Want as natural a childbirth as possible? Talk to your doctor early on

My cousin's wife is expecting a baby next week. She wants to have a natural childbirth, and her birth plan includes requests to allow spontaneous rupture of membranes, to avoid pain relief/epidural unless she asks, to steer clear of the labor-inducing drug oxytocin, to avoid episiotomy, and also to only have intermittent fetal monitoring.

For expectant mothers like her, the recent report, Evidence-Based Maternity Care: What It Is and What It Can Achieve, is welcome news. It sheds light on several overused maternity practices, including labor induction, epidurals for pain, and Cesarean section. It points out that such practices can lead to a host of additional interventions, are associated with risk of maternal and newborn harm, and add considerable costs to patient care.

The report confirms what many women have asserted for decades: High-tech delivery is not better, and it's not backed by science. So why are those interventions used in a large percentage of childbearing women, often without consideration, or even disclosure, of other options?

Perhaps because there are mounting pressures on physicians to perform certain procedures in an attempt to reduce medical liability. (In the most recent American College of Obstetricians and Gynecologists (ACOG) survey, conducted in 2006, of the 10,450 respondents to the question, 65 percent reported having made one or more change to their practice as a result of the risk or fear of professional liability claims of litigation. Of those, 37 percent reported increasing the number of Cesarean deliveries they performed, 33 percent decreased the number of high-risk obstetric patients, and 33 percent stopped offering/performing vaginal births after Cesareans.)

Perhaps, too, this may be because women feel particularly vulnerable during their pregnancies and are at times more susceptible to the inclinations and habits of the obstetrician with regard to how their care is managed.

In reality, pregnancy and delivery should be a great experience for both mother and baby. Hopefully, this study will empower women to ask their doctors to provide all the options available to them—not just those that seem to favor the preferences of the doctor.

Have the conversation about choices with your practitioner early in your pregnancy. Ask him/her to spell out your alternatives and discuss your preferences. Your best chance of success lies in recognizing the pressures that affect your practitioner and in being as collaborative as possible. I've occasionally heard advocates of natural childbirth use forceful verbs like "insist," "refuse," and "demand" to express their passion, but such wording is unlikely to create the alliance you are seeking with your obstetrician.

I liked the language used by my cousin and his wife as a prelude to their birth plan: "During labor, I would appreciate the patience and understanding of my care providers and ask them to refrain, in the absence of medical urgency, from any procedure that could stand in the way of my having the most calm and natural birth possible. I would prefer to have/do the following, unless it becomes medically necessary to do otherwise." I'm sure that they are more at ease knowing that the medical evidence now supports them.

—Orly Avitzur, M.D., medical adviser to Consumers Union

Read our full report on safer childbirth, test your knowledge on childbirth procedures with our maternity care quiz, and get more background information on epidurals and episiotomies (subscribers only).