About 38 weeks (266 days) after conception, the fetal brain signals the release of hormones, specifically oxytocin, to prepare the fetus and mother for labor. The average baby is born after 12 hours of active labor for first births and 7 hours for subsequent births, although often birth takes twice or half as long, with biological, psychological, and social circumstances all significant. The definition of “active” labor varies, which is one reason some women believe they are in active labor for days and others say 10 minutes.

Birthing positions also vary—sitting, squatting, lying down. Some women give birth while immersed in warm water, which helps the woman relax; some cultures expect women to be upright, supported by family members during birth; some doctors insist that a woman must lie down on her back. Figure 4.3 shows the universal stages of birth.

Newborns usually breathe and cry on their own. Between spontaneous cries, the first breaths of air bring oxygen to the lungs and blood, and the infant’s color changes from bluish to pinkish. (Pinkish refers to blood color, visible beneath the skin, and applies to newborns of all hues.) Eyes open wide; tiny fingers grab; even tinier toes stretch and retract. The newborn is instantly, zestfully, ready for life.

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Nevertheless, there is much to be done. If birth occurs with a trained professional, mucus in the baby’s throat is removed, especially if the first breaths seem shallow or strained. The umbilical cord is cut to detach the placenta, leaving an inch or so of the cord, which dries up and falls off several days later to leave the belly button. The infant is often given to the mother to preserve its body heat and to breast-feed a first meal of colostrum, a thick substance that helps the newborn’s digestive and immune systems. Either before or after the mother holds the baby, the attending doctor or midwife weighs and examines the newborn, making sure that lungs, heart, legs, spine and so on are all as they should be.

One widely used assessment of infant health is the Apgar scale (see Table 4.3), first developed by Dr. Virginia Apgar. When she earned her MD from Columbia Medical School in 1933, Apgar wanted to become a surgeon but was told that only men did surgery. Consequently, she became an anesthesiologist. She saw that “delivery room doctors focused on mothers and paid little attention to babies. Those who were small and struggling were often left to die” (Beck, 2009, p. D-1).

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To save those young lives, Apgar developed a simple rating scale of five vital signs—color, heart rate, cry, muscle tone, and breathing—to alert doctors to newborn health. Since 1950, birth attendants worldwide have used the Apgar (often remembering the acronym “Appearance, Pulse, Grimace, Activity, and Respiration”) at one minute and again at five minutes after birth, assigning each vital sign a score of 0, 1, or 2. (See also Visualizing Development, p. 126.)

If the five-minute Apgar is 7 or higher, the baby is okay. If the five-minute total is below 7, emergency help is needed (the hospital loudspeaker may say, “Paging Dr. Apgar”).

How closely any particular birth matches the foregoing description depends on the parents’ preparation, the position and size of the fetus, and the customs of the culture.

Midwives are as skilled at delivering babies as physicians, but in the United States only medical doctors are licensed to perform surgery. One-third of U.S. births occur via cesarean section (c-section, or simply section), whereby the fetus is removed through incisions in the mother’s abdomen. Cesareans are controversial: The World Health Organization suggested that c-sections are medically indicated in only 15 percent of births. In some nations, cesareans are less than 5 percent of births, and birth is hazardous for both mother and child.

Most nations have fewer cesareans than the United States, but some—especially in Latin America—have more (see Figure 4.4). The rate has stabilized in the United States, but in many countries the rate is increasing. The most dramatic increases are in China, where the rate in 1991 was 5 percent, by 2001, 20 percent, and in 2008 40 percent nationwide with 64 percent in major cities (Feng et al., 2014; Juan, 2010).

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In the United States, the rate rose between 1996 and 2008 (from 21 percent to 34 percent) before stabilizing. Variation is dramatic from one hospital to another—from 7 to 70 percent (Kozhimannil et al., 2013). Cesareans have many advantages for doctors and hospitals (easier to schedule, quicker, and more profitable).

One reason for the rise in c-sections is that modern medicine can eliminate pain in the lower half of the body while keeping the mother awake. One woman, named Resch, had a cesarean because her fetus was in a breech position (buttocks first, not head first).

Resch felt “a lot of rough pushing and pulling” and “a painless suction sensation” as if her body were “a tar pit the baby was wrestled from.” She heard the doctor say to the resident: “Hold her up by the hips,” and Resch peered down. She saw her daughter for the first time, wet and squirming… Resch’s husband held the baby next to Resch’s cheek. Resch felt “overwhelmed by emotions … joy, awe, anxiety, relief, surprise.” She gave thanks for her healthy baby, and for modern obstetrical care.

[Lake, 2012, p. 23]

The disadvantages appear later. C-sections increase medical complications after birth and reduce breast-feeding (Malloy, 2009). By age 3, children born by cesarean have double the rate of childhood obesity: 16 percent compared to 8 percent (Huh et al., 2012). The reason may be that babies delivered vaginally have beneficial bacteria in their gut but those delivered surgically do not (Wallis, 2014).

A century ago, at least 5 of every 100 newborns in the United States died (De Lee, 1938), as did more than half of newborns in developing nations. In the least developed nations, the rate of newborn death is now about 1 in 20, although an accurate count is not available as some rural newborn deaths are not tallied. One estimate is that worldwide almost 2 million newborns (1 in 70) die each year (Rajaratnam et al., 2010).

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Every year, an estimated 273,500 women die in pregnancy or birth, almost all of them in nations with very poor medical care (Alkire et al., 2012). A suggested solution is to increase training of doctors or midwives so that cesarean sections could be more available when women were unable to deliver vaginally.

Currently in the United States, newborn mortality (when a baby is born alive but dies in the first day) is about 1 in 250—a statistic that includes very fragile newborns weighing less than 1 pound. That rate is far too high; about forty nations do better. Nonetheless, in the United States and elsewhere, medical measures have saved millions of babies and thousands of women. Almost never does a woman in the United States die of complications of pregnancy, abortion, or birth—the rate is about 1 in 50,000, although some indications are that the rate is rising slightly, as more pregnancies are unintended (Finer & Zolna, 2014).

Critics point out, however, that survival should not be the only measure of success. Several aspects of birth arise from custom or politics, not from necessity.

A particular issue in medically-advanced nations concerns the attention lavished on “miracle babies” who require intensive care, microsurgery, and weeks in the hospital (Longo, 2013). Those who survive often, but not always, need special care all their lives. Only happy outcomes are published; the public cost and the family burden are not publicized.

Questions of costs—emotional as well as financial—abound. All types of medical intervention vary more by doctor, hospital, day of the week, and region than by the circumstances of the birth—even in Sweden, where obstetric care is paid for by the government (Schytt & Waldenström, 2010).

A rare complication (uterine rupture), which sometimes happens when women give birth vaginally after a cesarean, has caused most doctors to insist that, after one cesarean, subsequent births must be cesarean. Many women and some experts think this is too cautious, but juries blame doctors for inaction more than for action. To avoid lawsuits, doctors intervene (Schifrin & Cohen, 2013).

Most U.S. births now take place in hospital labor rooms with high-tech operating rooms nearby in case they are needed. Another 5 percent of U.S. births occur in birthing centers (not in a hospital), and less than 1 percent occur at home (home births are illegal in some jurisdictions). About half of the home births are planned and half not, because of unexpectedly rapid labor. The unplanned ones are hazardous if no one is nearby to rescue a newborn in distress.

Compared with the United States, planned home births are more common in many other developed nations (2 percent in England, 30 percent in the Netherlands) where midwives are paid by the government. In the Netherlands, special ambulances called flying storks speed mother and newborn to a hospital if needed. Dutch research finds home births better for mothers and no worse for infants than hospital births (de Jonge et al., 2013).

A crucial question is how supportive the medical professionals are. One committee of obstetricians decided that planned home births are acceptable because women have “a right to make a medically informed decision about delivery,” but they also insisted that a trained midwife or doctor be present, that the woman not be high-risk (e.g., no previous cesarean), and that speedy transportation to a hospital be possible (American College of Obstetricians and Gynecologists Committee on Obstetric Practice, 2011).

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Historically, women in hospitals labored by themselves until birth was imminent; fathers and other family members were kept away. No longer, as the opening anecdote illustrates. Almost everyone now agrees that a laboring woman should never be alone.

Many women have a doula, a person trained to support the laboring woman. Doulas time contractions, use massage, provide encouragement, and do whatever else is helpful. Every comparison study finds that the rate of medical intervention is lower when doulas are part of the birth team. Doulas have proven to be particularly helpful for immigrant, low-income, or unpartnered women who may be intimidated by doctors (Kang, 2014; Vonderheid et al., 2011).

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