Modern Childbirth: Failure to Progress

Pushed: The Painful Truth About Childbirth and Modern Maternity Care by Jennifer Block
New York: Da Capo Press, 2007, 400 pp., $26.00, hardcover

Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First by Marsden Wagner
Berkeley: University of California Press, 2006, 305 pp., $24.95, hardcover

Birth: The Surprising History of How We Are Born by Tina Cassidy
New York: Atlantic Monthly Press, 2006, 320 pp., $24.00, hardcover

Reviewed by Sarah Blustain

In spring 2005, a study of 5,000 planned homebirths in North America, one of the most comprehensive of its kind, found that women who had such births needed fewer interventions than those who had hospital births, and that the home births were as safe as the hospital births. The following spring, Great Britain’s secretary of health announced that by 2009 all low-risk British women would be given the option of a home birth. Then, in November 2006, the American College of Obstetricians and Gynecologists struck back. ACOG, the lobbying organization for the obstetric profession, announced,

The development of well-designed research studies of sufficient size, prepared in consultation with obstetric departments and approved by institutional review boards, might clarify the comparative safety of births in different settings. Until the results of such studies are convincing, ACOG strongly opposes out-of-hospital births [emphasis added].

Of course ACOG opposes out-of-hospital births! This is what American obstetrics is all about. Its first priority is not healthy birth per se, but obstetric birth. Two new books—Pushed, by Jennifer Block, and Born in the USA, by Marsden Wagner—tell us just what goes wrong when birth is controlled by obstetricians. In their view—based on evidence and science, albeit not in consultation with obstetric departments—that’s just about everything.

Wagner and Block come from different worlds. Wagner was formerly the director of Women’s and Children’s Health at the World Health Organization (WHO). He has experience as a medical doctor, an epidemiologist, and a scientist. While he is sympathetic to obstetricians, who he recognizes are stretched thin and unable to fully attend the unpredictable and often lengthy process of normal birth, he calls himself a “whistleblower.” He offers a scathing attack on professional standards of care, suggesting they are abusive at worst, and based on nonscience that mainly serves doctors’ interests at best. Block was an editor at Ms. magazine, and her book covers, in extraordinarily readable terms, much of the same scientific ground that Wagner’s does. As a reporter, however, her strength is in getting doctors and nurses—some self-satisfied and some repentant—to confess that obstetric care is corrupt to its very core. No woman who is pregnant, has been pregnant, or plans to be pregnant should set foot inside the office of her ob/gyn before reading these books.

Here are two central facts about American birth: first, the US spends more per capita than any other developed nation on maternity care. Second, the World Health Organization ranks the US thirtieth out of 33 developed countries in preventing maternal mortality, and 32nd  in preventing neonatal mortality. Our country is not doing well by mothers and babies.

Block, a wry and pointed writer, starts her narrative with a history of the Blonsky, a machine that received a patent in 1965. It was to spin a laboring woman around at a force of seven Gs (astronauts experience three Gs on liftoff), creating enough force “to push aside the constricting vaginal walls, to overcome the friction of the uteral and vaginal surfaces and to counteract the atmospheric pressure opposing the emergence of the child.” The baby was to be sucked out and land in a basket, which was to trigger an automatic shutoff. Lucky for all of us, the machine was never built, but, writes Block, the Blonsky “is eerily similar to how most American women give birth.”

Both these books describe, in splendid detail, the myriad interventions of “active management”—the practices perpetrated upon even a healthy woman planning the most unremarkable of births. Although these practices may help in critical situations, they are more likely to cause harm than good in a normal birth. For example, active management includes the induction of labor in as many as forty percent of all American births, even though this leads to longer and more painful labors and “ups a woman’s chance of a [cesarean] section by two to three times,” according to Block. Wagner warns that doctors (with ACOG’s approval) use the ulcer drug Cytotec for induction, despite the manufacturer’s pleas and evidence that it has caused maternal death by hyperstimulating the uterus until it ruptures. Active management also includes speeding up a woman’s labor with the use of Pitocin in perhaps a majority of American hospital births today. According to Block, “a recent ACOG survey found that in 43 percent of malpractice suits involving neurologically impaired babies, Pitocin was to blame.” And it includes routine electronic fetal monitoring, used in 93 percent of hospital births even though studies show that its only effect is to increase the c-section rate. The list goes on.

The quintessential intervention is the cesarean section, which is how nearly thirty percent of American women delivered their babies last year. WHO says that when a population has a c-section rate of higher than fifteen percent, the risks to the mother and baby outweigh the benefits—and a WHO study found that “the main cause of maternal deaths in industrialized countries is complications from anesthesia and cesarean section,” Block reports. She cites another study published last year, of 100,000 births, which found that “the rate of ‘severe maternal morbidity and mortality’—infection requiring rehospitalization, hemorrhage, blood transfusion, hysterectomy, admission to intensive care, and death—rose in proportion to the rate of cesarean section.” As for the baby, other research has found that “preterm birth and infant death rose significantly when cesarean rates exceeded between 10 and 20 percent,” and that “low-risk babies born by cesarean were nearly three times more likely to die within the first month of life than those born vaginally.” Nonetheless, ACOG not only rejects the fifteen percent target, but even continues to support the idea of elective c-section. Indeed, the doctor appointed head of ACOG in 2000, W. Benson Harer, has written treatises on “prophylactic elective cesareans” for preventing later incontinence—even though there has been no evidence that c-sections help at all.

So what is the purpose of all this intervention? In the most damning sections of these books, it becomes clear that there are several, none of which have anything to do with helping women.

The first is convenience. The Centers for Disease Control and Prevention (CDC) has noted what it calls the “weekend birth deficit.” As Block reports, Kathleen Rice Simpson, a professor of nursing at St. Louis University School of Nursing, found that doctors were “most concerned with increasing the oxytocin [Pitocin] rate to “keep labor on track’ and ‘get her delivered.’ … [One physician] remarked, ‘When I hear I’ve got a nurse who will go up on the Pit, I know it’s going to be a good day.’” Ethical? Given the risks of induction, probably not. Yet in 1999, ACOG reversed its policy on labor induction, sanctioning it for “social” or “logistic” reasons.

The second reason for the interventions is “standard of care” protocols, which doctors decide upon through trial and error. Both books include infuriating narratives about the sloppy and nonscientific research that led to today’s hospital protocols, including the demand that labor “must progress at a minimum speed and occur within a maximum duration” or be labeled “failure to progress.” As Block tells it, failure to progress is responsible for one-third of all c-sections. But as both books show, failure to progress in fact means failure to progress on the doctor’s schedule. More and more women are having problems not because they are unhealthy but because doctors have redefined normal. In another egregious example of arbitrary standards, Wagner cites a 1999 ACOG recommendation against vaginal birth after cesarean (VBAC). The rate of uterine rupture among VBACing women had been increasing “at an alarming rate, … almost certainly related to the fact that the percentage of births in which powerful drugs, such as Cytotec, were used to induce labor had doubled,” he writes. But instead of banning induction among VBACing mothers, ACOG banned VBAC itself, a decision that alone has led to a stunning increase in the c-section rate in this country.

The third is doctors’ fear of litigation and, related to that, rising malpractice insurance costs. Doctors are practicing “defensive” medicine—to women’s detriment. Electronic fetal monitoring and c-sections have become “a kind of insurance against litigation,” Wagner writes. In one of the many stunning admissions that Block has elicited from her sources, one doctor said,

The risks are maternal, and maternal risks are much smaller to us as obstetricians. There’s no doubt in my mind that there’s more maternal morbidity with a cesarean. But a hole in the bladder, a post-operative infection—that’s not going to ruin their lives. A bad baby is going to ruin our lives.

Another doctor told Block,

To be blunt, you don’t get sued when you do a cesarean. … You get sued when there’s a damaged baby. … And that causes doctors to say, “Well, it’s got to look like I’ve tried my best. And trying my best would be to deliver the baby.” So you explain to the mother that the fluid’s a little low.

What’s most nefarious about these justifications is that doctors lie to women in order to scare them into consenting. They play what one midwife Block interviews calls the “big baby card,” the “dying placenta card,” the “convenience card,” the “exploding uterus card,” and the ubiquitous “dead baby card.” Yet they do not routinely tell women of the risks of the interventions. Indeed, the standards of care are so inconsistent that ACOG opposes VBAC but offers no objection to amniocentesis, even though the risk of miscarriage after an amnio is one in 200—“the same as the risk of uterine rupture in a VBAC,” writes Block. Informed consent, these books make clear, is a fantasy.

There is, however, an alternative. In an amazing narrative, Block describes the experiences of one hospital in Florida after Hurricane Charley knocked out power in 2004. The labor-and-delivery nurse she interviews, who later quit in disgust, describes the scene: no woman was admitted unless she was in active labor. The hospital suspended induction. “Women were delivering within hours of arriving, even first-time mothers, without any Pitocin,” the nurse told Block. “We had no cases of fetal distress during labor and no respiratory distress of neonates following delivery. … We had an incredibly low cesarean rate. Amazingly, the babies were mostly evenly distributed between day and night shifts”—the weekend birth deficit vanished. “[B]asically, they did better than if they had been induced. We thought, wow, this is amazing!’”

As evidence is increasingly showing, the people who best enable normal births are midwives. Obstetricians, after all, are surgeons, and many never witness a natural, normal birth in their training. Midwives, in contrast, are women who know that one of the best answers to pain is sitting in a warm tub, who know how to manually palpate a woman’s belly to find the baby’s weight and position, and who know how to help a woman handle labor in ways that facilitate birth.

One of the most moving sections of Pushed comes as Block introduces us to two homebirth midwives: Linda, who practices in an undisclosed state; and Cynthia Caillagh, of Virginia, who attended some 2,500 births before a bad outcome drove her out of practice. (The family of her client, who later died, didn’t think Caillagh was responsible, but the state tried her anyway.) Block shows Linda attending births, providing a wonderful, woman-focused counterpoint to the medical births she’s dissected in earlier chapters. She frames her discussion in terms of women’s power and women’s rights but is not didactic, instead relying on the midwives’ words to make her point. Says Caillagh of her clients, “At no time did I own their health or the information they were gathering. … The choices were theirs.”

But midwifery in the US is up against some powerful forces—mainly, again, obstetricians and ACOG. Doctors throughout American history have worked to discredit midwives—labeling them dirty, uneducated, and unskilled—and to drive them out of business. Today certified nurse-midwives who practice in hospitals report having their hands tied by doctors and hospital protocol. Direct-entry midwives, who are not nurses and attend home births, and who are illegal in eleven states and the District of Columbia, are persecuted by doctors, who use any opportunity to convince the state to prosecute them into court. As Block reports, at ACOG’s 2006 conference, the group gave out bumper stickers that read, “Home Deliveries Are for Pizza.”

Block asks, “Do women have the right to give birth with whom, where, and in the manner in which they choose? And if so, is that right being upheld?” Other related questions come to mind: Is it ethical to allow women to give birth at home, as does every state, but to make it illegal or intimidating for her to be attended by a direct-entry midwife? Should doctors and courts decide what risks are acceptable for a birthing woman—based on nonscientific data? Even if their data were scientific, would they have the right to make a woman’s decisions for her? May a hospital compel electronic fetal monitoring if a woman refuses? May a doctor drop a patient out of fear of liability, if she refuses a c-section against medical advice?

Many of these complaints are not new, and much of the research showing the dangers of hospital birth dates from the 1970s and 1980s, as women and women’s health advocates realized that hospitals were following protocols that were more useful to the hospital than they were to women. We’ve all heard stories from women who birthed in the 1950s and 1960s, strapped to beds, drugged into twilight sleep.

What arose from the new, liberated women’s consciousness, though, was a concept of birthing that only appeared to be woman-centered. Hospital birthing rooms now have flowery wallpaper. The equipment is hidden behind pleasant drapes. And it is trendy for a pregnant woman to create a “birth plan” document, written in consultation with her doctor, to communicate her wishes to the hospital staff during her labor. For instance, she may specify that she wants to wear her own clothes, to birth without drugs, and to be free to walk around. But the truth is that most women are still required to give birth on their backs with their feet in stirrups—the least efficient way to push a baby out. As for the birth plan? “It’s an illusion,” Judith Lothian, author of The Official Lamaze Guide, tells Block. “[I]t does women a disservice because they really do think that they have choice, and then they don’t.”

The prospects for change under our current health care system are grim. Wagner believes universal healthcare may help. He also encourages families who feel their rights have been abused to litigate against their doctors. For her part, Block ends with a challenge to today’s organized feminists to bring birthing under the umbrella of “choice,” quoting childbirth educator Erica Lyon, who says, “I think this is the last leap for the feminist movement. This is the last issue for women in terms of actual ownership of our bodies.”

Is it possible for change to come from women themselves? It would take a revolution. These books deal only peripherally with one of the most problematic issues: what do you do when women freely choose, or think they freely choose, medical procedures that increase their risk and that of their children? If women believe their obstetricians are their best advocates, how do you convince them to think skeptically? Indeed, ACOG has tried to spin “patient choice” of cesarean section as a major issue. But as Block points out, a woman often “chooses” surgical birth after her doctor has handed her one or several of the risk “cards.” Until women take birth into their own hands, until they realize that doctors are not necessarily women’s advocates, until they seek out the evidence, which is in these books but not in doctor’s offices, about the normalcy of birth and the dangers of interventions, they are going to continue to believe that birth is a crisis about which only one person – the obstetrician – knows best.

If ever there was a book that gave credence to this concern, it is Tina Cassidy’s Birth. She writes, “for the vast majority of us over the years, the ‘best’ care has often meant isolating babies in nurseries, receiving an unnecessary episiotomy, or having a breast dipped in iodine before every feeding. … If only we’d known how skeptical we should have been. And should still be.”

Cassidy herself knows of what she speaks: she describes her own birthing experience, in which her baby was not in the optimal position during labor and got “stuck.”

I asked to have a midwife come and offer suggestions to move my labor along, but the harried staff said she was unavailable. I asked them to shut off the epidural (yes, I had succumbed the fifth time the nurse asked me if I wanted one), so that I could try other labor positions. They obliged but only, I think, because they were annoyed and knew the pain would be so severe I wouldn’t care what happened next. … My son’s heart rate was fine, but things had dragged on too long, as far as the staff was concerned. The doctor insisted upon an emergency c-section … throughout which I vomited and shook violently.

 

And yet Cassidy concludes that even knowing what she knows, “I doubt there’s much I would have changed.” She says, “Women will forever give birth in many different ways—either by design or through forces out of our control. As for the latter, we can only hope to be pleasantly surprised.” Oh how these final words infuriate me. Yes, she says, the emperor has no clothes—but my, what an interesting outfit he’s wearing.

At the core of these books are two issues: women’s right to make their own medical choices, and their right not to have their health compromised by the demands of the American medical system. These issues deserve much more than the amused shrug that Cassidy gives them. Despite our birth plans and natural birthing classes, American women are still giving birth in a patriarchal system that puts the needs of the hospital, the doctor, and the profession well above the safety of women.

 

Sarah Blustain is deputy editor of The American Prospect.

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