When the pregnancy test is positive, women are faced with three options. One of the three – a choice that over four million women make each year in the United States – is to keep the baby. Readers of On Common Ground may come to the abortion debate caring fervently about the rights and wellbeing of either the women or the babies, but we can unite when it comes to best taking care of the women having babies.
When a woman is expecting a child, our hope for her is a safe birth, a healthy baby, and, for those keeping the child, an easy transition to motherhood. This is a helpful framework for designing maternity care policies, except we must apply it to a large and diverse population of childbearing women. Must we approach maternity care prioritizing either women or babies, or can a maternity care system optimize the wellbeing of both? And can we reasonably expect care in pregnancy and birth to influence whether the transition to motherhood is an easy one?It sounds like a tall order, but in the mantra of the Obama campaign, “Yes, we can.”
Care practices that optimize the mother’s physical and emotional health are always good for babies. Excellent education and support of expectant parents can help foster confidence and resilience for new mothers to draw upon. And systems of care can protect and promote the healthy biological processes of mother-infant attachment. Consider these scientific findings, all of which come from rigorous controlled trials:
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- A model of group prenatal care that emphasizes self-care, community-building, and coordinated access to social services resulted in a 33% reduction in preterm birth among low-income women. This is the only prenatal intervention shown to have this magnitude of effect on prematurity, a condition that leads to chronic illness, developmental delays, and behavioral and emotional problems and is the largest contributor to the U.S. infant mortality rate. Group prenatal care had other benefits, too, including higher breastfeeding initiation rates and greater satisfaction with care.
- Providing a 4-hour labor support skills class to pregnant low-income women and the female companions the women selected to give them labor support increased the new mothers’ responsiveness to their infants about a month after giving birth. The supported women also were more likely to report easy transitions to motherhood and to have positive perceptions of themselves as women, their bodies’ physical strength, and their ability to be good mothers. Clinical benefits included shorter labors and higher Apgar scores.
- The simple act of placing the newborn skin-to-skin with the mother for the hour after birth resulted in more affectionate behavior by the mothers toward their infants 1-2 days later. This included more time holding their infants and more affectionate touch during breastfeeding. A systematic review of studies of early skin-to-skin contact showed that differences in some maternal attachment behaviors persisted as long as one year after the contact occurred. In addition, infants held skin-to-skin established effective breastfeeding sooner, were more likely to be breastfeeding at one to four months, and breastfed longer than infants without such early contact. Skin-to-skin contact has no harmful effects and is associated with other clinical benefits including higher blood-sugar and a lower risk of hypothermia in newborns.
Unfortunately, none of these practices is standard in the current package of maternity care in our country. Prenatal care is characterized by brief, procedure-driven visits and fragmented access to services such as domestic violence support, smoking cessation programs, and nutritional assistance. Attendance at childbirth education classes is declining, so women have fewer opportunities to learn what they need to know to make informed choices, or to form connections with other expectant parents. A national survey of women who gave birth in 2005 revealed that only 3% had continuous labor support from skilled companions (doulas). In the same survey, 4 out of 10 women reported that their babies spent most of the first hour with staff for routine, non-urgent care.
Most troubling of all, far from gaining a sense of resilience and confidence from giving birth, nearly 1 in 5 women may suffer from childbirth-related post-traumatic stress. When the survey researchers administered a standard post-traumatic stress disorder (PTSD) screening test designed to evaluate effects of the childbirth experience, 18% of the mothers reported symptoms of post-traumatic stress and 9% met all of the criteria for PTSD. It is not difficult to imagine the impact of such stress on women’s ability to care for themselves or their babies after birth.
Physical health outcomes are no better. Maternal mortality and serious morbidity are on the rise and one-third of women begin motherhood recovering from major abdominal surgery. We are moving away from Healthy People 2010 goals for preterm birth, low birth weight, cerebral palsy and mental retardation and have stagnated far below goal rates for other measures including rates of stillbirth and newborn death. Rather than improving, disparities in outcomes for black non-Hispanic women and babies are growing. There is no doubt that we could be doing better in getting new and growing families off to a good start.
The solution is clear. Maternity care systems built on midwife-led primary care yield better health outcomes for women and infants, and offer cost savings to boot. This is the model that nearly every other industrialized country is moving toward – if they’re not already there. The midwifery model of care is holistic and family-centered, emphasizes education and empowerment, and recognizes that childbirth produces both a baby and a mother. Two proposals currently before lawmakers would expand access to midwives. The Medicaid Birth Center Reimbursement Act, introduced recently in both the House (H. R. 2358) and the Senate (S.1423), would ensure access to midwifery care in freestanding birth centers, while a nationally coordinated campaign advocating for regulation and licensure of Certified Professional Midwives would increase access to community-based midwifery care. Both are proven approaches to mother-baby maternity care and far less costly than our current system.
Eighty-five percent of women in this country give birth and, to state the obvious, 100% of babies experience birth. If we could change something to make birth healthier and safer and the transition to motherhood a little bit easier, shouldn’t we be doing it?