The XX Factor

New Birth Guidelines Aim to Give Women More Control During Labor and Delivery

Low-risk women can benefit from fewer interventions.

Thinkstock/ DD_Brodella

Childbirth culture in the United States has long been divided among two camps. On one side, there are the “natural” childbirth advocates, many of whom believe that medicalization of labor and delivery should be avoided whenever possible. On the other side are doctors and hospitals, which tend to prioritize medical procedures over other options, often at the expense of the overall experience of the laboring woman. A new recommendation from the American Congress of Obstetricians and Gynecologists aims to bridge the rift by calling for maternity care providers to consider a wide range of approaches with low-risk pregnancies and working more closely with their patients to achieve the best outcome for everyone.


The Committee Opinion, which was also endorsed by the American College of Nurse-Midwives and the Association of Women’s Health, Obstetric and Neonatal Nurses, encourages medical care providers to:


  • consider allowing low-risk women to labor at home on their own for longer
  • avoid rupturing the amniotic sac if a woman is progressing normally
  • hold off on induction for a short period of time should the woman experience premature rupture of the amniotic sac
  • avoid constant fetal heart rate monitoring when appropriate (which would allow laboring women to move around)
  • allow women to switch positions and push in whatever manners works best for them during active labor
  • offer women non-pharmacologic pain relief techniques including massage, water immersion during the first stage of labor, and relaxation techniques
  • make sure women receive emotional support as well as medical support, which has been proven to lead to better outcomes.


They define low-risk as “a clinical scenario for which there is no demonstrable benefit for a medical intervention.”

Pushing for a birthing culture that supports a wider variety of birthing choices for women within the medical system is a no-brainer and long overdue. There was, however, one aspect of this recommendation that gave me pause: ACOG framed this opinion as “Approaches to Limit Intervention During Labor and Birth,” as opposed to, say, “Approaches to Better Accommodating Women During Labor.” What bothers me about this is that not all interventions are equal: Whereas women tend to want to avoid induction and cesarean sections, the majority of them choose epidurals. While the opinion acknowledges that “pharmacologic analgesia should be available for all women in labor who desire medication,” it doesn’t explicitly distinguish between epidurals and other interventions in its call to limit them.


I spoke with Jeffrey L. Ecker, chief of the obstetrics and gynecology department at Massachusetts General Hospital and Committee Opinion author, about whether this push toward fewer interventions was intended to be interpreted as a push away from epidurals.

“This wasn’t about suggesting patients don’t get epidurals, but about making sure that if a patient doesn’t want one, the alternative to the epidural isn’t simply nothing,” Ecker said. “Sometimes when a woman doesn’t want one it gets telegraphed as, ‘There’s nothing we can do about her pain,’ and that isn’t the case.” Ecker said that he expects most of patients will still want epidurals, and he doesn’t believe there is any reason for them to avoid them.

He explained that the overall motivation for the report was to encourage the medical community to move away from thinking about childbirth only in terms of the problems that may arise and focus more on helping low-risk women navigate healthy births.

This is a wonderful idea, but are our hospitals and maternity care providers prepared for and open to this kind of paradigm shift? Ecker thinks so. “My sense is that many of these things are already happening and/or can easily be happening at hospitals.”