heart rate to decrease. A natural drop, however, will still cause an alarm from a heart monitor, which may in turn lead to an unnecessary emergency intervention. Several studies have shown that intermittent—and thus less invasive—monitoring is as safe as continuous monitoring in low-risk pregnancies. Intermittent monitoring also allows for more mobility in labor, which can help labor progress.

The Childbirth Connection and other similar organizations, as well as concerned mothers, midwives and doctors in Rhode Island, see the increased medicalization of birth as the symptom of something larger: the tendency to treat pregnancy as an illness instead of a natural event.

Mothers and health professionals point to many reasons to explain the increased rate of birth interventions. There are emergencies that jeopardize the health of the baby or mother and make a Cesarean necessary. Both the American College of Obstetricians and Gynecologists and the Lamaze Institute cite medical reasons for induction that include a mother with high blood pressure, diabetes, lung disease or an infection of the uterus.

But less definitively medical reasons, such as fear of medical liability, also are at work. “It’s a medical-legal climate,” says Carroll Medeiros, an obstetrician/gynecologist who practices with Women’s Care. Russell Stokes, a Westerly pediatrician who is a member of the Rhode Island Birth Network, says that though both the American College of Pediatricians and the American College of Obstetricians and Gynecologists are concerned about the increase in Cesareans, fear of malpractice suits that could result from fetal injury help keep the rate of the operations high.

Some medical professionals point simply to patient demand. More patients want complete control of an unpredictable process. According to the CDC, 25 percent of inductions are elective — meaning they are not necessarily done for medical reasons. Many women also carry a tremendous fear of pain. Andrea Young-DeCiantis, a certified nurse-midwife, says most of her patients a decade ago sought her or one of the other sixty midwives who practice in Rhode Island because they wanted a more natural birth process. Today many women are too fearful of pain to consider it.

“I used to say that only about 6 percent of my patients had epidurals,” Young-DeCiantis says. “Now, it’s up to about 40 to 60 percent even for my practice. Women want someone who will assure them they can get the epidural if they want it.”

Medical technology has a place in the birth process, but is being overused, says Goodman, thirty-three, who formed the Rhode Island Birth Network in 2004. The Network is a grassroots effort that supports informed decision making about birthing care and the six normal birth practices prescribed by the Lamaze Institute: labor should begin on its own; women should have freedom of movement during labor; mothers deserve continuous labor support; there should be no routine medical interventions; mothers should not be lying down to deliver; and babies should not be separated from mothers after birth.

The philosophy behind Lamaze and other natural birthing methods is based on the belief that a more natural birth will result in fewer medical complications and less severe labor pain. Another important by-product of natural birth, say its advocates: mothers who are more confident in themselves and their own maternal abilities.

Goodman says her own birth experiences point out the need for more health professionals who support such natural birth practices in Rhode Island.

While training as a yoga instructor she learned about holistic, natural healing, and when leading pre- and post-natal yoga classes, she often heard women’s concerns about prenatal testing or birth interventions.

“A lot of what stuck out for me was wo-men saying things like, ‘My doctor wouldn’t let me,’ ” Goodman says. “I saw they were giving over power to their doctors.”

When she became pregnant with her first child, she decided a drug-free, natural birth felt like the best option for her. Like many mothers who seek a natural birth, Goodman sought out care from a nurse-midwife. These health professionals are advanced practice nurses who have received additional training in prenatal care, delivering babies and postpartum care. They are trained to view birth as a natural process, while obstetricians receive more intensive training in medical interventions and surgery. Goodman also chose a doula, a nonmedical birth assistant who lends emotional support and practical birthing advice to pregnant and laboring women, usually providing even more one-on-one time than nurse-midwives.

For the first nearly seven hours of labor, she relaxed at home, went grocery shopping, cooked, cleaned her house and walked in her Charlestown yard.

“Then, while eating grilled cheese sandwiches, I began to feel something was changing,” Goodman says. “It was still not painful, but the sensations were getting more intense, and I thought we should start heading to the hospital.”

Her daughter, Lily, was born in June 2004 less than an hour after Goodman, her husband and doula arrived at Westerly Hospital. The birth was on her own terms; the experience, she says, was personally empowering. And when she became pregnant with her second child less than two years later, she sought to replicate it. She discovered, however, that one of the two midwives who had cared for her had left the state. The other had joined a group obstetrical practice that wouldn’t guarantee the midwife’s presence at Goodman’s birth.

At that time in Rhode Island, a nurse-midwife was required to have a doctor as backup during a birth in case emergency intervention was needed. At the hospital where Goodman would give birth, an obstetrician outside the group practice might end up being the backup, depending on who was on call the day she went into labor. And not all the obstetricians would agree to work with a midwife. Plus, she was turned off by the group practice’s lack of personal attention.

Goodman shopped for a different caregiver. The midwifery practice of Mary Mumford-Haley and Deb Erikson-Owens was recommended by friends. At an initial consultation, Erikson-Owens spent an hour talking with Goodman about birthing options and philosophy, getting to know her and playing with Lily. Goodman had found the right match. The only problem: Erikson-Owens practiced in Pawtucket’s Memorial Hospital, so Goodman would have to travel across the state to give birth.

“I remember, during labor, as the birth was getting close, feeling very overwhelmed and for the first time feeling pain,” she says of the birth of her son, Quinn. “At that time my midwife, labor nurse, husband and doula stepped up their support. Not one of them offered to try to take the pain away, but instead they helped me to refocus and work with my body instead of against it.”

When Quinn was born in May 2006, Goodman reached down and helped lift him up, discovering his gender on her own. “I had several moments to savor him on my own without anyone trying to do anything to either of us,” she says. “It was beautiful.”

Mumford-Haley, a certified nurse-midwife with the East Bay Community Action Program and instructor in the University of Rhode Island’s midwife training program, attended the birth of Goodman’s son. She says she is angry that healthy mothers-to-be like Goodman cannot find an abundance of medical professionals who encourage and support natural birth.

“I meet a lot of women who feel they just want some control or input into their experience,” she says. “Women just want to know that decisions are not being made arbitrarily. If I make a recommendation, they know it’s not just because everyone does this. They want someone who will take twenty minutes with them rather than two.”

Haley, Goodman and the group of about thirty women and men who attend Birth Network meetings are not alone in their concerns. Dr. Medeiros says the goal of her practice is for women without medical complications to give birth vaginally whenever possible.

“Our desire is for everyone to have a vaginal birth,” she says. “The babies do better and the moms do better. They recover better and they have less pain later.”

But Medeiros says anxiety about the unknown contributes to patients’ decisions to have medical intervention, even among patients who say they want a natural birth. She has a nine-year-old daughter and two sons, seven and four; she had what she terms a high-tech birth with her first child, and a natural birth with her second and youngest.

“Every one of my deliveries had something positive to it because what I took home was so positive,” she says. “When you are in it, it’s a whirlwind experience. I can see how some patients feel they were talked into things. Having a baby should truly be a partnership. There is give and take on both sides between the doctor and patient.”

Kelly LaChance Guertin is a certified childbirth educator and doula who opened Bellani maternity in Warwick in November to provide a one-stop location for a variety of pre- and post-natal classes, support groups, information, and maternity and infant gear. About 700 people have taken Bellani classes, which range from breastfeeding essentials and newborn basics to laboring with epidural anesthesia and natural childbirth.

A class called Prepared Childbirth, in which the wide range of birth choices are presented and discussed, is one of the most popular classes, she says.

“I’m seeing a split — maybe about half the women are saying that it is great we now could consider scheduling a Cesarean section or induction and then about half are really questioning that,” Guertin says. “About five years ago, no one was really questioning anything.”

Some who are questioning are doing so because they say that too often interventions are taken not because of medical necessity but rather because panic-stricken mothers in the midst of impersonal and hectic medical settings are not getting the reassurance they need to make informed decisions.

Kathy McGuigan, a social worker who runs pregnancy support groups at Bellani and in Providence, says it can be hard in Rhode Island to find this kind of educated reassurance. Her groups, she says, do not advocate a particular birth option, but give moms-to-be extensive information, and support whatever birth choices they make.

Before her own unmedicated birth experience eighteen months ago, she actively sought out information from her doula and a pregnancy support group. She was living in California at the time. “I had a lot of concerns about medical interventions,” she says. “But I was also very nervous about the pain. The group helped me understand that it was possible to have a successful unmedicated birth.” During her labor, McGuigan’s doula helped alleviate her anxiety, and she was able to stay at home until she was ten centimeters dilated.

When she moved to Rumford in June and began facilitating pregnancy groups, some women here wanted to explore natural birth options, but there were simply not as many available in Rhode Island. “Just finding a Bradley Method [a popular natural birthing method] class is harder here. Finding a doula here is harder,” she says.

Guertin believes there are only about a half dozen doulas certified by the Association of Labor Assistants and Childbirth Educators or DONA International practicing in Rhode Island. Judy Batson, a certified doula in North Kingstown, says she is in demand but can accommodate only about two births a month because of the time she spends with each mother. Besides meetings and discussions in the weeks leading up to the birth, she remains with the mother throughout labor and delivery.

Mothers and medical professionals says there should be more work to ensure all mothers are educated and empowered to make the choices that are right for them — and that there should be more resources in the state to support this.

“Birth is a very important event for women; one they will always remember,” says Nanni, the midwife at Women’s Care. “They should feel well taken care of both physically and emotionally.”

Nanni draws an analogy between climbing Mount Washington and giving birth. There are those who choose to spend eight hours hiking to the top of Mount Washington and those who drive up in their cars. Both are adamant about their methods, but the view from the top is the same for both. The bottom line: what everyone wants is a healthy mother and healthy baby, regardless of the procedures used.

For Severine Degnan, being in the ABC helped ease her fears and gave her exactly the kind of birth she wanted. Degnan says her daughter’s birth was also a happy experience largely because her obstetrician respected her birth plan.

When her water broke at 6 p.m. on June 19, she went to the hospital, but because she was not having contractions, her doctor sent her home and recommended she return at 6 a.m. When she returned, though, she still wasn’t having contractions and was given a choice: go to the regular maternity ward and begin induction or walk the parking lot until gravity and movement helped labor start naturally. She, her husband and her doula walked until labor started; they headed back inside when she was four centimeters dilated.

Anais Adia Degnan, weighing in at an even seven pounds, was born twenty-three hours after her mother’s water broke in the peaceful surroundings of the ABC. There were no bright lights, no IV needle, no pain-killing medication, no drugs to induce labor, no surgery from which to recover. “I learned during this fabulous experience how important it is to have a birthing plan and to talk to your doctor about it,” she says. “Had I gone upstairs in a regular room to deliver, my story would be different.”

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 - May, 2007

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