Dr. Fletcher is Assistant Professor in the Department of Family Medicine at the Medical College of Georgia in Augusta, Ga. In his book, The Christian Mind, Englishman Harry Blamires adjures true believers to "think Christianly" about every facet of their lives. Encouragingly, more Christians seem to be doing just so in this last quarter of the 20th century.
The Christian's Guide to Pregnancy and Childbirth (Crossway Books, 1986) by John Jefferson Davis, Ph.D., is a noble effort to stimulate Christian worldview about issues that, in their eternal outcome, touch upon the creativity of God Himself and must be close to His heart - issues that have been swept before and under the tide of secularism in recent decades.
The book was written for lay people (ie, non-medical, non-theologians), but as a physician who delivers babies, I found it quite thought-provoking (and even educational) myself. It is extensively referenced yet easy to read.
In Chapter One he begins at the beginning, unashamedly acknowledging his presuppositional basis in Scripture. He describes the diversity and ambiguity of modern America's regard toward childbirth, children and family. Many readers will identify with him as those of us who have felt the resistance from even older Christians as we have challenged the sacrosanctity of that American middle class dictum: Two (and precisely 2) children and a (suburban) mortgage.
The Biblical assumption seems clear that married couples will have children and that voluntary childlessness (surreptitiously popular these days) is not a Biblical option. Postponement of childbearing until the thirties (also popular), while not perhaps unbiblical, may be medically unwise. Dr. Davis is practical; he suggests the creative alternative of having one's family in one's twenties and postponing career until a suitable point after the children have grown and left the home, or are at least older and less dependent.
In his discussion of means of contraception, which is generally helpful, some of his conclusions about medical data may be slightly misleading. For instance, he raises the specter of breast cancer associated with the use of birth control pills. Yet significant medical studies and the Food and Drug Administration have refuted this association. Likewise, studies have failed to bear out the hypothesized linkage between topical spermicides and birth defects or miscarriage.
There are generally helpful comments regarding drug use (including alcohol and tobacco) during pregnancy and regarding nutrition. One dubious paragraph (p. 23) cites The Mother Earth News on nutrition and other health practices during pregnancy; this should have been deleted. Later in the book there are helpful tips on exercise and maternal spiritual/father and sibling preparation for birth.
Infertility is discussed, and he appropriately sketches the dilemma of many couples in face of a shrinking pool of adoptable children, a shrinkage brought about by societal acceptance of fornication and mother-only "families," murder by abortion, and infertility itself. He also appropriately discerns artificial insemination (AI) for the ethical dilemma it is for Christians. While AI by the husband within marriage seems a viable option for conscientious Christians, AI by a donor, with its problems in areas of medical technology, law and truth-telling (not to mention its moral ambiguities), should probably be avoided by Christians. To many, including myself, AI by donor is tantamount to high-tech adultery.
Dr. Davis also discusses in vitro fertilization (IVF). Apart from being very expensive and plagued by high failure rates, IVF poses another serious ethical dilemma for Christians since multiple eggs are fertilized to become embryos outside the body. The crucial question becomes: What happens to the embryos not implanted? "Washing them down the drain," for those who hold the "high view" of life that begins at conception, is tantamount to murder. On the other hand, if more than one is implanted (or if multiple gestation is induced by other means such as ovulation-causing drugs), a new, morally repugnant practice is looming on the medical horizon. 1,6 Dubbed "selective embryo reduction," it (killing embryos with a needle through the mother's abdominal wall) amounts to higher-tech abortion. Such a practice must be rejected by Christians, who should also give close moral scrutiny to those practices (IVF, drug-induced ovulation) which spawn the "need" for "reducing" embryos/fetuses.
Professor Davis skillfully draws together the philosophical and sociologic strands of feminism, environmentalism and materialism that have conspired to motivate U.S. couples to act in such a way as to drop our birth rate below the estimated replacement level of 2.12 children per couple. He also points out the probable consequences for a society of the situation where there are nearly as many aging citizens as there are younger, economically productive ones. The specter of what might result for "useless eaters" (as some have called them) in our society with its degraded view of the intrinsic worth of human life is chilling indeed.
Some cogent Biblical counsel on family size and materialism is dispensed. Christians should believe it when God says that children are a Blessing; to embrace them as such we must actively resist secularism's constant war to squeeze us into its antithetical thought mold with an unceasing barrage in the popular media. The key questions the Christian must entertain and answer are: How do children fit into God's calling in my life? Where shall I find most satisfaction in life? In the eternal perspective, how shall I maximize my investment of time and energy in the lives of people?
He also tackles the issue of choosing the sex of one's children. This remains tenuous ground technically and virtually untouched by Christian writers (Dr. Davis' is the first Biblical address of the issue I've seen). There are two basic means of "choosing" the sex of one's offspring: pre-facto and ex post-facto. Fertilization has become both the medical and ethical watershed regarding the beginning of life. As he writes, ex post-facto means of selection (ie, destroying the unwanted sex) . . . "is not a morally legitimate option for the Christian (p.42)." Choosing prior to fertilization by in vitro methods may have a rightful place for a Christian's consideration (eg, in cases of sex-linked genetically transmitted diseases), yet techniques are still shaky enough to give the thoughtful Christian pause. And as one who seeks to stand firmly in the Reformation stream, this reviewer agrees with Dr. Davis that when all is said and done, in most cases, Christian couples might do well (better) to leave sex determination of offspring in the hands of our providential God.
Some valuable insights into the Bible's teaching about children and childbirth are offered. We are reminded that "the desire to have children is the most natural instinct, implanted in the human heart by the Creator Himself (p.45)." This truth is connected insightfully to God's covenantal promise to Abraham and to contemporary Christians, to wit, that one of the most concrete of ways we may fulfill the Great Commission is by bearing and discipling Christian children (and many of them).
A number of Scripture passages and their bearing upon children are reviewed. We are reminded that in contrast to our judiciary (viz, the U.S. Supreme Court in Roe v. Wade) that the Bible (eg, Exodus 21: 22-25) takes the fetus seriously as a person and not in a utilitarian fashion as an amorphous blob of tissue.
A helpful caveat is offered regarding prenatal classes, which in their enthusiasm to be helpful can lead the naive to expect a painless (ie, "trouble-free") birth if the "right" techniques are employed. The Bible, never a book to pull punches, says otherwise and clearly declares that childbirth is hard work and a source of discomfort; yet it also concomitantly proffers God's grace to the believing mother.
Chapter Five focuses upon prenatal and complications of pregnancy. A key ethical issue, often ignored by secularists and Christians alike, is that prenatal testing is inseparably linked to the question of the value of human life. Prenatal testing and induced abortion go hand-in-hand. A high (Biblical) view of life truly simplifies much about prenatal testing. For instance, why bother to obtain an amniocentesis or a chorionic villus sample or an alpha fetoprotein level if one is not morally prepared to destroy a "blighted" offspring.
Actually, as Dr. Davis points out, there is a small niche for testing for prenatal diagnosis which is appropriate for Christians. One such possible diagnosis would be that of Rh (blood factor) incompatability.
He also takes pains to point out that prenatal tests may carry significant risks of complications and of conveying false information. Amniocentesis (obtaining fluid for analysis by transabdominal needle aspiration) carries a 1 to 1.5% risk of fetal loss.' Chorionic villus sampling and follow up chromosomal studies are associated with a small risk (estimated at 1-2% of fetal loss. Serum alpha fetoprotein (as a screening test for Down's syndrome) is felt by several experts to be a poor discriminator between affected and unaffected pregnancies;' it has also been shown that values of "normality" for the test are based on data derived from high-risk subpopulations and therefore may be inappropriately applied to lower-risk obstetrical patients.9 In addition, the possible long-term side effects of other prenatal tests (eg, ultrasound) are not perhaps fully known.
His argument to extend sincere comfort to, and to allow expected, normal grieving of parents who suffer a miscarriage is both touching and convicting. He helpfully sketches the Biblical and Christian teaching of miscarriage and the spiritual fate of the aborted child.
Chapter Seven ("Choices in Childbirth") is the heart of the book. Herein he details several areas in which " . . . parents [desiring] a participating `natural' birth experience at times [collide] with the `high tech' trends of modern medicine (p.105)."
One of the first areas he tackles is home birthing, "a movement" that began in the 1970s in (where else) California. Many physicians have opposed home births as unsafe. However, he cites a very interesting study from 1977. The researchers involved reviewed the outcomes of 1,146 home birth cases. There were no maternal deaths. There were 5 fetal deaths - 4.3%, as compared to a 10.2% general rate of fetal deaths in California in 1973; and 6 neonatal deaths - 5.2%, as compared to 10.3% in California. Among these deaths, only one occurred during labor; it was of unknown cause. A set of twins died in utero (at about 35 weeks gestation), and a baby died of sudden infant death syndrome at 2 weeks of age. Otherwise, the remaining deaths were from more readily understandable causes (eg, congenital anomalies).
There were 15 low-birth-weight babies (1.3%, compared to 6.4% in California in 1973) and 4 neurologically abnormal babies (0.3%, compared to a 1.7% incidence of neurologically abnormal infants at one year of age, as estimated by the National Institute of Neurological Diseases and Stroke). APGAR (a measure of general vigor and well-being at birth) were also better in the home-born babies: only 40 (3.5%) infants had 1-minute APGAR scores of 4-6 ("perfect" = 10), and only 7 (0.6%) had 1-minute scores of 3 or less and required resuscitation. One study published in 1966 found the overall incidence of 1-minute APGAR scores less than 7 to be about 21% (It must be said, however, that APGAR scoring is a somewhat subjective exercise.)
Twenty-eight women (2.4%) had cesarian section as an unexpected mode of delivery; 11 (1 %) required a low-forceps assist to deliver; 6 (0.5%) required the more difficult mid-forceps assist. Home births were much cheaper: $277 vs. $1,450 (estimated).
Thus, overall, these infants and mothers participating in home births, often supervised by lay midwives, fared quite well. However, in the same issue of the journal from which the California home birth data came, another interesting article appears, entitled "Some Problems of Professionally Attended Home Births."1° The author makes these points:
(1) The most serious postparum complication one may encounter, hemorrhage, is more difficult to deal with in an out-of-hospital setting;
(2) a 1963 British study stated that pneumonia was more common among babies born at home than in hospital;
(3) in Holland, whose high home birth rate Dr. Davis highlights, a report published in 1963 noted the lowest perinatal mortality rates were in areas of highest incidence of hospital confinement;
(4) in a report from Newcastle, Scotland, published in 1966, perinatal deaths due to infection were less common among hospital-delivered babies; and,
(5) separation of "low-risk" from "high-risk" pregnant women is easier to talk about than to accomplish. He urges making the hospital atmosphere more homelike for labor and delivery, an admonition many hospitals have taken seriously.
One must also remember that these California women were a self-selected and basically healthy group. Furthermore, despite any research data that might be cited, many physicians will surely persist in the conviction that home births are "just not as safe " as hospital deliveries. In obstetrics it is an axiom that when something goes wrong, it often goes wrong fast. This is a difficult mindset to change for those trained in hospitals and extremely accustomed to working in that setting where support services are close at hand. Hence, while home deliveries may be appealing for a number of reasons, the couple desiring one may have to search long and hard in this litigious society to find a physician who will serve as an accomplice.
He next discusses birthing centers which probably provide a safer, but still lower-cost and lower-tech birth environment for many couples. He wisely notes that little scientific information is available regarding the effects of the presence of other children (siblings) at the birth of a baby.
Alternate body positions for delivery, the use of enemas, and shaving the perineum (bottom) are discussed and some disdain is noted for "standard" (ie, fixed and required) practices. Although I tend to agree with him, I see no compelling evidence one way or the other. He is negatively inclined intravenous line placement (IVs); here I definitely disagree. An IV provides immediate access to the circulatory system when needed - fortunately not often as an emergency such as after the placenta is delivered and a dose of intravenous oxytocin helps the uterus contract quickly, thus reducing blood loss. Episiotomies are discussed; they may be over-utilized, as he indicates, but when one is necessary (eg, for a large baby's head to pass), "vitamin E oil and hot compresses" are simply not a reasonable substitute.
Electronic fetal monitoring (EFM) has been a subject of considerable debate in recent years. This reviewer tends to agree that it is over-utilized. At least one large study (among indigent women) has suggested that EFM is not necessary for all pregnancies, especially those considered low-risk."
Another common practice, artificial rupture of membranes (AROM) is also probably overutilized. A study by Schwarcz12 has shown that it may be "advisable to re-evaluate the common obstetrical practice of rupturing membranes artificially early in the first stage of labor as a routine procedure, since this practice appeared associated with a higher incidence of abnormal fetal heart rate recordings" (EFM).
Discussion of drug use (anesthesic, analgesic) in labor is included but will be unnecessary for many women undergoing "prepared childbirth," and statements linking drug use in labor to later "learning disabilities" are perhaps unnecessarily frightening for those who may use drugs appropriately. Almost all physicians trained recently would agree that little or no drug use in labor is to be preferred. Regional anesthesia (eg, epidural injection) is typically the choice beyond psychophysiologic techniques (viz, Lamaze) these days among women educated and prepared for childbirth. Apart from possibly causing a decreased desire by the birthing mother to "push" the baby out the last few centimeters of the birth canal, this type of anesthesia is, in my experience, "low-risk" for both mother and baby.
Considering all of these areas of potential dispute between parents and health care personnel, the key issue is perhaps the training of young physicians (who later perform the deliveries in private practice) in tertiary care (teaching) hospitals. Here intervention-oriented research protocols can be important to the young physician's mentors, and the population cared for is often high-risk in character and thus has a higher-than-average risk of pregnancy complications. It is my contention that these young physicians then exit training with the idea implanted that pregnancy/childbirth is an illness to be treated (vs. a physiologic event), and treated in the hospital. This mindset is antagonistic to that of many young couples today. On the other hand, couples would be well advised to avoid the obstructionism that may characterize the "consumerist" approach to health care (first popularized in the U.S. in the 1960s) in their interest to humanize the medical practices surrounding childbirth.
Postpartum decisions are a final area of consideration. A succinct, helpful rationale is presented for infant baptism. A discussion of children's names reminds us of an often overlooked but psychologically potent issue: whether or not one has interest in etymology or Biblical nomenclature, a child's name is important beware what tag you hang upon your bairns. Ophthalmic prophylaxis (use of medicine to prevent eye infection) in the newborn with antibiotics alternative to the standard silver nitrate solution (introduced to prevent gonorrheal eye infection in newborns) is recommended so that the infant will not develop chemical eye irritation and thus will "see" and "bond" better with parents in the first few days of life. Although this is a minor point, many hospitals are in fact switching to tetracycline or erythromycin ointments because of the increasing incidence of Chlamydia trachomatis (a sexually transmitted bacterium), which is the cause of 50% or more of newborn eye infections in some centers" and for which silver nitrate is ineffective. (It is hoped these diseases will not be a germane issue for Christian couples, however).
Circumcision is also discussed. This procedure has been embattled by the "liberal" arm of medicine seeking to "enlighten" us that circumcision is an outmoded and dangerous procedure only requested by "backward" parents. Yet, as Dr. Davis inquires, would God require circumcision for Hebrew males if it were inherently deleterious? Quite interestingly, in recent years several studies have supported its medical usefulness. It has been shown by Fergusson and colleagues14 that after infancy, penile problems are significantly higher in uncircumcised than circumcised boys. In addition, Wiswell and colleagues" showed in a study of over 422,000 infants that uncircumcised males had a 10-fold greater incidence of urinary infections than circumcised males. And as corroborative evidence, the same researchers demonstrated that as the frequency of circumcision fell from 85% of baby boys to 71% between 1975 and 1984 (thanks to "enlightenment"), there was a concomitant increase in urinary infections among male infants, 11-fold greater in the uncircumcised. 16 Thus, there may indeed be certain medical benefits to circumcision; others (eg, reduction in cervical cancer of female consorts) are more hotly debated.
There is also a well-reasoned case made for Christian women staying at home with their young children (at least until school age). Dr. Davis writes: "The home is not the limit of the Christian woman's service, but according to . . . Biblical texts, it should be the primary focus (p.143)." And with the curse of federally-chartered child care leering at us from the halls of Congress, this reviewer says: Amen!
Perhaps the overall theme of the book is that what really makes the difference as to whether childbirth is "horrible" or "fantastic" is the couple's attitude, and especially the mother's. As Dr. Davis writes: "A woman who realistically anticipates pain, prepares mentally for it, who has a supportive spouse and friends, and who has a positive attitude toward pregnancy and motherhood, is more likely to have a rewarding childbirth experience than women with negative attitudes (p.122)." Simply put, Christian couples and mothers should fare better in the process of pregnancy and childbirth, and in so doing will bear to the watching world a very poignant testimony of the God Who is there.
1. Centers for Disease Control, Cancer and Steroid Hormone Study. Long-term oral contraceptive use and the risk of breast cancer. ]AMA 1983; 249: 1591-5.
2. Oral Contraceptives and Cancer. FDA Drug Bulletin, April 1984, p. 2.
3. Data Do Not Support Association Between Spermicides, Birth Defects. FDA Drug Bulletin, November 1986, p. 21.
4. Louik, C.; Mitchell, A.A.; Werler, M.M.; et al. Maternal exposure to spermicides in relation to certain birth defects. New England Journal of Medicine, 1987; 317: 474-8.
5. Berkowitz, R.L.; Lynch, L.; Chitkara, U.; et al. Selective reduction of multifetal pregnancies in the first trimester. New England Journal of Medicine, 1988; 318: 1043-7.
6. Hobbins, J.C., Selective reduction - a perinatal necessity? New England Journal of Medicine, 1988; 318: 1062-3.
7. Pueschel, S.M. Maternal alpha fetoprotein screening for Down's Syndrome. New England Journal of Medicine, 1987; 317: 376-8.
8. Young, R.S. Personal communication.
9. Weiss, B.D. First-year results of routine alpha fetoprotein testing on prenatal patients in a family practice. Journal of Family Practice, 1988; 26: 273, ff.
10. Moawad, A.H. Some problems of professionally attended home births. Journal of Reproductive Medicine, 1988; 26: 273, ff.
11. Leveno, K.J.; Cunningham, F.G.; Nelson, S.; et al. A prospective comparison of selective and universal electronic fetal monitoring in 34,995 pregnancies. New England Journal of Medicine, 1986; 315: 615-9.
12. Schwarcz, R.; Athabe, O.; Belitzky, R.; et al. Fetal heart rate patterns in labors with intact and ruptured membranes. journal of Perinatal Medicine, 1973; 1:61.
13. Rapoza, P.A.; Quinn, T.C.; Kiessling, L.A.; Taylor, H.R. Epidemiology of neonatal conunctivitis. Ophthalmology, 1986; 93: 456-61.
14. Fergusson, D.M.; Lawton, J.M.; Shannon, F.T. Neonatal circumcision and penile problems: an 8-year longitudinal study. Pediatrics, 1988; 81: 537-41.
15. Wiswell, T.E.; Roscelli, J.D. Corroborative evidence for the decreased incidence of urinary tract infections in circumcised male infants. Pediatrics, 1986; 78: 96-9.
16. Wiswell, T.E.; Enzenauer, R.W.; Holton, M.E.; et al. Declining frequency of circumcision: implications for changes in the absolute incidence and the male to female sex ratio of urinary tract infections in early infancy. Pediatrics, 1987; 79: 338-42.
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