Birth

About 38 weeks (266 days) after conception, the fetal brain signals the release of hormones, specifically oxytocin, which prepares the fetus for delivery and starts labor, as well as increases the mother’s urge to nurture the baby. 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.

Choice, Culture, or Cohort? Why do it that way? Both of these women (in Peru, on the left, in England, on the right) chose methods of labor that are unusual in the United States, where birth stools and birthing pools are uncommon. However, in all three nations, most births occur in hospitals—a rare choice a century ago.

REUTERS/ENRIQUE CASTRO-MENDIVIL/LANDOV
FRANK HERHOLDT/GETTY IMAGES

Birthing positions also vary—sitting, squatting, lying down are all used. 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; and some doctors insist that women be lying down. Figure 4.3 shows the universal stages of birth.

A Normal, Uncomplicated Birth (a) The baby’s position as the birth process begins. (b) The first stage of labor: The cervix dilates to allow passage of the baby’s head. (c) Transition: The baby’s head moves into the “birth canal,” the vagina. (d) The second stage of labor: The baby’s head moves through the opening of the vagina (the baby’s head “crowns”) and (e) emerges completely. (f) The third stage of labor is the expulsion of the placenta. This usually occurs naturally, but the entire placenta must be expelled, so birth attendants check carefully. In some cultures, the placenta is ceremonially buried, to commemorate its life-giving role.

The Newborn’s First Minutes

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.

Nevertheless, there is much to be done. If birth occurs with a Western-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 to leave the belly button. The infant is examined, weighed, and 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.

One widely used assessment of infant health is the Apgar scale (see Table 4.3), first developed by Dr. Virginia Apgar. When she graduated from Columbia medical school with her M.D. in 1933, Apgar wanted to work in a hospital 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).

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 using an 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. 118.)

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

Medical Assistance

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. In developed nations, births almost always include sterile procedures, electronic monitoring, and drugs to dull pain or speed contractions.

Midwives are as skilled at delivering babies as physicians, but only medical doctors are licensed to perform surgery. More than 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.

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 was 5 percent in 1991, 20 percent by 2001, and 46 percent in 2008, as the surgery has become safer and more indicators of possible problems are used (Guo et al., 2013; Juan, 2010).

Too Many Cesareans or Too Few? Rates of cesarean deliveries vary widely from nation to nation. Latin America has the highest rates in the world (note that 40 percent of all births in Chile are by cesarean), and sub-Saharan Africa has the lowest (the rate in Chad is less than half of 1 percent). The underlying issue is whether some women who should have cesareans do not get them, while other women have unnecessary cesareans.

SOURCES: VARIOUS SOURCES FROM 2000 TO 2012. SINCE DATA CHANGE BY YEAR AND SOURCES PROVIDE DIFFERENT RATES, THIS CHART IS APPROXIMATE.

Pick Up Your Baby! Probably she can’t. In this maternity ward in Beijing, China, most patients are recovering from Cesarean sections, making it difficult to cradle, breast-feed, or carry a newborn until the incision heals.

WANG ZHAO/AFP/GETTY IMAGES

In the United States, the rate rose every year 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 are usually safe for mother and baby and have many advantages for hospitals (they are easier to schedule, quicker, and—when insurance pays surgeons and pays for days in hospitals—more expensive than vaginal deliveries). They also increase 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). This obesity connection could be correlation or causation.

Less studied is the epidural, an injection in a particular part of the spine of the laboring woman to alleviate pain. Epidurals are often used in hospital births, but they increase the rate of cesarean sections and decrease the readiness of newborn infants to suck immediately after birth (Bell et al., 2010). Another medical intervention is induced labor, in which labor is started, speeded up, or strengthened with a drug. The rate of induced labor in the United States tripled between 1990 and 2010, and is close to 20 percent. Starting labor before it begins spontaneously increases the incidence of cesarean birth (Jonsson et al., 2013).

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 may still be about 1 in 20, although 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).

Currently in the United States, newborn mortality is about 1 in 250—a statistic that includes very fragile newborns weighing only 1 pound. That rate is far too high; about forty nations have better rates of newborn survival than the United States. Nonetheless, considering rates in past decades, medical measures have saved the lives of billions of babies.

Several aspects of birth arise from custom or politics, not from necessity (Stone & Selin, 2009). 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, but critics note the public expense of keeping them alive and then the private burden borne lifelong by the parents.

The American Academy of Pediatrics recommends careful and honest counseling for parents of very preterm babies so that they understand the consequences of each medical measure. As an obstetrics team writes, “We should be frank with ourselves, with parents and with society, that there are gaps of knowledge concerning the management of infants born at very low gestational ages…including ethical decisions such as…when to provide intensive care and how extensive this should be” (Iacovidou et al., 2010, p. 133).

Alternatives to Hospital Technology

Questions of costs—emotional as well as financial—abound. For instance, c-section and epidural rates 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 & Walderenström, 2010). A rare complication (uterine rupture), which sometimes happens when women give birth vaginally after a previous cesarean, has caused most doctors to insist that, after one cesarean, subsequent births be cesarean. Many women and some experts think this is unnecessarily cautious, but juries blame doctors for inaction more than for action. To avoid lawsuits, doctors intervene.

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.

Birth in Afghanistan The Afghan doctor is explaining why this woman, who is pregnant with twins, will have an induced labor. Unfortunately, neither baby is expected to survive—a devastating blow this woman has already faced, having twice lost a baby less than a week old.

LYNNE SLADKY/AP PHOTO

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).

One 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 ready (American College of Obstetricians and Gynecologists Committee on Obstetric Practice, 2011).

Historically, women in hospitals labored by themselves until birth was imminent; fathers and other family members were kept away. Almost everyone now agrees that a laboring woman should never be alone. However, family members may not know how to help, and professionals focus more on the medical than the psychological aspects of birth. As a result, some women do not get adequate emotional support. Many women now have a doula, a woman trained to support the laboring woman, Doulas time contractions, use massage, provide encouragement, and do whatever else is helpful.

Often doulas begin their work before active labor begins. When the actual birth is imminent, they work beside the midwives or doctors. Many studies have found that doulas benefit low-income women with no partner, decreasing the disparity in birth outcomes between middle-class and poor women (Vonderheid et al., 2011). Indeed, doulas benefit anyone giving birth, rich or poor, married or not. For example, in one study 420 middle-class married women were randomly assigned a doula or not (McGrath & Kennell, 2008). Those with doulas needed less medical intervention.

Pressure Point Many U.S. couples, like this one, benefit from a doula’s gentle touch, strong pressure, and sensitive understanding—all of which make doula births less likely to include medical intervention.

KARL GEHRING/THE DENVER POST VIA GETTY IMAGES