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Penny Simkin Looks Back on 50 Years Serving Birthing Families



Over the years, I've seen many fluctuations in maternity care, women's lives, family structure, medical economics and the impact of risk managers and litigation lawyers in defining safety in obstetrics. It seems almost as if the well-being of mother and baby is only one of many dominant controlling influences. I feel privileged that I came on the scene when I did – in 1968. At the time, we had very few midwives in the U.S. (none in Seattle). A woman was rarely accompanied during labor and, if so, only by her husband, who had to prove with a marriage certificate that he was the husband. No other companions were allowed.

Women didn't walk around during labor; all had IVs, episiotomies, and gave birth on their back with their legs in stirrups and wrists strapped to the sides of the delivery table. The pain drugs were very strong and left them groggy, with no memory of their labor or birth. For the episiotomy and delivery, they had either a saddle block, a type of spinal, or a pudendal block, which numbed the entire birth canal. Forceps deliveries, sometimes very difficult, were very common.

But those times were changing just as I arrived on the scene. Throughout the 1970s, interest exploded in natural birth, husband participation (other companions would have to wait for years), midwives, out of hospital birth, movement during labor, and the baby's experience of birth. I was trained by Virginia Larsen, a visionary family physician who was deeply influenced by the pioneer of Natural Childbirth, Grantly Dick-Read. Our Childbirth Education Association grew rapidly. I was president from 1969 to 1971.

We taught women how to communicate with their doctors, to change positions, squat and smile during labor. It was an exciting time, and huge numbers of women attended childbirth classes – in fact, childbirth classes were THE thing to do in the mid-70s to early 90s.

In those early days, most married women with children were at-home mothers. Most childbirth reform activities were instigated in our homes by volunteers. Many a chaotic meeting took place in my home, with six or eight women and 10 or 12 lap babies and children "helping." We planned monthly educational meetings for the public at the Pacific Science Center; speakers' bureaus that sent speakers to PTA groups and high school health classes; conferences bringing Sheila Kitzinger, Elisabeth Bing, and Pierre Vellay to Seattle. We reviewed and modified the childbirth education curriculum, while the toddlers helped themselves to my cracker drawer, which I left open so that we could work!

Seattle had a free-standing birth center, "The Birthplace," on Aurora Avenue during the 1970s. The Childbirth Education Association here sponsored the International Childbirth Education Convention at Seattle Pacific University in 1976, with 1,300 registrants.

Today 300 to 400 is a typical number of registrants at national childbirth conferences.

Those seemed like boom times, but during the 70s and 80s, the cesarean rate climbed steeply from 5 percent in 1970 to 25 percent in 1987. This was also the time when epidurals had improved to the point where many obstetricians (and women) felt they were preferable to natural childbirth. Electronic fetal monitoring became routine, despite the fact that it had never, in numerous randomized controlled trials, been proven to result in better outcomes for the baby than periodic listening to the baby's heartbeat (which had been the usual practice until then). Outcomes for the mother worsened because the electronic monitoring resulted in lack of movement and a huge increase in cesareans for suspected fetal distress that turned out to be erroneous.

The 80s were also times when two-income families increased, and family size decreased. A less informed public, a weakening of birth activism, plus the rapid rise in litigation and fear of litigation, in obstetrics and all areas of life (fed by a huge surplus of newly educated lawyers, who avoided being drafted to Vietnam by attending law schools which sprung up to meet the demand) created a perfect storm. The result: an upward spiral in fear, among doctors, hospitals and the childbearing public. The belief that more interventions and more surgery resulted in fewer lawsuits led to an epidemic of labor inductions, epidural analgesia, cesarean deliveries, and increasing profits from the overuse of those procedures.

Today, unfortunately, we have passed a tipping point in maternity care. Almost every measure of quality is getting worse: infant and maternal mortality and morbidity; prematurity (although the rates have improved slightly for two years in a row), "near-misses" (mothers and babies who nearly died but survived) and the rates of Post-Traumatic Stress Disorder after childbirth, (which is now at almost 10 percent.)

I have lived through all this, and have been disappointed that so many of the changes in maternity care are based on claims that have actually been scientifically proven to be false: the claim that planned home births with midwives are unsafe; that episiotomies and electronic fetal monitoring are beneficial; that high induction rates are safe; that cesareans are as safe as vaginal births for healthy low-risk women; that babies are fully developed by 37 weeks' gestation; that mother- infant skin-to-skin contact can be delayed without any disadvantages; on and on and on.

At the rate we're going, we'll soon have to answer the questions: What if being born (vaginally) and giving birth (vaginally) become rare events? Will there be any repercussions for the human species? Does it matter how we are born and how we give birth? I fear we may find out.

To me, the three most meaningful consumer-driven successes are: 1) the emergence of the doula, 2) the small but insistent minority of women who have a midwife attend them during pregnancy and birth, and 3) the consumer efforts to allow women to have a vaginal birth after a previous cesarean. The persistence, by a small core of people, in striving to implement safer and more satisfying (for all family members) ways to give birth, gives me strength to keep going in today's climate that I have to describe as hostile to normal childbearing.

I do want to add that I'm not angry with individual care providers who find themselves in the midst of our broken system. They are doing the best they can – following the dictates of their professional societies and avoiding the controversies. I consider obstetricians and nurses as friends, and I admire how they continue to care for women even with the boundaries placed on them in the form of policies and rules. I think they are swallowed up in a system that gives little leeway to the clinician.

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