By the time Trina Millenheft gave birth to her eighth child in 17 years, one might have thought that she knew everything a woman could know about having a baby. She thought so, too.
So when her certified nurse midwife, Hillary Handlesman of La Clinica in in Medford, Ore., who attended the December 2012 birth of Millenheft's youngest son, suggested she get her prenatal care via a group called CenteringPregnancy, Millenheft, 42, thought something along the lines of: What can a group of pregnant women tell me that I don't already know?
It turned out that she did learn a thing or two, like that magnesium supplements could help her control headaches during pregnancy. She also found that she loved going through her pregnancy with other women who were going through the same thing.
Birthing classes, all the rage about 40 years ago when many women felt labor and delivery were becoming too medicalized, are plummeting in popularity. Only one in three mothers takes childbirthing classes, according to a 2013 survey by Childbirth Connection, an organization providing evidence-based maternity information; 59 percent of first-time mothers take the classes, compared to only 17 percent of women who have previously given birth. That's down from an overall 70 percent of women who took such classes in 2000. "It's distressing to me that childbirthing classes are not routinely offered any more," says Diana Mason, professor of nursing at Hunter College in New York.
With 67 percent of mothers receiving an epidural, a local anesthetic that blocks the pain of contractions, it's not surprising that many women don't feel the need to learn, for example, breathing techniques aimed at reducing the pain of contractions. One in three women has a surgical delivery, or Cesarean section, again making many women feel they won't need to understand how to manage the pain that goes along with a vaginal delivery. And let's face it. With more than two-thirds of women working throughout their pregnancies, who has time for childbirth classes? Instead, expectant mothers get information from television, from friends and family, from books and from the internet.
The information can be alarmist, contradictory and just plain wrong. The lack of information no doubt contributes to a U.S. maternity process that seems like a conveyer belt to medical intervention—and the highest costs in the world to deliver a baby.
About 20 years ago, Sharon Rising, a certified nurse midwife and creator of what is now a national program called CenteringPregnancy, found that during pregnancy women gravitated toward the company of other pregnant women. Before starting the program, she did a lot of traditional one-on-one prenatal care. "One woman's question was another woman's question. I was repeating myself all day long," she says. "And who really has the wisdom here? The women do."
Today, there are 135 certified CenteringPregnancy groups throughout the country, with another 60 in development, and other non-certified programs that mimic many aspects of group prenatal care. Women in the groups, generally eight to 12 of them, meet on a traditional prenatal schedule—about 10 meetings per pregnancy. With the privacy of a screen, the midwife listens to the fetal heartbeat or does an exam if necessary.
A routine check-up that would take 10 or 15 minutes in a doctor's office becomes a two-hour meeting in which women share experiences like leg cramps, or having sex during pregnancy, or what kind of diapers to use, or their feelings about circumcision. They also talk about the pros and cons of pain medication and about their fears of too much medical intervention. "These can be touchy conversations. But we spoke very freely," says Jennifer Kuelz, 41, who had her first child after attending group centering classes with Group Health Cooperative in Bellevue, Wash. "It was nice to have constructive conversations about things we were all considering at the same time."
These groups may be at the leading edge of, a 21st century attempt for women to regain control of maternity care. At Group Health Cooperative, for example, the group centering classes started in January 2013, and already almost a third of pregnant women sign up for them, says Karen McConnell, lead certified nurse midwife of the program.
The economic issues of maternity care are huge. The present system of fee-for-service payments, in which physicians and hospitals are paid for every service they provide, encourage more intervention rather than less: a C-section is more profitable to doctors and hospitals; every dose of pain mediation has a profit incentive; and drugs to induce and speed up labor can add to the bottom line.
"The fee-for-service structure gets in the way of hospitals and communities doing the right thing," says Mason, who wrote an editorial for news@JAMA with a headline that sums up her feelings: "Transforming the Costly Travesty of U.S. Maternity Care." Some of those incentives are changing with the Affordable Care Act. Midwives, who used to be paid at 65 percent of what an ob/gyn is paid for an uncomplicated delivery, are paid, since January 2011, at the same rate as physicians. And maternity coverage will be required when the health care law is fully implemented next year. "I believe this will motivate insurance companies to provide maternity care in a way that's cost effective," Mason says. If insurers begin to use bundled payments—one set fee for pregnancy, rather than a payment for each service—the financial incentives will begin to move toward rewarding low-cost care and high-quality results.
That doesn't mean that pain medication won't be administered, or that C-sections won't be done when necessary or that premature births will be eliminated. Kuelz, 41, had her first child in June and her water broke 29 days before her delivery date. "Being in the group made me confident. I had a sense of knowing that everything was OK because we had talked about so many different scenarios," she says.
Karyn Reinbach doesn't want a C-section, but because she has gestational diabetes, she knows she might have to be induced because of the risk of the baby getting too big. And induced labors are more likely to result in surgical deliveries. "I don't want it, but if it's a question of the safety of my baby, I'll do what I have to do," she says. Her nurse midwife, Japke Buesseler, leads a centering group prenatal class through Women's Healthcare Associates in Portland, Ore., and Reinbach feels well prepared for any turn her delivery will take.
But sometimes, everything goes smoothly. Nicole Beaty just gave birth to her third child. For her first two pregnancies, labor was induced and she had an epidural. "I didn't feel exactly helpless, but I also didn't feel I was making decisions for myself," she says. "Everybody was too quick to go to pain medications." By the time she was expecting her third, she had changed insurers, and Group Health Cooperative offered a centering group class. "They didn't make it seem like you had a disease they were trying to treat," she says.
This time, without any medication, she and her husband talked and even laughed through her entire labor—except for the last two contractions. Those, admittedly, were hard. "But not so much that I couldn't bear it," she says. "I never really knew what my body could do before."
Also on USNews.com:
- Examining Pregnancy Stereotypes: Why One Teen Faked Her Own Pregnancy
- How to Have a Fit and Healthy Pregnancy
- The Hidden Costs of Pregnancy
An earlier version of this story misstated that Jennifer Kuelz had a C-section after her water broke prematurely. She had a natural delivery.