Fear about birth is everywhere I turn lately. In the popular press (for those who do not know me well, I am a shameless subscriber to People), celebrities discuss how afraid they are of giving birth. A recent online poll responding to one such story asked women “Are you scared of childbirth?” More than half (56%) said, “OMG [Oh my God] YES! The thought of it really freaks me out.” One-third said, “A little, but I know I'll be fine when the time comes.” Only 10% of those responding said that they were not frightened.1 While this is obviously not a scientific study, the results are strikingly similar to the Listening to Mothers II study, in which the majority of participants (53%) reported feeling fearful as they approached labor.2 There are many aspects of birth about which women are afraid, as evidenced by the fact that participants in Boucher et al.'s3 study in this issue rated fear as one of their reasons for choosing home birth. And fear surrounding birth is not limited to potential or current mothers. Midwives and other women's health care providers are also afraid, and their fears include the rapid rate with which intervention in birth is increasing and the seeming obsolescence of normal birth. It is easy to become discouraged and even paralyzed by all of this fear. Yet the new landmark report Evidence-Based Maternity Care: What It Is and What It Can Achieve4 gives me hope.
The facts about birth in the United States are disturbing. We receive disappointing returns on our huge investment in maternity care, which is the most frequent reason for hospitalizations and ambulatory visits. Outcomes are not improving and, in some cases, are worsening. We overuse interventions that do not work or are even harmful and underuse effective interventions. We are in desperate need of evidence-based maternity care, which “uses the best available research on the safety and effectiveness of specific practices to help guide maternity care decisions and to facilitate optimal outcomes in mothers and newborns.”4
The report begins by outlining the expenditures and performance of the maternity care system in the United States. Evidence-based maternity care is defined, and recommendations for determining the best available evidence are presented. A critical and wary review of care practices and research is encouraged. Both the short- and long-term benefits of physiologic childbirth are reviewed, followed by a discussion of overused and underused interventions. Midwives will not be surprised to find our profession and many of the practices we encourage—such as continuous labor support, delayed and spontaneous pushing, early skin-to-skin contact, and breastfeeding—in the section of effective but underused interventions.
The next section on barriers to evidence-based maternity care is enlightening. While these challenges may have been previously identified, it is refreshing to have all the elephants in the room gathered together and articulated so clearly. The report closes with policy recommendations followed by an appendix of resources and an extensive reference list.
This report paints a compelling picture of where we are with maternity care, where we should be, how to get there, and what is stopping us. It is essential reading for every midwife and women's health care provider in the United States, but we cannot stop there. This report needs to get into the hands of all the stakeholders, not just health professionals and health profession educators. State and federal policy makers, health care administrators, insurers, and researchers need to see this report, as do childbearing women and their families, consumer advocates, and journalists. Then each of us needs to look at the policy recommendations in the report to identify one or more ways we can help evidence-based maternity care become a reality.
As I write this, the United States is 1 month away from inaugurating a new President. During the election, we heard the words fear, hope, and change innumerable times. While it sometimes feels that birth has become mired in fear, I am hopeful that change is still possible in our maternity care system. As health care reform moves back to the forefront of the US policy agenda, the Evidence-Based Maternity Care report is an invaluable resource for the path that change should take.