Birth in the United States: an overview of trends past and present.
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 (i.e., hospitals) at which this approach to health care is practiced. Most births went from being normal, home-based events to becoming 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 (e.g., 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 (e.g., 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 (e.g., 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.