Learning about physiological birth in the USA: Evidence and reality

As an Australian midwife who has been teaching maternal-newborn nursing for over 22 years, I am still excited to hear students share their clinical stories with each other as they learn about maternity care. Now that I am in the United States, students’ stories reflect a unique and different culture. Each year my students visit a wide variety of hospitals to gain experience working with childbearing women and they ultimately become an important part of many women’s childbirth stories.  As students share their first experiences of labour and birth with their peers in the classroom, I am always excited to hear their accounts of caring for their first labouring woman and love listening to personal reflections of their “first birth” experience.

I am sometimes puzzled by the unique culture of “normal” childbirth in the USA and how this differs from my own experiences of midwifery. Over my years in teaching I have found that students are a wonderful gauge for what is going on in clinical reality and a great source of open and sometimes brutal critique of the healthcare system. They readily compare what we talk about in the classroom and what they read about in the literature with what they actually observe and experience in the real clinical world. Given their passion for high quality evidence based care I am confident that the students of today will be great future leaders and agents for change. But while they struggle to navigate the student role, they are often frustrated by culture-based practice and feel a need to fill the gaps between evidence and practice.

Each week at the beginning of the class I ask my students to reflect on their clinical experiences in the previous week. I usually begin with “who saw a birth last week?” I see excited hands go up and I ask students to describe their first experience of labour or birth to their peers.  So often, the description of the first observed birth experience starts with “yes I saw a birth last week, but it was a caesarean section.”  I should not be surprised by that, given that in the USA, 1 in 3 births is surgical. I usually go on to ask what they learned from the birth experience. I might ask whether the baby was placed skin to skin, or whether the mother breastfed and what they observed about opportunities for the family and newborn to bond soon after surgery. It is clear from my student’s accounts over recent years that there is recognition in many clinical settings of the importance of positive caesarean section experiences for women and their babies, including the use of early skin to skin contact after surgery. I am also certain that students gain much from observing surgical birth, if anything, to be able to compare it to normal physiological birth when the opportunity eventually presents itself.

When I go on to ask the question, “Who has seen a normal physiological birth?” few students raise their hand. When I try to expand the question to encourage those who have actually seen a baby born vaginally to speak up, the culture of labor and birth is evident. Physiological labor and birth are still rare events for student nurses to observe in many hospital settings in the USA. Interventions such as induction of labor, augmentation of labor and continuous electronic fetal monitoring are still widespread, and use of epidural for pain relief is experienced by the vast majority of women. Few women are given the option to eat during labour and many spend their labour in the bed, almost disconnected from the experience, as their body contracts painlessly until it is time to push.

So, how do we educate students about the benefits of physiological birth when physiological labour is so hard to find in reality? How do we get the right balance between teaching students evidence based care and preparing students for what they will actually see in clinical settings? How do we prepare students to make a positive contribution to childbirth experiences that are far from ideal? There are no easy answers to these questions. What I can recommend is remaining positive and working hard to ensure students are aware of the best available evidence to support their clinical decision making in the future. I encourage them to learn from all experiences, even if it is learning about the things they want to change. I suggest that they seek out positive role models and embrace opportunities to observe the practices of the many great clinicians out there supporting women and families and practicing evidence based maternity care.

There is light on the birthing horizon and research remains a critical ingredient for better practice. Therefore, as researchers, even though the clinical world can be frustrating and slow to change, we must continue to explore the most effective models of care for keeping healthy pregnant women ‘low risk’. As teachers, we should continue to educate our nursing students about normal physiological labour and effective ways to support women in achieving normal physiological births, even if they might not have the opportunity to see it. As we discover more about the potential epigenetic effects of caesarean birth1 and understand more about the importance of the mode of birth on the long term health for mothers and babies, there will be greater impetus for change in the way care is delivered. I remain positive that physiological birth will become “normal” again.

Allison Shorten RN RM PhD

Yale University School of Nursing

Connecticut, USA.


1. Almgren M, Schlinzig T, Gomez-Cabrero D, et al. Cesarean delivery and hematopoietic stem cell epigenetics in the newborn infant: implications for future health? Am J Obstet Gynecol 2014;211:502.e1-8



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