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International Journal of Gynecology & Obstetrics 75 Ž2001.


Fish can’t see water: the need to humanize birth

M. Wagner
Formerly Women’s and Children’s Health, WHO, Copenhagen, Denmark


Humanized birth puts the woman in the center and in control, focuses on community based primary maternity care
with midwives, nurses and doctors working together in harmony as equals, and has evidence based services. Western,
medicalized, high tech maternity care under obstetric control usually dehumanizes, often leads to unnecessary, costly,
dangerous, invasive obstetric interventions and should never be exported to developing countries. Midwives and
planned out-of-hospital births are perfectly safe for low-risk births. 䊚 2001 International Federation of Gynecology
and Obstetrics. All rights reserved.

Keywords: Humanized birth; Unnecessary interventions; Out-of-hospital birth; Midwives; Evidence based practice

1. Introduction a nice extra, it is absolutely essential as it makes

the woman strong and therefore makes society
Humanizing birth means understanding that strong.
the woman giving birth is a human being, not a Humanized birth means putting the woman
machine and not just a container for making giving birth in the center and in control so that
babies. Showing women ᎏ half of all people ᎏ she and not the doctors or anyone else makes all
that they are inferior and inadequate by taking the decisions about what will happen. Humanized
away their power to give birth is a tragedy for all birth means understanding that the focus of ma-
society. On the other hand, respecting the woman ternity services is community based primary care,
as an important and valuable human being and not hospital based tertiary care with midwives,
making certain that the woman’s experience while nurses and doctors all working together in har-
giving birth is fulfilling and empowering is not just mony as equals. Humanized birth means mater-
nity services which are based on good scientific
evidence including evidence based use of tech-
E-mail address: marsden.patricia@starpower.net ŽM. nology and drugs.
Wagner.. However, we do not have humanized birth in

0020-7292r01r$20.00 䊚 2001 International Federation of Gynecology and Obstetrics. All rights reserved.
PII: S 0 0 2 0 - 7 2 9 2 Ž 0 1 . 0 0 5 1 9 - 7
S26 M. Wagner r International Journal of Gynecology & Obstetrics 75 (2001) S25᎐S37

many places today. Why? Because fish can’t see Now the present conference will consider the
the water they swim in. Birth attendants, be they next step ᎏ giving birth back to the woman and
doctors, midwives or nurses, who have experi- her family. Doctors are human; birthing women
enced only hospital based, high interventionist, are human. To err is human. Women have the
medicalized birth cannot see the profound effect right to have any errors committed during their
their interventions are having on the birth. These birthing be their own and not someone else’s.
hospital birth attendants have no idea what a Labor and birth are functions of the autonomic
birth looks like without all the interventions, a nervous system and are therefore out of con-
birth which is not dehumanized. This widespread science control. Consequently there are, in princi-
inability to know what normal, humanized birth is ple, two approaches to assisting at birth: work
has been summarized by the World Health Orga- with the woman to facilitate her own autonomic
nization: responses ᎏ humanized birth; override biology
and superimpose external control using interven-
‘‘By ‘medicalizing’ birth, i.e. separating a woman from her tions such as drugs and surgical procedures ᎏ
own environment and surrounding her with strange people medicalized birth.
using strange machines to do strange things to her in an In practice, care during birth may include a
effort to assist her, the woman’s state of mind and body is
combination of the two approaches: facilitation of
so altered that her way of carrying through this intimate
act must also be altered and the state of the baby born
the woman’s own responses usually dominating
must equally be altered. The result it that it is no longer out-of-hospital management of birth while the
possible to know what births would have been like before superimposition of external controls usually
these manipulations. Most health care providers no longer dominates hospital birth management. However,
know what ‘non-medicalized’ birth is. The entire modern whether the care is medicalized or truly human-
obstetric and neonatological literature is essentially based
ized depends on whether or not the woman giving
on observations of ‘medicalized’ birth w1x.’’
birth is in absolute control.
Why is medicalized birth necessarily dehuman-
izing? In medicalized birth the doctor is always in
control while the key element in humanized birth 2. Why medicalized birth?
is the woman in control of her own birthing and
whatever happens to her. No patient has ever The past 15 years has seen a struggle between
been in complete control in the hospital ᎏ if a these two approaches to maternity care become
patient disagrees with the hospital management intense and global. Today there are three kinds of
and has failed in attempts to negotiate the care, maternity care: the highly medicalized, ‘high tech’,
her only option is to sign herself out of the doctor centered, midwife marginalized care found,
hospital. Giving women choice about certain ma- e.g. in the USA, Ireland, Russia, Czech Republic,
ternity care procedures is not giving up control France, Belgium, urban Brazil; the humanized
since doctors decides what choices women will be approach with strong, more autonomous mid-
given and doctors still have the power to decide wives and much lower intervention rates found,
whether or not they will acquiesce to a woman’s e.g. in the Netherlands, New Zealand and the
choice. Scandinavian countries; a mixture of both ap-
Fifteen years ago in Fortaleza, Brazil, a World proaches is found, e.g. in Britain, Canada, Ger-
health Organization Conference recommended many, Japan, Australia.
birth be controlled, not just by individual doctors Today in developing countries there are usually
and hospitals but by evidenced based care moni- medicalized maternity services in the big cities
tored by the government. Birth, which had been while in the rural areas medicalized services have
taken from the community and slowly but surely not yet penetrated and humanized services re-
changed into hospital-based care during the last main. Prevalent medical opinion is that ‘modern’,
100 years, is to be given back to the community. i.e. Western obstetric-intensive maternity care
M. Wagner r International Journal of Gynecology & Obstetrics 75 (2001) S25᎐S37 S27

saves lives and is part of development and at- started in Brazil, it was gratifying to see maternal
tempts to bring maternity care excesses under mortality fall significantly but meanwhile ce-
control are retrogressive. The present situation in sarean section rates soared, even in the poorest
developing countries reinforces the idea that the states Žsee below..
only reason out-of-hospital, midwife intensive Obstetricians often claim ‘high tech’ medical-
birth still exists in places is because modern medi- ized maternity care in rich countries is real
cal practice is not yet available. progress but the scientific evidence suggests oth-
However, we override biology at our peril. For erwise. There has been no significant improve-
example, if we stop using our bodies, they go ment in highly industrialized countries the past 20
wrong. It is ‘modern’ to get around in a car or years in low birth weight rates or cerebral palsy
public transport resulting in little walking much rates. The slight fall in the perinatal mortality
less running. Then science finds that our bodies rate the past 10 years in these countries is due
need such exercise or we get cardiovascular prob- only to a slight improvement in neonatal mortal-
lems. The post-modern idea is to go back to ity associated with neonatal intensive care and
walking and running Žjogging. and this is seen as not with obstetric care. In highly developed coun-
progressive, not retrogressive. By the same token, tries, all attempts to show lower perinatal mortal-
humanizing maternity services is not retrogressive ity rates with higher obstetric intervention rates
but post-modern and progressive. have failed. A US National Center for Health
Every change in the human condition, includ- Statistics study comments: ‘The comparisons of
ing development, has the potential for positive perinatal mortality ratios with cesarean section
and negative effects. The positive effects of devel- and with operative vaginal rates finds no consis-
opment overwhelm the negative effects until so- tent correlations across countries’ w6x. A review of
cial and economic benefits reach everyone, then the scientific literature on this issue by the Ox-
hidden negative effects begin to emerge. The ford National Perinatal Epidemiology Unit states:
negative effects of development on infant mortal- ‘A number of studies have failed to detect any
ity, always there, have now emerged w2x. The relation between crude perinatal mortality rates
negative effects of development on maternal mor- and the level of operative deliveries’ w7x.
tality are also emerging. Obstetric interventions We are now at the point in maternity care in
such as cesarean section sometimes save lives and industrialized countries where the positive effects
sometimes kills ᎏ maternal mortality even for of development and technology are approaching
elective Žnon-emergency. cesarean section is the maximum and the negative effects are surfac-
2.84-fold or nearly three times higher than for ing. This helps to explain why advances in tech-
vaginal birth w3x. The maternal mortality ratio in nology and in development cannot lead to im-
the US, after decades of steady decline, rose from provements in health unless the technology is in
7.2 in 1987 to 10.0 in 1990 according to the US harmony with natural biological processes and is
Centers for Disease Control and Prevention w4x. accompanied by humanized health care. A simple
While this ratio continued to decline in other example. If an elective cesarean section is done
industrialized countries, in the US the maternal after labor has started, it may in some cases
death rate continued a slow but steady rise facilitate natural processes. But waiting until labor
through the 1990s and according to the World starts means doctors lose the possibility of
Health Organization is now higher than at least scheduling the procedure at their convenience.
twenty other highly industrialized countries w5x. But if, as is almost always the case today, the
Because WHO relied heavily in the past on doctor tries to circumvent natural processes by
obstetricians from highly developed countries with performing elective cesarean section before labor
little or no experience in developing countries, starts, there is a greater risk of respiratory dis-
their programs tended to emphasize the role of tress syndrome and prematurity, both leading
doctors in birth care. This is a double edged killers of newborn infants. We override nature at
sword ᎏ when Safe Motherhood Programs our peril.
S28 M. Wagner r International Journal of Gynecology & Obstetrics 75 (2001) S25᎐S37

This is why international development agencies the 1950s and thalidomide for pregnant women in
such as the World Bank now acknowledge that the 1970s as examples of obstetric interventions
economic development cannot lead to improve- which have had tragic consequences because they
ments in the human condition unless accom- went into widespread use before adequate scienti-
panied by social development, including educa- fic evaluation.
tion. Most clinicians cannot understand how popula-
The greatest danger with western, medicalized tion based scientific data applies to individual
birth is its widespread export to developing coun- patients, resulting in, e.g. objections to using re-
tries. Scientific evidence shows giving routine IV commended rates for cesarean section w12x. This
infusion to every woman in labor is unnecessary failure of some clinicians to understand epidemi-
but such a practice in a rich country, while a ology is often combined with the failure of public
waste of money, is not a tragedy. I have seen health professionals to confront clinicians regard-
routine IV infusion during labor in small rural ing excesses in clinical practice because of their
district hospitals in developing countries where fear of the power of clinicians and their loyalty to
the same hospitals have so little money they are colleagues in the same profession w13x.
reusing disposable syringes. Routine IV infusion Clinicians in most places still rely on peer re-
during labor in developing countries is a tragic view and community standards of practice. Using
waste of extremely limited resources. When de- fellow doctors as a central element in developing
veloping countries adopt western obstetric prac- and monitoring practice guidelines predictably has
tices which are not evidence based, the result is failed. ‘Community standards of practice’, based
other women in those countries dying of cancer on leading clinicians practices on individual
not found early enough because of lack of funds patients, still are the gold standard even though
for such unglamorous but essential care as out- they have been revealed as nothing more than
reach cancer screening programs for poor women. ‘that’s what we all do’, leading to a lowest com-
Obstetricians, like all clinicians, work hard mon denominator standard of care rather than a
helping one patient at a time. In balancing effi- best care standard based on evidence.
cacy and risks, doctors desire to help puts their The one approach clinicians can understand is
focus on efficacy rather than risks. For example, single case, anecdotal evidence. This approach
in US publications there are 41 randomized con- leads to the ‘what if’ scenario in which applying
trolled trials ŽRCT. on misoprostol ŽCytotec. for population data to their practices is rejected by
labor induction proving efficacy but not a single clinicians because ‘what if’ this or that goes wrong
RCT is large enough to adequately measure risks with an individual patient. There is no better
such as uterine rupture w8x. So the Cochrane example of this than planned out-of-hospital birth.
Library recommends not using midoprostol for Many clinicians and their organizations con-
this purpose w9x. But it works and is easy and tinue to believe in the dangers of planned out-of-
cheap so it is used widely in the US, even though hospital birth, either in a center birth or at home,
not approved by the FDA for this purpose. Now rejecting the overwhelming evidence that planned
research is emerging showing serious risks for out-of-hospital birth for low risk women is safe.
using misoprostol for cervical ripening or labor The clinician’s response to this evidence is: ‘But
induction in women with a uterine scar w10,11x. what if there is an out-of-hospital birth and some-
But it is too late for the many US women with thing happens?’ Since most clinicians have never
previous cesarean section whose uterus ruptured attended an out-of-hospital birth, their ‘what if’
after induction with misoprostol and their many question contains several false assumptions. The
dead babies. Misoprostol for labor induction on first assumption: in birth things happen fast. In
women with previous cesarean section in the 1990s fact, with very few exceptions, things happen
joins prenatal X-ray pelvimetry in the 1930s, di- slowly during labor and birth and a true emer-
ethyl-stillbesterol DES. for pregnant women in gency when seconds count is extremely rare and,
M. Wagner r International Journal of Gynecology & Obstetrics 75 (2001) S25᎐S37 S29

as we will see below, often in these cases the support the single case, anecdotal ‘ what if’ scen-
midwife in the birth center or home can take care ario used by some doctors to scare the public and
of the emergency. politicians about out-of-hospital birth.
The second false assumption, when trouble de- Recently there is a desirable movement to-
velops there is nothing an out-of-hospital midwife wards basing medical practice on evidence and
can do, can only be made by someone who has many obstetricians work hard to bring their prac-
never observed midwives at out-of-hospital births. tices in line with the latest evidence. But still
A trained midwife can anticipate trouble and today many doctors are not familiar with recent
usually prevent it from happening in the first evidence nor with the means to obtain it. In a
place as she is providing constant one-on-one 1998 British study 76% of practicing physicians
care, unlike in the hospital where usually nurses surveyed were aware of the concept of evidence
or midwives can only look in occasionally on the based practice, but only 40% believe that evi-
several women in labor for which they are respon- dence is very applicable to their practice, only
sible. If trouble does develop, with few exceptions 27% were familiar with methods of critical litera-
the out-of-hospital midwife can do everything ture review and, faced with a difficult clinical
which can be done in the hospital including giving problem, the majority would first consult another
oxygen, etc. For example, with shoulder dystocia, doctor rather than the evidence w16x. This helps
there is nothing which can be done in the hospital explain the continuing gap between clinical prac-
except certain maneuvers of the woman and baby, tices and the evidence.
all of which can be done just as well by the
Some obstetricians, as members of society, tend
out-of-hospital midwife. The most recent success-
to blind faith in technology and the mantra: tech-
ful maneuver for such shoulder dystocia reported
nology s progress s modern. The other side of
in the medical literature is named after the home
the coin is the lack of faith in nature, best ex-
birth midwife who first described it ŽGaskin ma-
pressed by a Canadian obstetrician: ‘Nature is a
neuver. w14x.
bad obstetrician.’ In attempting to conquer na-
The third false assumption is there can be
ture, the 20th century has seen a series of failed
faster action in the hospital. The truth is in most
private care the woman’s doctor is not even in the attempts to improve on biological and social evo-
hospital most of the time during her labor and lution. Doctors replaced midwives for low risk
must be called in when trouble develops. The births, then science proved midwives safer w17᎐20x.
doctor ‘transport time’ is as much as the ‘trans- Hospital replaced home for low risk birth, then
port time’ of a woman having a birth center or science proved home as safe with far less unnec-
home birth. Even in hospital births, when a ce- essary intervention w21᎐25x. Hospital staff re-
sarean section is indicated, it takes on average 30 placed family as birth support, then science proved
min for the hospital to set up for surgery, locate birth safer if family present. Lithotomy replaced
the anesthesiologist, etc. In one study of 117 vertical birth positions, then science proved verti-
hospital births with emergency cesarean section cal positions safer w26x. Newborn examinations
for fetal distress, 52% of cases had a ‘decision to away from mothers in the first 20 min replaced
incision’ time of over 30 min w15x. So during this leaving babies with mothers, then science proved
30 min either the doctor or the out-of-hospital the necessity for maternal attachment during this
birthing woman are in transit to the hospital. This time. Man-made milk replaced woman-made milk,
is why it is important for a good collaborative then science proved breast milk superior. The
relationship between the hospital and the out-of- central nursery replaced the mother, then science
hospital midwife so when the midwife calls the proved rooming-in superior. If more doctors ex-
hospital to inform them of the transport, the perienced an earthquake or volcano, they would
hospital will waste no time in making arrange- realize their ideas of controlling nature are
ments for the incoming birthing woman. These nothing more than stories to rewrite insignifi-
are the reasons there are no data whatsoever to cance.
S30 M. Wagner r International Journal of Gynecology & Obstetrics 75 (2001) S25᎐S37

3. Unnecessary cesarean section: symbol of sary obstetric interventions also threatens the
dehumanization larger community. Not even the richest countries
in the world have the financial resources to trans-
The quintessential example of medicalization plant all the hearts, dialyze all the kidneys, give
and dehumanization of birth is unnecessary ce- new hips to all the people who might benefit from
sarean section ŽCS. in which the surgeon is in these procedures. Choices must be made about
charge and the woman no longer has any control. which medical and surgical treatments to fund
CS saves lives but there is no evidence that rising and these choices will determine who shall live. A
CS rates the past two decades in many countries CS which is done without any medical indication
has improved birth outcomes w6,7x. How can this but only because a woman chooses it requires a
be? As indications for CS broaden and rates go surgeon, possibly a second doctor to assist, an
up, lives are saved in a smaller and smaller pro- anesthesiologist, surgical nurses, equipment, an
portion of all CS cases. But the risks of this major operating theater, blood ready for transfusion if
surgical procedure do not decrease with increas- necessary, a longer post-operative hospital stay,
ing rates. It is only logical that eventually a rate is etc. This costs a great deal of money and, equally
reached at which CS kills almost as many babies importantly, a great deal of training of health
as it saves. personnel, most of which is at government ex-
Women and their babies are currently paying a pense, even if the CS is done by a private physi-
big price for the promotion of CS by some doc- cian in a private hospital. If a woman receives an
tors. The scientific data on maternal mortality elective CS simply because she prefers it, there
associated with CS suggest the rising maternal will be less human and financial resources for the
mortality rates in the US and Brazil may be, at rest of health care.
least in part, the result of their high CS rates w3x. This dangerous drain on financial resources, as
Both these countries need to carefully audit all noted earlier, is far greater when CS practices in
maternal deaths to test the strong hypothesis that places like the US are exported to developing
rising rates of maternal death are associated with countries with far fewer resources for health ser-
high rates of cesarean section. The data on other vices. For example, in one State in Brazil, 59
risks for both woman and baby associated with CS hospitals have CS rates over 80%, three health
mean both are paying a big price both in the districts have CS rates over 70% while an additio-
current birth and in future pregnancies as well nal 13 health districts have CS rates over 60%
w27x. and the entire State has a CS rate of 47.7% w29x.
Why so much unnecessary CS? When mater- Clearly this is a huge drain on Brazil’s limited
nity care is controlled by doctors, and midwives health resources. While some doctors claim these
are marginalized or absent, higher CS rates are high rates are because Brazilian women request
found. Many studies have shown lower obstetric CS, recent research proves this is not the case
intervention rates when midwives attend low risk ´
ŽProfessor A. Faundes, personal communication..
birth than when doctors are providing primary The women of Brazil are also paying another
birth care to low risk women w28x. It is no coinci- price. The data given above proving the higher
dence that in the US, Canada and urban Brazil, maternal mortality with elective CS in the UK are
where obstetricians attend the majority of normal further substantiated by data showing a recent
births and there are few midwives attending few rise in maternal mortality rates in those areas of
births, the highest CS rates in the world are Brazil with these shockingly high CS rates w30x.
found. Having a highly trained gynecological sur- CS on demand is an expensive and dangerous
geon attend a normal birth is analogous to having luxury.
a pediatric surgeon baby-sit a normal 2-year-old In the light of these issues, the Committee for
child. High CS rates are a symbol of the lack of the Ethical Aspects of Human Reproduction and
humanization of birth. Women’s Health of FIGO Žthe international um-
The overuse of elective CS and other unneces- brella organization of national obstetric organiza-
M. Wagner r International Journal of Gynecology & Obstetrics 75 (2001) S25᎐S37 S31

tions. states in a 1999 report: ‘Performing ce- medicalized birth must be given to health care
sarean section for non-medical reasons is ethi- practitioners, public health officials, politicians
cally not justified’ w31x. There are also individual and the public. Everyone must see the water that
obstetricians and some medical organizations many doctors and hospitals are swimming in and
working to bring down CS rates and humanize see that sometimes there are sharks that may not
birth. eat doctors but may eat some women and babies.
The need to broaden the horizon of doctors
concerning maternity care is not a new problem.
4. Solutions In a medical book from the year 1668: ‘Doctors
who have never seen a home birth and yet feel
So far we have not been clever enough, in competent to argue against it resemble those
developed or developing countries, to take the geographers who give us the description of many
advantages of medicalized birth care while avoid- countries which they never saw.’ We must require
ing the disadvantages such as the drift to obstetric doctors to look at the water in which humanized
excesses. Humanizing birth has the potential to maternity care exists in order to get a physiologi-
combine the advantages of western medicalized cal standard against which they can measure all
birth with the advantages of redirecting the care their experiences. In an obstetric training pro-
so as to honor the biological, social, cultural and gram in The Philippines, every doctor must at-
spiritual nature of human birth. There are several tend a minimum number of planned home births.
strategies for humanization of birth ᎏ strategies Every obstetric training program should require
which will put the woman and the family back in visits to planned out-of-hospital births, including
control of the birth of their own child while birth centers and home births. Midwives and
empowering the woman to believe in herself obstetric nurses in training need the same experi-
through experiencing what her own body can ence.
accomplish. The education of women, especially pregnant
The first strategy is education. Those who con- women, is of paramount importance but here the
trol information hold the power. In the past the issue is: what the women are told. In some places
medical profession often has maintained control prenatal education programs are controlled by a
of medical care through protecting and withhold- few obstetricians who insist on giving only
ing information. Patient confidentiality, a legiti- doctor-friendly information to pregnant women.
mate excuse for limiting access to information on Many anesthesiologists in the US have managed
individual patients, is not an excuse for limiting to gain access to prenatal classes where they
information on grouped data such as hospital preach the wonders of epidural block and usually
data and community data. The information revo- say nothing about the considerable risks of this
lution is profoundly changing medical care. The invasive procedure.
advent of the internet and world wide web is More recently, for some doctors to succeed in
having a profound effect on bringing medical promoting women choosing cesarean sections for
information to everyone. In the new millenium a which there are no medical indications it is neces-
global movement is demanding accountable and sary to provide limited, highly selected informa-
transparent health care practitioners and health tion w27x. It is highly unlikely women would ever
care facilities Žincluding hospitals. as a basic re- consider choosing CS if they were given the full
quirement of any democracy. Complete and scientific evidence on the risks for themselves and
honest information must be given to the public, their babies. The key ethical issue is not the right
even when it means doctors give up power and, in to choose or demand a major surgical procedure
some cases, can threaten the continuation of cer- for which there is no medical indication but the
tain obstetric practices ᎏ maternal mortality right to receive and discuss full, unbiased infor-
rates a prime example. mation prior to any medical or surgical proce-
Full information on the good and bad results of dure.
S32 M. Wagner r International Journal of Gynecology & Obstetrics 75 (2001) S25᎐S37

A liberated woman correctly strives not to be based practice guidelines approved by the com-
controlled by men, an effort even more difficult if munity.
she lives in a male chauvinist society. There are Another essential strategy in humanizing birth
many ways in which women giving birth in hospi- is: who is the primary care giver for women dur-
tals in ‘macho’ cultures are oppressed and given ing pregnancy and birth. The tradition of doctors
the message that they are not important and not insisting on controlling their own practices with
free but controlled by often belligerent staff ᎏ little or no interference from the community or
for example they are told not to make loud noise its representatives goes back a long time. As long
with labor contractions. as doctors provide primary care to normal, healthy
But if a woman accepts the medicalized, male pregnant and birthing women, women will not be
dominated obstetric model of care with its selec- in control and humanization of maternity care
tive information, she gives up any chance to con- will not happen.
trol her own body and make true choices. Volumes Countries must work hard not to allow doctors
have been written about how liberating and em- to come from places with highly medicalized ma-
powering it is for a woman to give birth when she ternity care like the US and try to sell the system
controls what happens. Without fully informed of maternity care of the visiting doctor. Maternity
choice, she will give up any control and comply care in the US has extreme medicalization as
with the wishes of the doctors and hospitals. Sadly doctors give primary care to over 90% of normal,
a few feminists who correctly fight for women’s healthy women giving birth. As a result, birth is a
rights have been drawn into believing biased doc- surgical procedure with high rates of unnecessary
tor-friendly information and as a result have un- interventions. Women giving birth are disempow-
wittingly promoted the right of women to demand ered and there are huge wastes of resources,
obstetric procedures which are dangerous to them financial and professional. In the US, twice as
and their babies. much is spent per capita on maternity care as any
A second strategy for humanization of birth is other country and midwives are marginalized. This
the promotion of evidence based maternity prac- is not a system to emulate ᎏ the US maternal
tices. Peer review and community standards of mortality rate, perinatal mortality rate and infant
practice have failed to close the gap between mortality rate are much higher than the rates in
present obstetric practices and the evidence. And nearly every other industrialized country.
in many places public health professionals and By contrast, midwifery has a long tradition of
government agencies have failed to aggressively placing the birthing woman in the center with all
pursue closing the gap between obstetric prac- the control in the woman’s hands and with the
tices and evidence, often out of fear of the power midwife providing the kind of support which will
of the medical establishment w13x. empower the woman and strengthen the family.
When speaking to hospital obstetric depart- For this reason, having primary maternity care in
ments, I present a simple table with their own the hands of midwives is a central strategy in
rates of interventions Žinduction, episiotomy, humanization of birth.
lithotomy, operative vaginal, cesarean section. in Countries might want to study the maternity
a column on the left and the evidence-based rates care in countries much further along the road to
opposite in a column on the right. The ensuing humanization such as New Zealand, The Nether-
discussion is often characterized by more heat lands, and Scandinavian countries. In these coun-
than light, always with at least a few doctors as tries, over 80% of women see only midwives dur-
concerned as I about the gap between their prac- ing pregnancy and birth Žin or out of hospital.
tices and the evidence. As we enter the era of and they have some of the lowest maternal and
post-modern medical care, the GOBSAT ŽGood perinatal mortality rates in the world.
Old Boys Sit Around Table. clinical practice Considerable scientific research has demon-
guidelines of yore, royalist in sentiment and strated four major advantages to autonomous
pompous in tone, will be replaced by evidence midwifery. First, there can no longer be any doubt
M. Wagner r International Journal of Gynecology & Obstetrics 75 (2001) S25᎐S37 S33

that midwives are the safest birth attendant for jor cost savings. In a paper reviewing the data on
low risk birth. One meta-analysis of 15 studies cost saving w28x, one study found a cost saving of
comparing midwife-attended birth with physician US $500 for every case where a midwife is birth
attended birth found no difference in outcomes attendant.
for women or babies except for fewer low birth Another advantage of midwifery care, often
weight babies with midwives w17x. Two ran- disparaged by advocates of medicalized birth, is
domized controlled trials ŽRCT. in Scotland the pregnant and birthing woman’s satisfaction
w18,19x and six RCTs in North America all found with her care. The evidence in the literature is
no increase in adverse outcomes with midwife- overwhelming: midwifery care is statistically sig-
attended birth w28x. nificantly more satisfying to the woman and her
The most definitive study of the safety of mid- family w28x.
wife-attended birth, published in 1998, looked at Since hospitals are doctor territory and no
all births in 1 year in the US ᎏ over 4 million woman has ever been in control of her own care
births. Selecting only singleton, vaginal births and in a hospital setting, another important strategy
removing cases of social or medical risk factors, for humanization of birth is to move birth out of
they compared outcomes between midwife- the hospital. There have always been and always
attended low-risk births and physician-attended will be women everywhere who choose planned
low-risk births. Compared with physician-attended home birth and need a midwife to attend the
low-risk births, midwife-attended births had 19% birth. But today, as a result of decades of propa-
lower infant mortality, 33% lower neonatal mor- ganda about how dangerous birth is and how safe
tality and 31% lower low birth weight rates w20x. hospital birth is, told by doctors who are them-
After reviewing the extensive evidence for the selves afraid of birth and need the security of
safety of midwives, a recent article in an obstetric hospitals, there are many women who have bought
journal concludes: ‘a search of the scientific liter- into the myth that home birth is dangerous.
ature fails to uncover a single study demonstrat- It is unbelievable that obstetric organizations in
ing poorer outcomes with midwives than with some highly industrialized countries such as the
physicians for low-risk women ᎏ evidence shows US still have the same official policy against home
primary care by midwives to be as safe or safer birth which they wrote in the 1970s. At that time
than care by physicians’ w28x. analyses of out-of-hospital births did not separate
The second advantage of midwives over doctors planned home birth from unplanned precipitous
as primary birth attendants is a drastic reduction out-of-hospital birth and the latter had high mor-
in rates of unnecessary invasive interventions. Sci- tality due to preemies born in taxis, etc. Then
entific evidence shows that, compared with physi- when scientists separated out planned home birth,
cian-attended low-risk birth, midwife-attended it proved to have perinatal mortality rates as low
birth has statistically significantly: less am- or lower than low risk hospital birth. A large
niotomy, less IV fluids or IV medication, less scientific literature documents this, including
routine electronic fetal monitoring, less use of when the home birth practitioner is a nurse mid-
narcotics, less use of anesthesia including epidu- wife w21x or when the midwife is not also trained
ral block for labor pain, less induction and aug- as a nurse w22᎐24x. A meta-analysis of the safety
mentation, less episiotomy, less forceps and vac- of home birth, published in 1997, conclusively
uum extraction, less cesarean section, more vagi- demonstrates the safety of home birth and in-
nal birth after cesarean section w28x. cludes an excellent review of the literature w25x.
The third advantage of using midwives as the So the real issue with home birth is not safety
principal birth attendant for most births is cost but freedom and sanctity of the family. For the
savings. While it varies from country to country, over 80% of women who have had no serious
midwives salaries are almost always considerably medical complications during pregnancy, planned
less than doctor’s salaries. And of course, the home birth is a perfectly safe choice. Any doctor,
lower intervention rates with midwives mean ma- hospital or medical organization attempting to
S34 M. Wagner r International Journal of Gynecology & Obstetrics 75 (2001) S25᎐S37

discourage a low risk woman from choosing home pharmacological methods including walking and
birth is denying basic human rights by withhold- sexual stimulation such as massage of the nipples.
ing full-unbiased information and limiting a In the hospital, staff are not always present and
woman’s freedom of choice of place of birth. The change every 8 h while in the ABC there is the
birth of a baby is one of the most important continuous presence of one midwife throughout
events in the life of the family and when the the labor. In the hospital the new baby is taken
family chooses a planned home birth, the sanctity away from the mother for various reasons such as
of the family must be honored. doing a newborn examination while in the ABC
Because of the frightening propaganda of many the new baby is never taken from the mother.
in the obstetrical profession about how dangerous Are ABCs a safe place for a woman to give
birth is, many women want the freedom to con- birth if she has had no complications during the
trol their own birthing but need the ‘security’ of pregnancy? This is a key question because in the
an institution. How can women today be in con- struggle between the medicalized and humanized
trol of giving birth and be empowered by birth approaches to maternity care, the ABC is a big
and be assisted by a midwife and still feel com- threat to doctors and hospitals and the industry
fortable and protected by an institution? By producing all the obstetric technologies. Because
choosing an alternative birth center ŽABC. which medicalized birth is so expensive with costly hos-
is ‘free-standing’ Ži.e. out-of-hospital. and staffed pital stay, highly paid obstetricians using so much
by midwives. costly high tech intervention, the doctors and
The first essential characteristic of an ABC is hospitals must convince the public and those who
that it is free of any control by a hospital. A control funding of health services that their way is
hospital which claims to have a ‘birth center’ is the only safe way. Otherwise they will quickly lose
like a bakery which claims to sell ‘home-baked much of their business. So obstetric organizations
bread’. To be a birth center, the birthing woman usually fight against all birth where they are not
must be in control of everything that happens to in control. Their first line of defense against any
her and her baby. This means the ABC should be planned out-of-hospital birth is to label it unsafe.
staffed with midwives using protocols made by The only way to determine if ABCs are safe is
midwives. to turn to the scientific evidence. A thorough
The type of care provided in an ABC is quite review of the scientific evidence on ABCs w32x
different from a hospital. In a hospital the doctor reports that in the 1970s and 1980s there were a
is always in absolute control while in an ABC the number of descriptive studies on ABCs. Then in
woman is in control. In the hospital the emphasis 1989 a most important paper on ABCs was pub-
is on routines while in the ABC the emphasis is lished: ‘The US National Birth Center Study’
on individuality and informed choice. Hospital involving 84 ABCs and 11 814 births w33x.
protocols are designed with all the possible com- Regarding safety, the US National Birth Center
plications in mind while ABC protocols focus on Study had no maternal mortality and an intra-
normality, screening and observation. In hospitals partum and neonatal mortality rate of 1.3 per
pain is defined as an evil to be stamped out with 1000 live births, a rate comparable with the rates
drugs while in the ABC it is understood that in low risk hospital births. The infant mortality
labor pain has a physiological function and can be rate and Apgar scores in the ABCs was also
relieved with scientifically proven, non-pharmaco- comparable with low risk hospital rates. Sixteen
logical methods such as immersion in water, percent of ABC births were transferred to the
changing position and moving about, massage, hospital. Such rates of transfer of planned ABC
presence of family, continuous presence of the birth to hospital because of complications com-
same birth attendant. pare favorably with the number of planned hospi-
In the hospital, induction is frequent using tal births which are transferred from the labor
powerful, dangerous drugs that increase pain rooms to the surgical suite because of complica-
while in the ABC labor is stimulated with non- tions. The intention to treat analysis was used in
M. Wagner r International Journal of Gynecology & Obstetrics 75 (2001) S25᎐S37 S35

which all complications, interventions and out- 10 years, Germany has gone from having one
comes from ABC births transferred to hospital ABC to over 50 ABCs. In Japan, a network of
are included in the ABC statistics. midwife birth houses provided a significant part
The safety of ABC birth is further substanti- of maternity services the first half of the last
ated by eight additional studies done in the 1990s century but during the American occupation, US
in which the outcomes of ABC births ᎏ perinatal Army doctors and nurses put pressure on the
mortality, neonatal mortality, Apgar scores, low Japanese to close the birth houses. Now, however,
birth weight rates ᎏ in all studies were as good there is a resurgence of birth houses in Japan.
or better than the outcomes with hospital birth Another strategy in humanizing birth is to inte-
w32x. grate out-of-hospital and in-hospital birth care
In addition to the evidence for the safety of and practitioners. This was accomplished with
ABCs, these studies had further data on the excellent results in Fortaleza, Brazil with commu-
characteristics of women choosing ABCs. After nity-based traditional midwives collaborating
their ABC birth was over, 99% said they would closely with hospital obstetricians w26x. This model
recommend ABC birth to their friends and 94% program, which had gained worldwide recogni-
said they would return themselves to the ABC for tion, was sadly eliminated when the visionary
any future births. A RCT found that 63% of ABC obstetrician who established it died. Data from
women had an increase in self-esteem while 18% places such as Australia show that when home
of women with hospital birth had an increase in birth midwives and local hospital doctors col-
self-esteem w32x. laborate, fewer babies die and everyone learns
With regard to the promotion of breastfeeding, from each other.
studies in the US, Denmark and Sweden all found Birth is political. An essential strategy is for
significantly increased rates of successful breast- advocates of humanized birth to be politically
feeding in ABC women. active. Politicians and government agencies make
The review of literature on ABCs w32x com- crucial decisions about maternity care and their
pared a number of obstetrical intervention rates education about and involvement in humaniza-
in the US National Birth Center Study with the tion of birth is essential. Advocates of humanized
rates of obstetrical intervention in all hospitals in birth must warn politicians and policy makers of
one State ŽIllinois.. In ABCs, 99% were sponta- the use of scare tactics by some of the more
neous vaginal births compared with 55% of hospi- reactionary elements of the medical and nursing
tal births. Less than 4% of ABC births had induc- establishment who raise the issue of safety and
tion or augmentation with artificial rupture of claim without a shred of evidence that humanized
membranes andror oxytocin compared with 40% birth is dangerous ᎏ that midwives are less safe
of hospital births. Routine electronic fetal moni- than doctors and out-of-hospital birth less safe
toring was done in 8% of ABC births and 95% of than hospital birth.
hospital births. Another common scare tactic is for some
Regional or general anesthesia Žincluding obstetricians to say that every out-of-hospital birth
epidural block. was done in 13% of ABC births transported to the hospital is a ‘train wreck’. The
and 42% of hospital births. Operative vaginal answer to this criticism is ‘of course’. A compe-
birth Žforceps or vacuum. was done in less than tent out-of-hospital midwife will only transport
1% of ABC births and 10% of hospital births. those few cases where there is a serious problem
Cesarean section was done in less than 5% of requiring surgical interventions not available in
ABC births and in 21% of hospital births. Look- the home. So for the obstetricians who have never
ing at these comparisons of interventions, clearly attended a home birth Žin many places this is
the logical question is not if ABC birth is safe but nearly all obstetricians ., these out-of-hospital
if hospital birth is safe. transports with problems are their only experi-
As the news about the safety of ABCs spreads, ence with out-of-hospital birth and they erro-
more and more are being established. In the past neously assume these cases are representative of
S36 M. Wagner r International Journal of Gynecology & Obstetrics 75 (2001) S25᎐S37

all out-of-hospital birth. This is why doctors need References

to experience out-of-hospital birth first hand.
These scare tactics are motivated by the at-
w1x World Health Organization. Having a baby in Europe.
tempt of some doctors Žand sometimes nurses. to
European Regional Office, 1985.
protect maternity care as their territory. Often w2x Wagner M. Public health aspects of infant death in
doctors attempt to overwhelm legislators with industrialized countries: the sudden emergence of sud-
technical language which implies that only doc- den infant death. Ann Nestle 1992;50:2.
tors can possibly understand so the listener must w3x Hall M, Bewley S. Maternal mortality and mode of
delivery. Lancet 1999;354:776.
simply ‘trust me, I’m a doctor’. Politicians and
w4x McCarthy B. US maternal death rates are on the rise.
policy makers should be urged to ask those mak- Lancet 1996;348:394.
ing these scare statements: ‘Please show me the w5x World Health Organization. WHO revised estimates of
scientific data to prove what you are saying.’ It maternal mortality: a new approach by WHO and
can also be illuminating for legislators to ask UNICEF. Report no. WHOrFRHrMSMr96.11.
Geneva: WHO, 1996.
those making scare statements how many out-of-
w6x Notzon F. International differences in the use of obstet-
hospital births they have attended. ric interventions. J Am Med Assoc 1990;263:3286᎐3291.
w7x Lomas J, Enkin M. Variations in operative delivery
rates. In: Chalmers I, Enkin M, Keirse M, editors.
Effective Care in Pregnancy and Childbirth. Oxford:
5. Conclusion Oxford University Press, 1989.
w8x Wagner M. Misoprostol Žcytotec. for labor induction: a
cautionary tale, Midwifery Today 1999;49:31᎐33
The final solution is to evolve new social and w9x Hofmeyr GJ. Misoprostol administered vaginally for cer-
political forms for the medical profession and for vical ripening and labor induction with a viable fetus,
medical care. And there are obstetricians joining The Cochrane Library 1999;2:1᎐18.
in the effort to find these new forms for their w10x Plaut M, Schwartz M, Lubarsky S. Uterine rupture
associated with the use of misoprostol in the gravid
profession. Maternity care needs turning around patient with a previous cesarean section. Am J Obstet
so that, instead of drifting away from physiology Gynecol 1999;180:1535᎐1540.
and from the social and cultural environment, the w11x Blanchette H, Nayak S, Erasmus S. Comparison of the
process moves toward respecting and working with safety and efficacy of intravaginal misoprostol with those
nature and with the woman and family, turning of dinoprostone for cervical ripening and induction of
labor in a community hospital. Am J Obstet Gynecol
control of medical care over to the people. For 1999;180:1543᎐1550.
those who fear chaos, remember Churchill’s w12x Sachs B, Castro M, Frigoletto F. The risks of lowering
warning: democracy is the worst form of govern- the cesarean-delivery rate. New Engl J Med 1999;
ment until one considers the alternatives. 340:54᎐57.
This turn around has started in places with w13x Wagner M. The public health versus clinical approaches
to maternity services: the emperor has no clothes. J
local public committees deciding on health care
Public Health Policy 1998;19:25᎐35.
policies and priorities ᎏ post-modern maternity w14x Bruner J. All-fours maneuver for reducing shoulder
care. Everything about pregnancy and birth ᎏ dystocia during labor. J Reprod Med 1998;43:439᎐443.
how it is perceived by society, how the pain of w15x Chauhan S, Roach H. Cesarean section for suspected
birth is endured by women, how birth is ‘managed’ fetal distress: does the decision-incision time make a
difference? J Reprod Med 1997;42:347᎐352.
by birth attendants ᎏ is highly cultural. Local w16x Olatunbosun O, Edouard L, Pierson R. British physi-
control leads to empowerment of women which, cian’s attitudes to evidence based obstetric practice. Br
in turn, leads to a stronger family and society ᎏ Med J 1998;316:365.
local women need to give birth in local waters. w17x Brown S, Grimes D. A meta-analysis of nurse practition-
People have been swimming in the physiological, ers and nurse midwives in primary care. Nurs Res
social and cultural primordial sea for a long, long
w18x Hundley V, Cruickshank R, Lanf G, Glazener C. Mid-
time, can see the water, know where the sharks wifery managed delivery unit: a randomized controlled
are and are adept at eventually finding their way comparison with consultant led care. Br Med J
forward to reclaiming humanized birth. 1994;309:1401᎐1404.
M. Wagner r International Journal of Gynecology & Obstetrics 75 (2001) S25᎐S37 S37

w19x Turnbull D, Holmes A, Shields N, Cheyne H. Ran- w27x Wagner M. Choosing caesarean section. Lancet
domized, controlled trial of efficacy of midwife-managed 2000;356:1677᎐1680.
care. Lancet 1996;348:213᎐218. w28x Wagner M. Midwifery in the industrialized world. J Soc
w20x MacDorman M, Singh G. Midwifery care, social and Obstet Gynecol Can 1998;20:1225᎐1234.
medical risk factors, and birth outcomes in the USA. J w29x ´
Rattner D. Sobre a hipotese ˜ das taxas
de estabilizaçao
Epidemiol Commun Health 1998;52:310᎐317. ´
de cesarea do Estado de Sao ˜ Paulo, Brasil. Rev Saude
w21x Murphy P, Fullerton J. Outcomes of intended home
Publica 1996;30:19᎐33.
births in nurse-midwifery practice: a prospective descrip- w30x Secretariat of Health, Sao Paulo State, Brazil, 1999.
tive study. Obstet Gynecol 1998;92:461᎐470.
w31x FIGO Committee for the Ethical Aspects of Human
w22x Durand AM. The safety of home birth: the farm study.
Am J Public Health 1992;82:450᎐453. Reproduction and Women’s Health. Ethical aspects re-
w23x Schramm W. Neonatal mortality in Missouri home garding cesarean delivery for non-medical reasons. Int J
births. Am J Public Health 1987;77:930᎐935. Gynecol Obstet 1999;64:317᎐322.
w24x Hinds M. Neonatal outcome in planned v. unplanned w32x Stephenson P, Ford Z, Schaps M. Alternative birth
out-of-hospital births in Kentucky. J Am Med Assoc centers in Illinois: a resource guide for policy makers.
1985;253:1578᎐1582. University of Illinois at Chicago Center for Research on
w25x Olsen O. Meta-analysis of the safety of home birth. Women and Gender, and the Health and Medicine
Birth 1997;24:4᎐16. Policy and Research Group, 1995.
w26x Wagner M. Pursuing the birth machine: the search for w33x Rooks J. The National Birth Center Study. New Engl J
appropriate birth technology. Sydney: ACE Graphics, Med 1989;321:1804᎐1811.