I want to run to the rooftops to yell a warning to US women: Watch out! Wake up! You're in danger. This summer the Centers for Disease Control and Prevention (CDC) released the most recent cesarean rates, and the 2002 average of 26.1 percent is the highest rate in US history. At least four times as many women die of causes related to cesarean birth as those related to vaginal birth. What this cesarean rate really means is that the number of women dying in childbirth is on the rise. As always, poor and minority women are overrepresented in these numbers. Tragically, a woman's chance of dying during pregnancy or birth in the US has not decreased significantly in more than 25 years.

The revealing thing about these statistics is that where a woman lives may be her greatest risk factor for a cesarean. Of the 18 areas with the highest cesarean rates, 11 are in the South and 7 are in the East. Puerto Rico has the highest rate, of 44.7 percent, and the next three highest are Mississippi at 31.1 percent, New Jersey at 30.9 percent, and Louisiana at 30.4 percent. Of the 18 states with the lowest rates, 10 are in the West and 5 in the Midwest: Utah at 19.1 percent, New Mexico at 19.1 percent, Alaska at 19.4 percent, and Idaho at 19.7 percent.

These statistics are very disillusioning. Many of us have worked for childbirth reform for over 30 years, only to feel that we are losing ground. Have we not done a good enough job of educating mothers? Have mothers themselves come to accept technological, surgical birth as normal? Is the practice of defensive medicine so widespread that evidence-based care is just impossible?

In many ways, we have failed new mothers with the illusion of free choice. In my generation, fathers were not allowed in the delivery room, women's hands and feet were routinely strapped down, and silver nitrate was applied to the baby's eyes immediately after birth. In my generation, we had no choices. The concept of informed consent was not widely known, and the rights of hospital patients were unheard of. It was generally assumed that if you gave birth in a hospital, you would have to comply with questionable practices. This was in the seventies, when feminism informed a generation of women about hidden societal oppression and empowered us to believe in ourselves.

Now we believe that we're already liberated. Young, vulnerable, pregnant women assume they are receiving evidence-based care. The reassurance that they can choose pain relief during labor if they want it or that they can even have a cesarean birth if they want one gives women the illusion of choice. In truth, the choices are meaningful only within a very limited context of interventionist and therefore unsafe birth. In light of normal birth, they are pitiful gestures from a system in which the illusion of choice is the only real standard.

Where is our insistence on real standards for normal birth, goals based on evidence, talk of the baby? In my generation, we talked of all decisions during pregnancy and birth in light of what effect they might have on the baby. It was assumed one would err on the side of caution. Now we don't always talk about the baby in relationship to drugs in labor, for example, or prenatal tests. Do we ask, "What effect might this ultrasound have on my baby?" Do we ask, "Will these anesthetic drugs I'm going to take during labor have an effect on my baby?" I read an article in the New York Times a couple of years ago espousing the virtues of "walking" epidurals. In the entire article, the word baby was not mentioned once. We act as if we believe that pregnancy and birth are the experiences of the mother alone, and her body is simply a vehicle. What about the baby?

I think we have failed as childbirth educators because we've framed natural childbirth as just another choice, rather than as the best choice. Natural childbirth is the best choice because it is the safest choice. It is safest because, by definition, it involves fewer medical interventions, and it is these interventions that contribute to at least 50 percent of maternal deaths.

We have also failed to produce enough midwives. While midwife-attended births have increased dramatically, from 1 percent in the 1970s to 10 percent today, there are simply not enough midwives. Despite the fact that all countries with better infant-mortality rates than the US use midwives as primary birth attendants, most women in the US associate them with inferior care. Even though studies consistently show that midwives use fewer interventions and have better birth outcomes than doctors, most women in the US can't easily find one.

It's very tempting to blame doctors for the high cesarean rate. Certainly, the distribution of cesarean rates suggests that local and regional standards of care affect the likelihood of interventions. Yet these variations in care are directly related to increasing medical and legal pressures on doctors. In 1970 the cesarean rate was 5 percent. By 1995 the rate had increased to 20.8 percent because of the changing definition of acceptable risk. Breech babies were routinely delivered vaginally before 1970, for example, and are now routinely delivered by cesarean. Many babies who might previously have been delivered using forceps are now candidates for cesarean birth. The increased use of the electronic fetal monitor, with its wide variations in interpretations, has caused more cesareans to be performed. In addition, abnormal labor has been diagnosed more frequently in the last 30 years. All of these reasons for the increased cesarean rate have to do with changes in doctors' practice, not changes in women's capacities.

The cesarean rate reached its previous high of 24.7 percent in 1988. At that time, efforts were made to reduce the number of repeat cesareans, which account for one-third of all cesareans, and vaginal births after cesareans (VBACS) were encouraged. The current high cesarean rate is expected to increase even more because many birth services and institutions are no longer making VBACS available due to increased legal and peer pressures. These pressures impede implementation of evidence-based practices recommended by the World Health Organization (WHO) and the Coalition to Improve Maternity Services (CIMS), both of which recommend a VBAC rate of 75 percent. These organizations recommend a cesarean rate of between 10 and 15 percent, as does the federal government, which has set the goal of a 15 percent cesarean rate in the US.

Reluctantly, I blame the mothers. I blame women when we don't expect more of ourselves. I blame women when we believe we have a limited capacity. I blame women for being immobilized by cultural myths about birth. I blame women for acquiescing to a system that requires dependence and compliance. I blame women for not being willing to differentiate between prejudice and evidence. Think about it. Nature would not make a pregnant woman dependent. Nature would make her powerfully intuitive in response to the deepest needs of her baby, and it would equip the human female with everything she needs to birth normally. Nature would not make the biological process essential to the survival of our species fraught with danger. Nature would make it simple. And while birth is more successful in community, the human female is a self-contained biological imperative, able to give birth and feed her infant all by herself.

Woefully, American women don't believe this. When I tell women that the evidence shows that birth is safe in any setting-that is, birth is equally safe at home, in a birth center, or at the hospital-they nod hopefully, but I know they don't believe me. Admittedly, it's hard to believe that birth is normal when your community does not share this belief. It's human nature to be influenced by the beliefs of those around you, even if they are incorrect. When it comes to birth, most of us operate more on prejudice than on evidence. We simply do not believe that birth is normal because we have not been exposed to or experienced normal birth.

Instead, we believe erroneously that we have a right to pain-free birth. We are so accustomed to taking drugs for our pain that we do not recognize that pain is an ally during birth. While we would certainly expect and even require pain medication for physical injury, the pain of labor is bearable, short-lived, and part of the feedback system. Pain medication during labor puts the baby at unnecessary risk, and there is no medical evidence to support its use in normal birth. Perhaps most important, we can handle the pain. We are human females. We are designed to handle it.

When we cease to believe this, we are in trouble. Will we find our way back to normal birth in the US? Or will we go the way of South America, where cesarean rates are in the 50 to 80 percent range? We need older women to come forward to tell younger women their stories about normal birth. We need childbirth educators who are independent enough to tell families the truth about the politics of birth. And we need more midwives, the purveyors of normal birth. It's time that birthing women knew about the national and international health initiatives to determine evidence-based guidelines for maternal and newborn care. Both WHO and CIMS provide evidence-based percentages for the frequency of common obstetrical interventions. (See my book, Having a Baby, Naturally, Appendix 1: "Birth Report Card," page 291.)

Ask your practitioner what his or her individual cesarean rate is. Ask what the rate is for the practice. Ask about other interventions and how they compare to evidence or federal guidelines. If the question is balked at or not taken seriously, be cautious. Don't become a statistic. Individuals or practices proud of their statistics will be familiar with them and tell them to you in an instant.

We can't wait for doctors to change. Their medical, legal, and peer pressures do not allow them to practice evidence-based care. Our current standard of maternity care is based on considerations of patient preference, potential liability, and monetary concerns. It is not evidence-based and does not aspire to be. It aspires to be profitable. Revenues from health care are a cornerstone of our gross domestic product.

What we really need is an awakening of mothers. We need mothers who think more highly of themselves than to be subjected to experimental care. We need women who believe in the normalcy of birth. We need families to advocate for normal birth and for midwifery. In the 1980s it was citizen activism that advocated for vaginal birth after cesareans and ultimately lowered the cesarean rate. At that time there were many organizations and institutions advocating for normal birth and for homebirth: The National Association of Parents and Professionals for Safe Alternatives in Childbirth (NAPPSAC), Home Oriented Maternity Experience (HOME), Informed Homebirth (IH), Alternative Birth Coalition (ABC), and the Association for Childbirth at Home International (ACHI).

As always, it will be up to the women. I believe in women. Each woman contains the genetic blueprint for normal birth and can trust the inherent integrity of her biology. She has the authoritative knowledge of normal birth within her. Normal birth gives birth not only to the child but also to the instinctual intelligence of the mother. We can use that intelligence to differentiate between prejudice and evidence. We can be mature enough to consider the needs of our babies during birth.

When we have a new baby, his or her need to touch us and feed from us inconveniences us many times during the early months and years. During that time we are prepared as new mothers to subjugate our needs because we realize that our babies are more vulnerable than we are. During birth it's the same. Just as we did during pregnancy, we continue to make choices during birth that assure the safest and healthiest environment for the baby. That means enduring labor full on, no holding back, and protecting the baby with our courage from the potential harm of questionable interventions. As the baby grows, there will be many times we will be unable to protect him or her from harm. Birth is one time that we can. It's what this rite of passage is all about.

Peggy O'Mara

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