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Birth in the United States: an overview of trends past and present
Nurs Clin N Am 37 (2002) 735–746
Birth in the United States: an overview of trends past and present William F. McCool, PhD, RN, CNM*, Sara A. Simeone, BS, SNM Midwifery Graduate Program, University of Pennsylvania School of Nursing, 315 S. 44th St., Philadelphia, PA 19104, USA
As dawn brightens the sky, the great event takes place. Something so perfect has appeared, as if from nowhere. There is something mystical and emotional about this scene. It’s as if they have received a gift from the gods. —Description of monolith ‘‘birth’’ scene on prehistoric Earth from 2001: A Space Odyssey [1] ‘‘I suppose computers have been known to be wrong.’’ —Dr. Dave Bowman, Jupiter Mission Commander, 2001: A Space Odyssey
The ‘‘future’’ of Arthur C. Clarke and Stanley Kubrick’s 2001: A Space Odyssey has arrived, and much has changed since that landmark movie was released in 1968. Most people would agree that today’s world is quite different than the twenty-first century depicted by Clarke and Kubrick, yet there were several similar factors between the fiction of their world and the reality of ours today. One of these factors is the continued wonder of birth. The description of the prehistoric humans’ reaction to the ‘‘birth,’’ or discovery, of the godlike monolith found in 2001: A Space Odyssey could easily be applied to the reaction of most parents when a child is born. At the same time, a second movie ‘‘fact’’ applicable to today’s world is the impressive presence of technology in all aspects of modern life, including pregnancy and birth, and the accompanying muted skepticism that the character of Dr. Dave Bowman expressed toward this technology on which much of human living has come to depend. In the United States today, birth is at a crossroads between the naturalness of this biologic event and the modernization of human life through technological advances. Health care providers, including midwives and obstetrical nurses, have been centrally involved in the many changes that have occurred in childbearing care over
* Corresponding author. E-mail address: [email protected] (W.F. McCool). 0029-6465/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 0 2 9 - 6 4 6 5 ( 0 2 ) 0 0 0 2 0 - 8
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the past half-century. Though one can argue about the importance, safety, or ethics of these changes, it is first relevant to understand how birth has developed leading up to today. Short history of childbirth in the United States: 1700–1950 Birth in the area now known as the United States occurred for centuries in Native American cultures prior to the arrival of Europeans, but birth as it culturally exists today primarily reflects developments that began with the childbirth practices of the first European settlers. In the early days of the New World, most children were born to Puritan wives in their early 20s. Women in the 1700s typically devoted the next 20 years of their lives to childbirth, often with children born every 15 to 20 months. A woman’s childbearing years would end either with menopause or with her death [2]. Early American childbirth practices, characterized as following a social childbirth philosophy, were strongly influenced by the practices of England [2]. Women in labor delivered at home and were attended by lay female relatives and friends, a female midwife, and occasionally a trained female nurse. Only the richest families would also have a physician in close contact in the case of an emergency. After delivery, a woman remained with her female support system for a ‘‘lying-in’’ period during which she recuperated and became acquainted with her new child. The involvement of women in the birth process was a mechanism through which women supported, loved, and cared for each other. It has been noted that ‘‘for colonial women, the practice of social childbirth acted as a palliative, a respite from incessant child care over a period of twenty to twenty-five years of their lives’’ [2]. This quality of togetherness encouraged the persistence of the social childbirth philosophy at home births throughout the nineteenth century and into the early twentieth century. Any changes in childbirth practices throughout the earlier period of colonial history were influenced not by a breakdown in this social childbirth philosophy, but by growing differentiations in social class and the increasing value placed in the medical profession and its activities. Midwifery philosophy in Colonial America could be described, using today’s terminology, as noninterventional. This was where American midwives differed from their European counterparts. In Europe, where such items as forceps were invented, and where the availability of physicians was more pronounced, there was greater use of technology to assist in the progression of labor than was seen in the United States. When the labor of an American woman was progressing normally, the midwife and other attendants saw their role as sustaining the strength of the individual and reassuring her of her progress. Only in a labor where things were not progressing well did colonial midwives use some ‘‘technologies’’ in their practice, including herbs and enemas. To decrease pain in a particularly long or strenuous labor, midwives would give the mother opium; if contractions were partic-
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ularly troubling, the midwife might add belladonna to the opium. When physicians later began to assume responsibility for childbirth, they looked to the midwives’ techniques and adopted the use of opium and belladonna. Midwives in Europe at that time also were reported to use ergot to induce labor and stop postpartum bleeding, but there is no evidence that American midwives used the same practice [2]. The rate of maternal death during childbirth in the United States experienced a large decline between the eighteenth and nineteenth century. Preparing for birth in the 1700s was, in a sense, synonymous with preparing for death. Women feared childbirth because they had a strong reason to believe that they would not survive the experience. Yet, in the 1800s, there was a significantly reduced maternal death rate. In fact, in the nineteenth century, there are reports of maternal death rates as low as 5% in some areas of the United States. Positive birth outcomes were more likely in United States than in Europe at that time. At a time when the medical world had yet to discover germ theory, it is thought that the American philosophy of minimal intervention by the midwife or doctor during labor and birth contributed to this difference [2]. Despite reductions in maternal deaths, women still feared the birth process, and the medical world increased its efforts to reduce the morbidity and mortality of birth. During the nineteenth century, part of these efforts focused on identifying and understanding puerperal fever. With the advent of germ theory and the initial understanding of infectious disease, some scientists began to link maternal postpartum death, which was particularly prevalent after hospital-based births, to contamination from autopsy material or disease from other hospital patients [2,3]. With the safety of childbirth increasing in the nineteenth century, the focus of care became controlling pain. The predominant psychologic and physical beliefs of the Victorian era, both in Europe and here in the United States, influenced childbirth in unique ways. Pain in childbirth was exacerbated by the interaction of physical conditions such as corsets, decreased activity, stuffy rooms, venereal disease, and psychologic expectations that required women of that era to be weak. In response to the call to reduce pain, Dr. Walter Channing of Boston pioneered the use of chloroform during delivery in 1848, though use remained minimal during the later half of the century [2]. Women continued to use folk remedies to help ease childbirth. Among these practices were the ‘‘fruit diet’’ and the ‘‘water cure.’’ It was suggested that adherence to a diet of only fruits and a few selected vegetables during pregnancy would produce a bone-free, ‘‘soft baby’’ by restricting food such as wheat that was considered essential to bone formation. Proponents of the water cure advocated for pregnant women to take walks in the fresh air and to drink frequently and bathe in cold water in order to ease labor. Despite these efforts, women still experienced pain during labor and,by the end of the 1800s, began requesting a method that would truly relieve all pain while giving birth [2]. Beginning in the 1900s, this increased desire for labor-pain relief helped to contribute to an increase in the percentage of births occurring in hospitals.
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Within this shift was an inherent conflict: hospital births promised pain relief, but there remained the increased risk of dying from infection. Regardless, from 1900 to 1920, during which time the medical establishment initiated a campaign to take control of pregnancy health care from midwives [3], the percentage of in-hospital births increased tenfold. This transition from home to hospital marked a radical conceptual change in the process of childbirth. Wertz and Wertz put forth that within this era ‘‘began the major transformation of birth: from home to hospital, from suffering to painlessness, from patient care to disease care’’ [2]. The twentieth century saw the end of the social childbirth philosophy found in earlier America, and replaced it with a medical illness model, the influence of which persists today. No longer were parturient women surrounded at home by women from their families and/or communities; instead, individuals giving birth were alone in sterile hospital delivery rooms accompanied by medical personnel, usually female nurses and male physicians. To add to this sense of isolation, each decade of the twentieth century saw the introduction of new technology into the birthing process. As birth moved increasingly into the hospital, greater use was made of the ‘‘delivery table,’’ a narrow metal bed onto which the birthing woman was strapped in the lithotomy position so as to make the delivery most accessible for the attending physician [4]. In the 1920s, the routine use of forceps during uncomplicated births was promoted [5]. This contributed to the greater use of anesthesia during labor and birth, aided in part by the numerous discoveries and chemical inventions of modern pharmaceutical firms. By the 1950s, most American women were not alert or even conscious while giving birth, and because of the use of amnesiac medications, did not recall most of the events of labor and birth [2]. Childbirth in the United States: 1950–2000 Technological advances continued to be introduced into the hospital delivery room. In the 1940s, continuous caudal analgesia-anesthesia was first given to laboring women and continued to be used into the 1960s [6]. As with prior uses of anesthesia, this method of pain control required that the woman be confined to bed. Because family or friends were not allowed to visit the laboring woman, bed confinement further isolated her from any potential contact with familiar, supportive individuals. It became the task of the obstetrical nurse to replace the community of women who attended the needs of laboring women prior to the twentieth century. Refinement in anesthesia techniques led to the introduction of continuous lumbar epidural anesthesia in the 1960s. This type of anesthesia required less medication than caudal anesthesia and was easier and faster to administer. During this same decade, electronic fetal monitoring (EFM) was developed for use in the labor and delivery rooms [7]. Hospital personnel could now listen to a fetal heartbeat electronically, thus allowing for continuous monitoring of the fetus’ heart rate and freeing the physicians
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and nurses to conduct other tasks. Unfortunately, the soon-to-be widespread use of both the epidural anesthesia and EFM confined the laboring woman to bed, usually in just one primary position for several hours. The centuries-old practice of ambulation in labor was lost to the development of these modern technologies. The thought that epidural and EFM use would benefit laboring women and their infants was based on theory, and not on any evidence at the time of the technologies’ introduction. Research over the last decade, however, has raised questions about the clinical value of these ‘‘advancements’’ that led to a bed-ridden, strapped laboring woman [8–10]. In the 1970s, the greatest change in obstetrical care was based on technology developed by the U.S. Navy during World War II. Sonar for detecting submarines and other ships during the war was used to develop ultrasound imaging, enabling medical personnel to view the pregnant woman’s fetus and uterus [6]. Initially, this technology allowed for gross measures, such as fetal position and a rough estimate of fetal weight. Refinement of ultrasound technique and equipment has now led to its use for increasingly accurate dating of a woman’s estimated date of delivery (EDD), discovery and sometimes in utero treatment of fetal abnormalities, and assessment of fetal sex during the pregnancy [11]. Today, most pregnant women in the United States have at least one ultrasound assessment over the course of the gestation period. Though many women look forward to their first visual glimpse of their fetus through ultrasonography, some scholars have raised concerns about the widespread use of this technological advance because of unknowns about any long-term effects of sound wave use on fetuses, and because of the increasing disconnection between women and their pregnancies and fetuses [12,13]. The latter concern goes beyond ultrasonography and applies to many of the technological and clinical practice changes that have occurred during the past 50 years regarding pregnancy and childbirth. Though the laboring woman of the past was surrounded by family and friends at home, the laboring woman of the latter part of the twentieth century was supported mostly by unknown hospital personnel. No longer could women walk during labor but instead were confined to the hospital bed. In an effort to help alleviate the pain of labor, women came to giving up total feeling of the lower half of their bodies. The first connection with their developing fetus was no longer through the sense of touch when they first could feel fetal movement, but now was through sight and sound when they could see and hear the fetus through ultrasound. It has been noted that women are increasingly dependent on technology for connecting with their children, and they are moving closer and closer to being viewed as biologic vessels for fetal growth and delivery rather than a single maternal/fetal unit. Indeed, it has been suggested that, by the end of the twenty-first century, human gestation could take place entirely outside of the woman’s body and be confined to a laboratory environment [14].
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Not all changes regarding pregnancy, labor, and birth in the late 1900s were technological in nature. Beginning as far back as the 1940s, practitioners in Europe began to promote a return to a noninterventionist labor and birth for women, one in which the woman ambulated during labor, used breathing and imagery for pain control, and was supported again by family members and friends. In the United States during the 1960s, this push for a return to natural birth, coupled with the expanding Second Wave of Feminism, or the ‘‘Women’s Movement,’’ led to a call for women to take back control of their pregnancies and birth from the medical establishment, and to forgo much of the technology introduced during the twentieth century into the world of pregnancy health care. As a result of consumer demands, there was an increase in the number of women who chose to experience a home birth, and there was growth in the number of birth centers in the United States, where women could experience the ‘‘social childbirth’’ practiced by the Pilgrims yet feel the safety that many individuals had come to believe was offered by medical technology [14,15]. Before the end of the twentieth century, hospital administrators and obstetricians responded to these changes in consumer health practices by replacing traditional labor and delivery rooms and equipment with ‘‘labor and delivery suites’’ or ‘‘birthing rooms.’’ Through the use of interior decorating, an attempt has been made to create a home-like environment in the hospital where women can labor and birth. The technology remains and is used as extensively as ever, yet it is surrounded by curtains and wooden bed frames in order to soften its appearance [14].
Birth in the United States today What does birth in the United States look like today? The latest birth certificate data, for the year 2000, reports a total of 4,058,814 live U.S. births. Vaginal delivery continues to be the predominant method of delivery, accounting for 3,108,188 (77%) of the births that year. The remaining 23% of births were either primary or repeat cesarean sections. After declining in the early 1990s, the c-section rate has risen again each year from 1997 to 2000. Conversely, the number of vaginal births after a previous c-section (VBAC) has declined close to 20% during that time period after having risen in the early 1990s [16]. One can speculate that this occurred because of a question regarding the safety of VBACs. Blanchette, Blanchette, McCabe, and Vincent studied the VBAC safety at a community hospital in Massachusetts (N ¼ 1418) [17]. They found that the VBAC attempt rate was 50.1% (N ¼ 727), and that the neonatal outcomes in the VBAC and repeat csection groups (N ¼ 754) were similar. Uterine rupture occurred in 12 of the VBAC women, 11 of whom had experienced induction of labor, augmentation of labor, or both. The authors concluded that VBACs should be considered safe if induction of labor is not used.
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Though there has been a decline in the United States of the use of forceps at time of birth to 4.2% of all vaginal deliveries in 1999, vacuum extraction has become more prevalent, having been used in 8.4% of all 1999 vaginal deliveries [18]. Induction of labor was used in 20% of all births in 2000. This was an increase of greater than 100% since 1989. Augmentation of labor has also been increasing (64% rise since 1989). In 1999, it was employed in 18% of all births. Ultrasound and EFM are the most prevalent technological interventions used during pregnancy and labor, currently reported at 66% and 84%, respectively [16]. The majority of babies born in the United States are full-term singletons of average weight. Pre-term (<37 weeks) births constitute 11.6% of all births; a 10% increase since 1990. The percentage of live births of very preterm infants (<32 weeks) is 1.96, a percentage with little change since the 1990s. The increase in preterm infants parallels the rise in multiple births. Since 1980, there has been a 50% increase in the number of twins born yearly. Additionally, as can be expected with increased prevalence of multiple births and preterm infants, the number of low birth weight infants has risen steadily since 1980 [16]. Considerable effort and attention has been spent in the United States reducing both neonatal and maternal death during childbirth. In 1990, it was reported that annually there had been between 300–500 reported pregnancy related maternal deaths and an additional 500–800 deaths that went unreported. A pregnancy related maternal death is one that occurs during pregnancy, labor, and delivery, or within 1 year of the end of pregnancy, and is a result of the complications of pregnancy or a condition aggravated by pregnancy [19]. There were 7.5 maternal deaths per year for every 100,000 live births during the years 1982–1996. This figure declined slightly in 1998 to 7.1 deaths per 100,000 live births. The Healthy People 2000 goal for maternal morbidity in the United States was 3.3 deaths per 100,000 births [20], and that figure remains unchanged for Healthy People 2010 [21]. The causes of maternal mortality include hemorrhage, pulmonary embolism, complications resulting from pre-eclampsia or eclampsia, infection, heart disease, and complications from anesthesia. Women older than age 35 years and those of lower socioeconomic status are more likely to die during pregnancy or childbirth. Which health care professionals attend births in the United States today? Nine out of ten deliveries (91.7%) are attended by a physician in a hospital setting. Though still very high, this number has shown a decrease since 1975 when physicians attended 98.4% of all births. Family practice physicians continue to be responsible for some of these physician-attended hospital births, although less than one third of family physicians are practicing obstetrics today, compared with 50% who had an obstetrical practice in 1975. The number of midwife-attended births has risen from 1% in 1975 to 7.7% in 1999, including 9.4% of spontaneous vaginal deliveries. Much of this growth (95%) has been occurring in the hospital setting. In fact,
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96% of births attended by certified nurse-midwives (CNMs) occur in the hospital, while the overall rate of hospital births is 99%. Concurrently, there has been a slight decline, attributed to economic difficulties with access to malpractice insurance and reimbursement for services, in the number of CNM-attended births outside the hospital setting. Of the 1% of planned births occurring outside the hospital, 65% are residential, or in the home, and 27% occur in free standing birthing centers [22]. Non-CNM attended births (certified professional midwives, lay midwives) continue to be predominantly in residences [23]. Management of pain during labor remains an area of pregnancy health care that receives significant contemplation and resources. The past 4 decades have witnessed a continual increase in the number of laboring women who choose to use regional analgesia and anesthesia during labor and delivery [24]. Though in the past epidural use was reserved for medically necessary instances such as complicated or long labors, this form of anesthesia is commonly used today during an uncomplicated labor at the mother’s request [25]. Estimates vary depending on place of delivery and birth attendant, but King reported that epidural use among U.S. women ranges from 13–60% [26]. In 90% of U.S. hospitals with more than 100 beds, laboring women have round-the-clock options for epidural anesthesia provided by 24-hour obstetric anesthesiology service [27]. Nonpharmacologic modalities of relieving pain, such as cognitive, behavioral, and sensory interventions, are increasingly popular but still lag far behind epidurals in use [24]. Some cognitive strategies include attention focusing, hypnosis, and relaxation. In the behavioral realm, women are encouraged to be active during labor and delivery and to use different positions that may help alleviate pain as well as vocalize as they desire [24]. Additional modalities such as transcutaneous electrical nerve stimulation (TENS) and hydrotherapy are thought to relieve pain by competing for conduction on superficial nerve fibers. These modalities, especially emersion in water, are gaining in popularity [24,28].
Institutional/hospital policies As with other nursing specialties, labor and delivery units of hospitals have been suffering from cutbacks and staffing constraints related to financial conditions. The increase in technology used at the bedside of laboring women has functioned to both decrease the need for one-on-one nursing care and also shift the roles and responsibilities of intrapartum nurses [29]. This shift in skills is characterized by less palpation and auscultation of the laboring woman and fetus, and more surveillance of the technological monitoring devices. Hoerst and Fairman suggested that ‘‘this shift in skills has significantly altered the intimacy of the relationship between nurses and laboring women’’ [29].
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Labor and delivery staffing is further complicated by the unpredictable nature of the patient census on a labor and delivery unit. Nurse managers have needed to use innovative methods to predict staffing needs that are clinically safe and fiscally sound [30]. Jenkin-Cappiello described a method used at a university affiliated medical center that employs a computer program to estimate staffing needs based on average patient acuity and census [30]. In 1996, in an unprecedented act of federal legislation, the government enacted the Newborns’ and Mothers’ Health Protection Act for addressing shortened hospital lengths of stay (LOS) after delivery based on the type of insurance that mothers carried. The legislation prohibited insurance companies from restricting LOS at hospitals after delivery. According to the legislation, LOS after vaginal delivery should not be restricted to less than 48 hours, and LOS after cesarean section delivery should be not less than 96 hours. The legislation became effective in 1998. State laws and insurance policy changes sped the compliance of this law: in 1995, 37% of women stayed in the hospital 1 day or less after delivery; in 1997, only 25% experienced a similarly brief length of stay. The law requires enforcement by the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury. Additionally, if a mother elects to deliver outside the hospital but is admitted to the hospital for childbirth-related reasons, she is guaranteed a minimum 48-hour length of stay [31].
Summary The picture of birth in the United States today is complex and, as the data above indicates, difficult to describe in simplistic terms. Though many women today have come to believe that there are choices surrounding pregnancy and birth, the beliefs and practices of providers, insurers, and hospital administrators play a major role in either influencing those choices or dictating how they will be manifested. On one hand, technological advances have given women greater options with regard to the outcomes of pregnancy and birth. On the other hand, these very same technological advances place limits on the choices available to the individual. For example, increased efficiency in the placement and use of epidural anesthesia has made this a pain-control option for most of the childbearing women in the United States. The use of an epidural, however, puts limits on the choice of an institution at which to give birth and on the movements/activities of the woman during labor. Twentieth-century developments led to the almost complete demise of midwifery practice in the United States, thus taking birth away from the control of the individual woman and her close, matriarchal support system, and placing it in the hands of the patriarchal world of medicine and the institutions (ie, hospitals) at which this approach to health care is practiced. Most births went from being normal, home-based events to becoming
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illness-oriented, hospital-based procedures. Just as some steps were being taken in the latter part of the twentieth century to return some of the control of birth back to pregnant women (eg, childbirth education classes, the modern home-birth movement, increases in the number of midwifery-tended births), technological advances contributed to continued control by physicians and the hospitals of their practice (eg, fetal monitoring, epidural anesthesia). Advances in technology have made birth possible for many individuals who otherwise would not have had the opportunity for this experience or a chance for a positive outcome (eg, sufferers of infertility or the woman whose fetus has congenital yet repairable problems). But the widespread application of many of these advances to almost all pregnant and laboring women has raised questions as to just what is necessary for a healthy pregnancy, and are there limits to the role that technology should play in the course of what is viewed by many as a normal, nonmedical event. Just as the characters in 2001: A Space Odyssey recognized the incredible power of change that occurred in their lives as a result of the monolith being ‘‘born’’ into their world, so too do many women acknowledge the prodigious nature of giving birth in terms of the experience itself and the resulting effect on their lives [14]. But, as with the acknowledgment of Dr. Dave Bowman in 2001: A Space Odyssey that the technology of the fictitious future still could be wrong, thoughts of U.S. women giving birth today tend to be ‘‘in-between’’ a belief in the integrity of nature and a trust in the power of technology [14]. One can certainly conjecture that birth in the United States today, more than any other time in history, is at a crossroads, one in which the mostly natural, matriarchal community system of the sixteenth through nineteenth centuries is intersecting with the mostly technological, patriarchal system of the twentieth century. Will birth return to the home under the guidance of midwives, as was the case for most of America’s past and as remains the case throughout much of the world? [32] Or will technology take birth to the other extreme, making it possible to eventually gestate outside the womb and rendering ‘‘delivery’’ a term not referring to passage through the birth canal, but to the dropping off a healthy term baby at the respective mother’s doorstep? Certainly no one can predict what is to occur, but whatever that may be, hindsight will likely point to the start of the twenty-first century as the beginning of a new paradigm for birth in the United States. It should make for an interesting future.
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[4] Rothman B. In: Labor: women and power in the birthplace. New York: Norton & Co; 1991. [5] DeLee J. The prophylactic forceps operation. Am J Obstet Gynecol 1920;1:32–44. [6] University of Pennsylvania Department of Obstetrics & Gynecology. A century of obstetrics. 2002. Available at: http://www.obgyn.upenn.edu/history/clinobhis.html. Accessed January 15, 2002. [7] Martin C. Electronic fetal monitoring: a brief summary of its development, problems and prospects. Eur J Obstet Gynecol Reprod Biol 1998;78(2):133–40. [8] Albers L. Monitoring the fetus in labor: evidence to support the methods. J Midwifery Womens Health 2001;46(6):366–73. [9] Rosen M, Dickinson J. The paradox of electronic fetal monitoring: more data may not enable us to predict or prevent infant neurologic morbidity. Am J Obstet Gynecol 1993; 168(3):745–51. [10] Thacker S, Stroup D. Continuous electronic heart rate monitoring for fetal assessment during labour (Cochrane Review). In: The Cochrane Library, issue 2. Oxford: Update Software; 2000. [11] Cunningham F, Gant N, Gilstrap L, et al. Williams Obstetrics. New York: McGraw-Hill; 2001. [12] Browner C. Press N. The normalization of prenatal diagnostic screening. In: Ginsburg F, Rapp R, editors. Conceiving the new world order: the global politics of reproduction. Berkeley: University of California Press; 1995. pp. 307–22. [13] Lumley J. Through a glass darkly: ultrasound and prenatal bonding. Birth 1990;17(4): 214–7. [14] Davis-Floyd R. Birth as an American rite of passage. Berkeley: University of California Press; 1992. [15] Varney H. Varney’s midwifery. Sudbury, MA: Jones and Bartlett; 1997. [16] Martin J, Hamilton B, Ventura S, et al: Births: final data for 2000. Hyattsville, MD: National Center for Health Statistics; 2002. National Vital Statistics Report 50(5). [17] Blanchette H, Blanchette M, McCabe J, et al. Is vaginal birth after cesarean safe? Experience at a community hospital. Am J Obstet Gynecol 2001;184(7):1478–87. [18] Popovic J. 1999 national hospital discharge survey: annual summary with detailed diagnosis and procedure data. Hyattsville, MD: National Center for Health Statistics, 2001. Vital Health Statistics 13(151). [19] Center for Disease Control and Prevention. Maternal mortality: United States, 1982–1996. Morbidity and Mortality Weekly Report 1998;47(34):705–7. [20] People H. 2000: national health promotion and disease prevention. Collingdale, PA: DIANE Publishing; 1991. (Full report, 1994). [21] US Department of Health and Human Services. Healthy People 2010, ed 2 (vol.2). Washington, DC: US Government Printing Office; 2000. [22] Ventura S, Martin J, Curtin S, et al. Births: final data for 1999. Hyattsville, MD: National Center for Health Statistics, 2001. National Vital Statistics Reports 49(1). [23] Curtin S, Park M. Trends in the attendant, place, and timing of births, and in the use of obstetric interventions: United States, 1989–97. Natl Vital Stat Rep 1999;47(27):1–12. [24] Lowe N. The pain and discomfort of labor and birth. JOGNN 1996;25(1):82–92. [25] Rooks J. Midwifery and childbirth in America. Philadelphia: Temple University Press; 1997. [26] King T. Epidural anesthesia in labor: benefits versus risks. J Nurse Midwifery 1997; 42(5):377–88. [27] Graniger E, McCool W. Nurse-midwives’ use of and attitudes toward epidural analgesia. J Nurse Midwifery 1998;43(4):250–61. [28] Eckert K, Turnbull D, MacLennan A. Immersion in water in the first stage of labor: a randomized controlled trial. Birth 2001;28(2):84–93. [29] Heorst B, Fairman J. Social and professional influences of the technology of electronic fetal monitoring on obstetrical nursing. West J Nurs Res 2000;22(4):475–91.
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[30] Jenkin-Cappiello E. Oh baby! A labor and delivery staffing system measures patient census and acuity. Nursing Management 2000;31(2):35–7. [31] Kuper D. Newborns’ and Mothers’ Health Protection Act: putting the brakes on drivethrough deliveries. Spec Law Dig Health Care Law 1998;227:9–31. [32] World Health Organization. Care in normal birth: report of a technical working group. Geneva, Who, 1997.
Birth in the United States: an overview of trends past and present William F. McCool, PhD, RN, CNM*, Sara A. Simeone, BS, SNM Midwifery Graduate Program, University of Pennsylvania School of Nursing, 315 S. 44th St., Philadelphia, PA 19104, USA
As dawn brightens the sky, the great event takes place. Something so perfect has appeared, as if from nowhere. There is something mystical and emotional about this scene. It’s as if they have received a gift from the gods. —Description of monolith ‘‘birth’’ scene on prehistoric Earth from 2001: A Space Odyssey [1] ‘‘I suppose computers have been known to be wrong.’’ —Dr. Dave Bowman, Jupiter Mission Commander, 2001: A Space Odyssey
The ‘‘future’’ of Arthur C. Clarke and Stanley Kubrick’s 2001: A Space Odyssey has arrived, and much has changed since that landmark movie was released in 1968. Most people would agree that today’s world is quite different than the twenty-first century depicted by Clarke and Kubrick, yet there were several similar factors between the fiction of their world and the reality of ours today. One of these factors is the continued wonder of birth. The description of the prehistoric humans’ reaction to the ‘‘birth,’’ or discovery, of the godlike monolith found in 2001: A Space Odyssey could easily be applied to the reaction of most parents when a child is born. At the same time, a second movie ‘‘fact’’ applicable to today’s world is the impressive presence of technology in all aspects of modern life, including pregnancy and birth, and the accompanying muted skepticism that the character of Dr. Dave Bowman expressed toward this technology on which much of human living has come to depend. In the United States today, birth is at a crossroads between the naturalness of this biologic event and the modernization of human life through technological advances. Health care providers, including midwives and obstetrical nurses, have been centrally involved in the many changes that have occurred in childbearing care over
* Corresponding author. E-mail address: [email protected] (W.F. McCool). 0029-6465/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 0 2 9 - 6 4 6 5 ( 0 2 ) 0 0 0 2 0 - 8
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the past half-century. Though one can argue about the importance, safety, or ethics of these changes, it is first relevant to understand how birth has developed leading up to today. Short history of childbirth in the United States: 1700–1950 Birth in the area now known as the United States occurred for centuries in Native American cultures prior to the arrival of Europeans, but birth as it culturally exists today primarily reflects developments that began with the childbirth practices of the first European settlers. In the early days of the New World, most children were born to Puritan wives in their early 20s. Women in the 1700s typically devoted the next 20 years of their lives to childbirth, often with children born every 15 to 20 months. A woman’s childbearing years would end either with menopause or with her death [2]. Early American childbirth practices, characterized as following a social childbirth philosophy, were strongly influenced by the practices of England [2]. Women in labor delivered at home and were attended by lay female relatives and friends, a female midwife, and occasionally a trained female nurse. Only the richest families would also have a physician in close contact in the case of an emergency. After delivery, a woman remained with her female support system for a ‘‘lying-in’’ period during which she recuperated and became acquainted with her new child. The involvement of women in the birth process was a mechanism through which women supported, loved, and cared for each other. It has been noted that ‘‘for colonial women, the practice of social childbirth acted as a palliative, a respite from incessant child care over a period of twenty to twenty-five years of their lives’’ [2]. This quality of togetherness encouraged the persistence of the social childbirth philosophy at home births throughout the nineteenth century and into the early twentieth century. Any changes in childbirth practices throughout the earlier period of colonial history were influenced not by a breakdown in this social childbirth philosophy, but by growing differentiations in social class and the increasing value placed in the medical profession and its activities. Midwifery philosophy in Colonial America could be described, using today’s terminology, as noninterventional. This was where American midwives differed from their European counterparts. In Europe, where such items as forceps were invented, and where the availability of physicians was more pronounced, there was greater use of technology to assist in the progression of labor than was seen in the United States. When the labor of an American woman was progressing normally, the midwife and other attendants saw their role as sustaining the strength of the individual and reassuring her of her progress. Only in a labor where things were not progressing well did colonial midwives use some ‘‘technologies’’ in their practice, including herbs and enemas. To decrease pain in a particularly long or strenuous labor, midwives would give the mother opium; if contractions were partic-
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ularly troubling, the midwife might add belladonna to the opium. When physicians later began to assume responsibility for childbirth, they looked to the midwives’ techniques and adopted the use of opium and belladonna. Midwives in Europe at that time also were reported to use ergot to induce labor and stop postpartum bleeding, but there is no evidence that American midwives used the same practice [2]. The rate of maternal death during childbirth in the United States experienced a large decline between the eighteenth and nineteenth century. Preparing for birth in the 1700s was, in a sense, synonymous with preparing for death. Women feared childbirth because they had a strong reason to believe that they would not survive the experience. Yet, in the 1800s, there was a significantly reduced maternal death rate. In fact, in the nineteenth century, there are reports of maternal death rates as low as 5% in some areas of the United States. Positive birth outcomes were more likely in United States than in Europe at that time. At a time when the medical world had yet to discover germ theory, it is thought that the American philosophy of minimal intervention by the midwife or doctor during labor and birth contributed to this difference [2]. Despite reductions in maternal deaths, women still feared the birth process, and the medical world increased its efforts to reduce the morbidity and mortality of birth. During the nineteenth century, part of these efforts focused on identifying and understanding puerperal fever. With the advent of germ theory and the initial understanding of infectious disease, some scientists began to link maternal postpartum death, which was particularly prevalent after hospital-based births, to contamination from autopsy material or disease from other hospital patients [2,3]. With the safety of childbirth increasing in the nineteenth century, the focus of care became controlling pain. The predominant psychologic and physical beliefs of the Victorian era, both in Europe and here in the United States, influenced childbirth in unique ways. Pain in childbirth was exacerbated by the interaction of physical conditions such as corsets, decreased activity, stuffy rooms, venereal disease, and psychologic expectations that required women of that era to be weak. In response to the call to reduce pain, Dr. Walter Channing of Boston pioneered the use of chloroform during delivery in 1848, though use remained minimal during the later half of the century [2]. Women continued to use folk remedies to help ease childbirth. Among these practices were the ‘‘fruit diet’’ and the ‘‘water cure.’’ It was suggested that adherence to a diet of only fruits and a few selected vegetables during pregnancy would produce a bone-free, ‘‘soft baby’’ by restricting food such as wheat that was considered essential to bone formation. Proponents of the water cure advocated for pregnant women to take walks in the fresh air and to drink frequently and bathe in cold water in order to ease labor. Despite these efforts, women still experienced pain during labor and,by the end of the 1800s, began requesting a method that would truly relieve all pain while giving birth [2]. Beginning in the 1900s, this increased desire for labor-pain relief helped to contribute to an increase in the percentage of births occurring in hospitals.
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Within this shift was an inherent conflict: hospital births promised pain relief, but there remained the increased risk of dying from infection. Regardless, from 1900 to 1920, during which time the medical establishment initiated a campaign to take control of pregnancy health care from midwives [3], the percentage of in-hospital births increased tenfold. This transition from home to hospital marked a radical conceptual change in the process of childbirth. Wertz and Wertz put forth that within this era ‘‘began the major transformation of birth: from home to hospital, from suffering to painlessness, from patient care to disease care’’ [2]. The twentieth century saw the end of the social childbirth philosophy found in earlier America, and replaced it with a medical illness model, the influence of which persists today. No longer were parturient women surrounded at home by women from their families and/or communities; instead, individuals giving birth were alone in sterile hospital delivery rooms accompanied by medical personnel, usually female nurses and male physicians. To add to this sense of isolation, each decade of the twentieth century saw the introduction of new technology into the birthing process. As birth moved increasingly into the hospital, greater use was made of the ‘‘delivery table,’’ a narrow metal bed onto which the birthing woman was strapped in the lithotomy position so as to make the delivery most accessible for the attending physician [4]. In the 1920s, the routine use of forceps during uncomplicated births was promoted [5]. This contributed to the greater use of anesthesia during labor and birth, aided in part by the numerous discoveries and chemical inventions of modern pharmaceutical firms. By the 1950s, most American women were not alert or even conscious while giving birth, and because of the use of amnesiac medications, did not recall most of the events of labor and birth [2]. Childbirth in the United States: 1950–2000 Technological advances continued to be introduced into the hospital delivery room. In the 1940s, continuous caudal analgesia-anesthesia was first given to laboring women and continued to be used into the 1960s [6]. As with prior uses of anesthesia, this method of pain control required that the woman be confined to bed. Because family or friends were not allowed to visit the laboring woman, bed confinement further isolated her from any potential contact with familiar, supportive individuals. It became the task of the obstetrical nurse to replace the community of women who attended the needs of laboring women prior to the twentieth century. Refinement in anesthesia techniques led to the introduction of continuous lumbar epidural anesthesia in the 1960s. This type of anesthesia required less medication than caudal anesthesia and was easier and faster to administer. During this same decade, electronic fetal monitoring (EFM) was developed for use in the labor and delivery rooms [7]. Hospital personnel could now listen to a fetal heartbeat electronically, thus allowing for continuous monitoring of the fetus’ heart rate and freeing the physicians
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and nurses to conduct other tasks. Unfortunately, the soon-to-be widespread use of both the epidural anesthesia and EFM confined the laboring woman to bed, usually in just one primary position for several hours. The centuries-old practice of ambulation in labor was lost to the development of these modern technologies. The thought that epidural and EFM use would benefit laboring women and their infants was based on theory, and not on any evidence at the time of the technologies’ introduction. Research over the last decade, however, has raised questions about the clinical value of these ‘‘advancements’’ that led to a bed-ridden, strapped laboring woman [8–10]. In the 1970s, the greatest change in obstetrical care was based on technology developed by the U.S. Navy during World War II. Sonar for detecting submarines and other ships during the war was used to develop ultrasound imaging, enabling medical personnel to view the pregnant woman’s fetus and uterus [6]. Initially, this technology allowed for gross measures, such as fetal position and a rough estimate of fetal weight. Refinement of ultrasound technique and equipment has now led to its use for increasingly accurate dating of a woman’s estimated date of delivery (EDD), discovery and sometimes in utero treatment of fetal abnormalities, and assessment of fetal sex during the pregnancy [11]. Today, most pregnant women in the United States have at least one ultrasound assessment over the course of the gestation period. Though many women look forward to their first visual glimpse of their fetus through ultrasonography, some scholars have raised concerns about the widespread use of this technological advance because of unknowns about any long-term effects of sound wave use on fetuses, and because of the increasing disconnection between women and their pregnancies and fetuses [12,13]. The latter concern goes beyond ultrasonography and applies to many of the technological and clinical practice changes that have occurred during the past 50 years regarding pregnancy and childbirth. Though the laboring woman of the past was surrounded by family and friends at home, the laboring woman of the latter part of the twentieth century was supported mostly by unknown hospital personnel. No longer could women walk during labor but instead were confined to the hospital bed. In an effort to help alleviate the pain of labor, women came to giving up total feeling of the lower half of their bodies. The first connection with their developing fetus was no longer through the sense of touch when they first could feel fetal movement, but now was through sight and sound when they could see and hear the fetus through ultrasound. It has been noted that women are increasingly dependent on technology for connecting with their children, and they are moving closer and closer to being viewed as biologic vessels for fetal growth and delivery rather than a single maternal/fetal unit. Indeed, it has been suggested that, by the end of the twenty-first century, human gestation could take place entirely outside of the woman’s body and be confined to a laboratory environment [14].
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Not all changes regarding pregnancy, labor, and birth in the late 1900s were technological in nature. Beginning as far back as the 1940s, practitioners in Europe began to promote a return to a noninterventionist labor and birth for women, one in which the woman ambulated during labor, used breathing and imagery for pain control, and was supported again by family members and friends. In the United States during the 1960s, this push for a return to natural birth, coupled with the expanding Second Wave of Feminism, or the ‘‘Women’s Movement,’’ led to a call for women to take back control of their pregnancies and birth from the medical establishment, and to forgo much of the technology introduced during the twentieth century into the world of pregnancy health care. As a result of consumer demands, there was an increase in the number of women who chose to experience a home birth, and there was growth in the number of birth centers in the United States, where women could experience the ‘‘social childbirth’’ practiced by the Pilgrims yet feel the safety that many individuals had come to believe was offered by medical technology [14,15]. Before the end of the twentieth century, hospital administrators and obstetricians responded to these changes in consumer health practices by replacing traditional labor and delivery rooms and equipment with ‘‘labor and delivery suites’’ or ‘‘birthing rooms.’’ Through the use of interior decorating, an attempt has been made to create a home-like environment in the hospital where women can labor and birth. The technology remains and is used as extensively as ever, yet it is surrounded by curtains and wooden bed frames in order to soften its appearance [14].
Birth in the United States today What does birth in the United States look like today? The latest birth certificate data, for the year 2000, reports a total of 4,058,814 live U.S. births. Vaginal delivery continues to be the predominant method of delivery, accounting for 3,108,188 (77%) of the births that year. The remaining 23% of births were either primary or repeat cesarean sections. After declining in the early 1990s, the c-section rate has risen again each year from 1997 to 2000. Conversely, the number of vaginal births after a previous c-section (VBAC) has declined close to 20% during that time period after having risen in the early 1990s [16]. One can speculate that this occurred because of a question regarding the safety of VBACs. Blanchette, Blanchette, McCabe, and Vincent studied the VBAC safety at a community hospital in Massachusetts (N ¼ 1418) [17]. They found that the VBAC attempt rate was 50.1% (N ¼ 727), and that the neonatal outcomes in the VBAC and repeat csection groups (N ¼ 754) were similar. Uterine rupture occurred in 12 of the VBAC women, 11 of whom had experienced induction of labor, augmentation of labor, or both. The authors concluded that VBACs should be considered safe if induction of labor is not used.
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Though there has been a decline in the United States of the use of forceps at time of birth to 4.2% of all vaginal deliveries in 1999, vacuum extraction has become more prevalent, having been used in 8.4% of all 1999 vaginal deliveries [18]. Induction of labor was used in 20% of all births in 2000. This was an increase of greater than 100% since 1989. Augmentation of labor has also been increasing (64% rise since 1989). In 1999, it was employed in 18% of all births. Ultrasound and EFM are the most prevalent technological interventions used during pregnancy and labor, currently reported at 66% and 84%, respectively [16]. The majority of babies born in the United States are full-term singletons of average weight. Pre-term (<37 weeks) births constitute 11.6% of all births; a 10% increase since 1990. The percentage of live births of very preterm infants (<32 weeks) is 1.96, a percentage with little change since the 1990s. The increase in preterm infants parallels the rise in multiple births. Since 1980, there has been a 50% increase in the number of twins born yearly. Additionally, as can be expected with increased prevalence of multiple births and preterm infants, the number of low birth weight infants has risen steadily since 1980 [16]. Considerable effort and attention has been spent in the United States reducing both neonatal and maternal death during childbirth. In 1990, it was reported that annually there had been between 300–500 reported pregnancy related maternal deaths and an additional 500–800 deaths that went unreported. A pregnancy related maternal death is one that occurs during pregnancy, labor, and delivery, or within 1 year of the end of pregnancy, and is a result of the complications of pregnancy or a condition aggravated by pregnancy [19]. There were 7.5 maternal deaths per year for every 100,000 live births during the years 1982–1996. This figure declined slightly in 1998 to 7.1 deaths per 100,000 live births. The Healthy People 2000 goal for maternal morbidity in the United States was 3.3 deaths per 100,000 births [20], and that figure remains unchanged for Healthy People 2010 [21]. The causes of maternal mortality include hemorrhage, pulmonary embolism, complications resulting from pre-eclampsia or eclampsia, infection, heart disease, and complications from anesthesia. Women older than age 35 years and those of lower socioeconomic status are more likely to die during pregnancy or childbirth. Which health care professionals attend births in the United States today? Nine out of ten deliveries (91.7%) are attended by a physician in a hospital setting. Though still very high, this number has shown a decrease since 1975 when physicians attended 98.4% of all births. Family practice physicians continue to be responsible for some of these physician-attended hospital births, although less than one third of family physicians are practicing obstetrics today, compared with 50% who had an obstetrical practice in 1975. The number of midwife-attended births has risen from 1% in 1975 to 7.7% in 1999, including 9.4% of spontaneous vaginal deliveries. Much of this growth (95%) has been occurring in the hospital setting. In fact,
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96% of births attended by certified nurse-midwives (CNMs) occur in the hospital, while the overall rate of hospital births is 99%. Concurrently, there has been a slight decline, attributed to economic difficulties with access to malpractice insurance and reimbursement for services, in the number of CNM-attended births outside the hospital setting. Of the 1% of planned births occurring outside the hospital, 65% are residential, or in the home, and 27% occur in free standing birthing centers [22]. Non-CNM attended births (certified professional midwives, lay midwives) continue to be predominantly in residences [23]. Management of pain during labor remains an area of pregnancy health care that receives significant contemplation and resources. The past 4 decades have witnessed a continual increase in the number of laboring women who choose to use regional analgesia and anesthesia during labor and delivery [24]. Though in the past epidural use was reserved for medically necessary instances such as complicated or long labors, this form of anesthesia is commonly used today during an uncomplicated labor at the mother’s request [25]. Estimates vary depending on place of delivery and birth attendant, but King reported that epidural use among U.S. women ranges from 13–60% [26]. In 90% of U.S. hospitals with more than 100 beds, laboring women have round-the-clock options for epidural anesthesia provided by 24-hour obstetric anesthesiology service [27]. Nonpharmacologic modalities of relieving pain, such as cognitive, behavioral, and sensory interventions, are increasingly popular but still lag far behind epidurals in use [24]. Some cognitive strategies include attention focusing, hypnosis, and relaxation. In the behavioral realm, women are encouraged to be active during labor and delivery and to use different positions that may help alleviate pain as well as vocalize as they desire [24]. Additional modalities such as transcutaneous electrical nerve stimulation (TENS) and hydrotherapy are thought to relieve pain by competing for conduction on superficial nerve fibers. These modalities, especially emersion in water, are gaining in popularity [24,28].
Institutional/hospital policies As with other nursing specialties, labor and delivery units of hospitals have been suffering from cutbacks and staffing constraints related to financial conditions. The increase in technology used at the bedside of laboring women has functioned to both decrease the need for one-on-one nursing care and also shift the roles and responsibilities of intrapartum nurses [29]. This shift in skills is characterized by less palpation and auscultation of the laboring woman and fetus, and more surveillance of the technological monitoring devices. Hoerst and Fairman suggested that ‘‘this shift in skills has significantly altered the intimacy of the relationship between nurses and laboring women’’ [29].
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Labor and delivery staffing is further complicated by the unpredictable nature of the patient census on a labor and delivery unit. Nurse managers have needed to use innovative methods to predict staffing needs that are clinically safe and fiscally sound [30]. Jenkin-Cappiello described a method used at a university affiliated medical center that employs a computer program to estimate staffing needs based on average patient acuity and census [30]. In 1996, in an unprecedented act of federal legislation, the government enacted the Newborns’ and Mothers’ Health Protection Act for addressing shortened hospital lengths of stay (LOS) after delivery based on the type of insurance that mothers carried. The legislation prohibited insurance companies from restricting LOS at hospitals after delivery. According to the legislation, LOS after vaginal delivery should not be restricted to less than 48 hours, and LOS after cesarean section delivery should be not less than 96 hours. The legislation became effective in 1998. State laws and insurance policy changes sped the compliance of this law: in 1995, 37% of women stayed in the hospital 1 day or less after delivery; in 1997, only 25% experienced a similarly brief length of stay. The law requires enforcement by the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury. Additionally, if a mother elects to deliver outside the hospital but is admitted to the hospital for childbirth-related reasons, she is guaranteed a minimum 48-hour length of stay [31].
Summary The picture of birth in the United States today is complex and, as the data above indicates, difficult to describe in simplistic terms. Though many women today have come to believe that there are choices surrounding pregnancy and birth, the beliefs and practices of providers, insurers, and hospital administrators play a major role in either influencing those choices or dictating how they will be manifested. On one hand, technological advances have given women greater options with regard to the outcomes of pregnancy and birth. On the other hand, these very same technological advances place limits on the choices available to the individual. For example, increased efficiency in the placement and use of epidural anesthesia has made this a pain-control option for most of the childbearing women in the United States. The use of an epidural, however, puts limits on the choice of an institution at which to give birth and on the movements/activities of the woman during labor. Twentieth-century developments led to the almost complete demise of midwifery practice in the United States, thus taking birth away from the control of the individual woman and her close, matriarchal support system, and placing it in the hands of the patriarchal world of medicine and the institutions (ie, hospitals) at which this approach to health care is practiced. Most births went from being normal, home-based events to becoming
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illness-oriented, hospital-based procedures. Just as some steps were being taken in the latter part of the twentieth century to return some of the control of birth back to pregnant women (eg, childbirth education classes, the modern home-birth movement, increases in the number of midwifery-tended births), technological advances contributed to continued control by physicians and the hospitals of their practice (eg, fetal monitoring, epidural anesthesia). Advances in technology have made birth possible for many individuals who otherwise would not have had the opportunity for this experience or a chance for a positive outcome (eg, sufferers of infertility or the woman whose fetus has congenital yet repairable problems). But the widespread application of many of these advances to almost all pregnant and laboring women has raised questions as to just what is necessary for a healthy pregnancy, and are there limits to the role that technology should play in the course of what is viewed by many as a normal, nonmedical event. Just as the characters in 2001: A Space Odyssey recognized the incredible power of change that occurred in their lives as a result of the monolith being ‘‘born’’ into their world, so too do many women acknowledge the prodigious nature of giving birth in terms of the experience itself and the resulting effect on their lives [14]. But, as with the acknowledgment of Dr. Dave Bowman in 2001: A Space Odyssey that the technology of the fictitious future still could be wrong, thoughts of U.S. women giving birth today tend to be ‘‘in-between’’ a belief in the integrity of nature and a trust in the power of technology [14]. One can certainly conjecture that birth in the United States today, more than any other time in history, is at a crossroads, one in which the mostly natural, matriarchal community system of the sixteenth through nineteenth centuries is intersecting with the mostly technological, patriarchal system of the twentieth century. Will birth return to the home under the guidance of midwives, as was the case for most of America’s past and as remains the case throughout much of the world? [32] Or will technology take birth to the other extreme, making it possible to eventually gestate outside the womb and rendering ‘‘delivery’’ a term not referring to passage through the birth canal, but to the dropping off a healthy term baby at the respective mother’s doorstep? Certainly no one can predict what is to occur, but whatever that may be, hindsight will likely point to the start of the twenty-first century as the beginning of a new paradigm for birth in the United States. It should make for an interesting future.
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[30] Jenkin-Cappiello E. Oh baby! A labor and delivery staffing system measures patient census and acuity. Nursing Management 2000;31(2):35–7. [31] Kuper D. Newborns’ and Mothers’ Health Protection Act: putting the brakes on drivethrough deliveries. Spec Law Dig Health Care Law 1998;227:9–31. [32] World Health Organization. Care in normal birth: report of a technical working group. Geneva, Who, 1997.