Among the factors that have fueled the movement to a high-tech birthing environment, the three most influential have probably been the “players” in the birthing scene: the consumers (childbearing women), the health care providers (physicians and nurse-midwives), and the caregivers (perinatal nurses).
Today’s childbearing women are very different from their mothers and grandmothers in regard to their views of childbirth, the options available to them, and the decisions they must make (Davis-Floyd, 2003). From a sociocultural perspective, the women born in the late 1970s or 1980s are known as generation Y (the successors to generation X) or as Echo Boomers (because their 80 million in number rivals the number of baby boomers). They have also been called the iGeneration because they were born into an era of technology and have known nothing else (Huntly, 2006).
In recent years, the author has observed a negative influence of the media on the view of pregnancy and childbirth for today’s childbearing women. Very seldom are labor and birth depicted in a positive manner on television, whether being discussed on syndicated talk shows, portrayed in soap operas or sitcoms, or in the new reality programs about childbirth. Books written for pregnant women regarding pregnancy and birth are far more likely to portray a negative attitude than a positive approach that encourages women and gives them confidence in their bodies’ ability to grow a healthy baby and to labor and give birth. When movie stars brag about their epidurals and elective cesarean births, it is difficult for today’s expectant women to have the self-confidence to counter this attitude.
The iGeneration is used to and comfortable with technology. They have known nothing other than fast-food restaurants, microwave cooking, drive-through banking and pharmacies, and fast easy access to communication and information. A technologically managed labor and birth that can be fast and efficient is not a negative concept and is not likely to be challenged. For example, when today’s pregnant women become impatient with the natural length of pregnancy, elective induction seems like an easy solution, particularly for White, well-educated, insured, married women who have had early prenatal care (Simpson & Atterbury, 2003). Anecdotal reports suggest that when a physician suggests induction of labor, the woman may be told that the baby is “ready” and if she waits for labor to begun spontaneously, the baby will be “too large” or will not tolerate labor. Most women do not have enough information to be able to critically evaluate what they are told, so they acquiesce (Lothian, 2006c). Parity, educational level, and financial status may also influence childbirth decisions. Women who had previous births and had the most education and income indicated the greatest preference for epidural analgesia (Stark, 2003).
Another trend is electing cesarean birth with no medical indication. This consumer demand, if it grows, will take us further into a routinely high-tech model of maternity care. Cesarean birth on maternal request (CDMR) may be the result of a number of factors: the impatience with being pregnant, fear of labor and the belief that a cesarean birth will be easier and less painful, the ability to plan and schedule the day of delivery, a lax attitude regarding surgery and a lack of awareness about the risks of cesarean birth, belief that vaginal birth is harmful due to the possibility of future pelvic floor problems, desire for personal control (Lothian, 2006b), or economic considerations such as being able to receive 8 weeks paid maternity leave from a job for a surgical procedure rather than 6 weeks for a vaginal delivery. Concern about this trend prompted the National Institute of Health to convene a State of the Science Conference in March 2006 to assess the current research related to CDMR. The actual incidence of CDMR is not clear at this time, with reports ranging from 2.5% to 18% (Mayberry, 2006; Young, 2006).
Pregnant women are placed in a difficult position if their care providers give information that is frightening. It is easy for them to be convinced to agree to interventions if they perceive that failure to do so will harm their babies, particularly if they have not had an opportunity to evaluate the information given to them. The author was informed of a situation in which a woman was told by her female obstetrician that “labor is barbaric.” The physician herself had had a primary elective cesarean delivery. This kind of negative influence is difficult for the patient to overcome. Women trust their caregivers and fear that if they do not comply or are “disobedient,” they will not receive good care (Davis-Floyd, 2003; Kitzinger et al., 2006; Wagner, 2006).
Decisions are therefore often made as a result of fear. Many expectant women today do not attend childbirth classes, so the benefit of being given pros and cons of various childbirth options, with time to think about and discuss the implications of their choices, may not be available. Some fears may be misplaced, however. For example, childbearing women agree to be induced because of harm to the baby if the due date is passed, but they do not fear the potential risks of the induction; they fear the pain of labor, but not the pain and potential medical complications from major abdominal surgery (Boyd, 2006). The author has observed that today’s women have very little confidence in their bodies’ ability to give birth or their ability to cope with the labor and birth process. For this reason, one of the stated goals of Lamaze International is to increase women’s confidence through education (Lamaze International, 2003).
No doubt the primary influence on physicians and nurse-midwives that has affected the change to high-tech birth is legal liability. Care providers believe that they must practice defensive medicine to avoid potential litigation. Despite the fact that pregnancy outcomes for both mothers and infants are better than they have ever been in our history, litigation has increased. Consumers’ zero tolerance for any bad occurrence has become the rule, not the exception (Hankins, Maclennan, Speer, Strunk, & Nelson, 2006; Wagner, 2006).
According to the ACOG, obstetricians have an average of 2.6 claims filed against them during their career; 61% of these are obstetrics related (Cherouny, Federico, Haraden, Leavitt, & Resar, 2005) and the majority for allegedly birth-related cerebral palsy (Hankins et al., 2006). The National Practitioner Data Bank reported that in 2003, there were 1,255 obstetric-related legal cases, which generated 8.1% of all physician malpractice payment reports and had the highest median ($290,000) and mean ($475,880) payment amounts. For the period from 1997 to 2003, the median malpractice award for a childbirth-related claim involving obstetricians and hospitals was $2.5 million (Horsham, 2005). Because of these statistics, liability insurance premiums for obstetricians and hospitals with large obstetrics services have risen dramatically, up to $299,420 per year in some states. This has forced some care providers to relocate to other states, to drop their obstetrics services and provide gynecology care only (1 of 11 have done so), or to leave medical practice (Hankins et al., 2006).
The clinical interventions that have been most fueled by liability concerns are elective induction of labor and cesarean birth. Care providers may believe that if they can obtain some control of the labor and birth process, they can control negative outcomes as well. These two clinical practices also enable physicians to gain control of their personal and professional schedules. There seems to be an attempt to fit childbirth into an 8:00 a.m. to 5:00 p.m. workday, so controlling the labor process with oxytocin or delivering a baby by a scheduled cesarean is very enticing (Wagner, 2006).
And yet, there is a philosophical schism within the medical community on cesarean birth versus vaginal birth. Some physicians practice in a manner to promote normal birth and decrease the cesarean rate, and others believe that cesarean delivery decreases litigation risk. This clash has been observed from one region of the country to another, between hospitals within the same community, and even among physicians within the same hospital system (Moore, 2005).
When surveyed, obstetricians from Maine expressed the belief that women have a right to select their mode of birth. Eighty-four percent stated that they would perform elective cesarean birth upon maternal request, but only 21% stated that they would elect a cesarean birth for themselves or their partners (Wax et al., 2005). This trend was found to be consistent in other areas of the United States and in other countries as well (Klein, 2005). Fears expressed about vaginal birth among obstetricians, whether in regard to their patient’s outcomes or in regard to their own births, are related to pelvic floor consequences (urinary or rectal incontinence and sexual problems). Some care providers seem to have lost regard for the normal physiology of birth and instead fear the process of childbirth in their clinical practices and in their personal lives (Klein).
The ACOG published a statement that it is ethically permissible to accede to a request for an elective cesarean birth from an informed woman, but also acceptable to refuse if the surgeon thinks that it is not in her interest (ACOG, 2003). When the providers’ professional organization supports consumer choice of surgical birth as ethically permissible, future escalation of this technology seems likely.
The best approach is to strive to balance both aspects of care, providing high-touch components along with technology as needed.
The nursing caregivers
Changes in the curricula of many nursing education programs over the past decade have resulted in very little time allocated for the maternal-newborn nursing course. In some schools, it is not even a required clinical experience but can be selected as an elective. In the time that is allocated for this specialty content, the focus has shifted from that of normal birth and nursing care to support it to a high-risk focus with all the accompanying high-tech interventions. Depending on where students have their clinical experiences, it is possible that they will never see a normal birth. Nurses have learned to manage labor from a distance with the use of monitors and other technology. The move to high-tech childbirth has therefore been a comfortable one for many new nurses.
In addition, a high-tech model of care has been accepted and even embraced in many hospitals, as a result of the nursing shortage or hospital fiscal constraints, or both, that inhibit increasing staffing. Many hospitals cannot meet AWHONN’s staffing guidelines of a 2:1 patient-to-nurse ratio for care during active labor (Schofield, 2003). It is easier to “macromanage” more patients if they all have epidural pain relief early in labor, if their labor pattern is being controlled by oxytocin, and if they are monitored so that contraction patterns and fetal status can be continually assessed from a distance (Simpson, 2000). This model of care requires fewer nurses.
The nursing shortage is not expected to improve in the near future. By 2015, it is expected that our country will have a 22% shortfall of nurses (Roberts, 2002; Sinclair, 2003). In 2004, the average age of nurses was 46.8 years, more than a year older than it was in 2000; the largest number of nurses working today are in the age group of 45 to 49 year, thus many of the nurse providing care today will be retiring in the next two decades (Health Resources and Services Administration [HRSA, 2004]). The resultant staffing situation is thus likely to play a part in the model of care that will be possible for childbearing women in the future.
As the primary caregivers for women during labor, nurses often find themselves walking a fine line between the wishes of the consumers and the preferences of the women’s medical care providers. Many perinatal nurses describe their feeling as though they are caught in a philosophical dilemma between the technology that has become a standard component of care and the belief that childbirth is normal and may not always require routine interventions. Although nursing caregivers and providers share the same goal of a healthy outcome for mother and baby, communication between them is sometimes a source of frustration, as they do not always agree on the model of care to achieve this goal (Simpson, James, & Knox, 2006). There is also a dichotomy among nurses, for some struggle with the current “medicalization” of childbirth, while others accept it without question.