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PUSHED: THE PAINFUL TRUTH ABOUT CHILDBIRTH AND MODERN MATERNITY CARE Jennifer Block (Da Capo)

The Obstetric-Industrial Complex

An exposé on birth in America just emphasizes how little things have changed.

By Noah Berlatsky
June 29, 2007

IF YOU GO to a hospital in the United States to deliver your child, you will probably do so flat on your back -- thought by many to be the worst possible position in which to give birth short of being hung by the feet. You have a one-in-three chance of having major abdominal surgery. If you don't, you've got another one-in-three chance of having your vagina slashed with a knife. And you will have a better chance of dying, or having your baby die, than do women in almost any other industrialized country.

All of these depressing details and more are available in Jennifer Block's new Pushed, an examination of American maternity care in general and the rising rate of cesarean births in particular. Block used to be an editor at Ms., and the book is loaded with interviews, statistics, and the kind of muckraking you'd expect from a veteran of the progressive media. But what's infuriating about her narrative isn't that she's turned up new evidence of incompetence and negligence, but that she hasn't.

Block cites the latest studies, but their conclusions simply bolster what the World Health Organization has been saying for years. Adjusting for risk factors, mothers are four times more likely to die after a C-section than after a vaginal birth -- and babies are at greater risk as well. During vaginal births, episiotomies (slicing open the area between the vagina and anus in order to widen the birth passage) can lead to infection, incontinence, and sexual dysfunction and according to research available since at least the 1980s are almost never medically necessary. If you induce labor with drugs like Pitocin the chances of a hard labor and of fetal distress both go up. Being hooked up to a fetal monitor has no proven medical benefit, makes the mother uncomfortable, and increases the risk of a cesarean. Again, all information available to doctors for decades -- and thanks in part to Jessica Mitford's wry, scathing indictment of obstetric practices, The American Way of Birth, published 15 years ago, available to the public too.

Despite all this, women like Block who question the efficacy of our nation's obstetric care, are often branded by doctors, acquaintances, and even family as recklessly matriarchal uberhippies -- ranting ideologues in hemp maternity clothes. But there's little ranting in Pushed. Block's tone is dry, her prose full of scientific minutiae about cesarean rates, obstetrician attitudes, historical studies, and the legal status of midwifery. Those undaunted by the facts and figures are rewarded with some quietly deft storytelling. Block's description of a typical C-section, for example, is neither overtly judgmental nor outraged. Instead she calmly piles on details -- the surgeon struggling to work around old scar tissue, the blood, the nurses choosing a radio station, the mother seeing her child for the first time in a digital picture. Anybody who's ever been in a hospital for a major procedure will recognize the studied depersonalization and the downplayed but lingering threat that something could go very wrong.

After reading this passage it's hard to believe that any woman would choose to have a baby like this, and yet more and more women do. Cesarean rates dipped in the mid-80s but they're back up from 15 percent of all births in 1980 to 30 percent today. Elective cesareans -- when a woman has a baby surgically removed by appointment before she goes into labor -- are also on the rise (though by Block's account exact numbers are harder to pin down). Doctors often claim the increase is a reflection of patient choice. Women, obstetricians suggest, are afraid of labor. Block reports that there's even a new word for it: tokophobia, the fear of giving birth.

Still, judging from Block's research, the popularity of cesareans is less about fear than about scheduling. Obstetricians are highly paid, highly trained, upper-middle-class emergency specialists. Their time is valuable and they want things to move along. Saint Louis University nursing professor Kathleen Rice Simpson goes so far as to say doctors encourage women to give birth during the week and during the day so they can maintain their own normal lifestyles, with regular sleep and weekends off. In a study of physician-nurse communication, Simpson found that during labor nurses often try to keep doctors away from mothers. Once an obstetrician gets involved, there are going to be interventions, even if they aren't medically needed. New York obstetrician Jacques Moritz notes that the prevalence of unnecessary inductions is the profession's "dirty little secret."

In part, this is because of liability. If something goes wrong during a birth, an obstetrician can become uninsurable. Block reports on doctors who, in a frantic effort to decrease their exposure, have begun to refuse to participate in vaginal births of twins, or of breech babies, or of babies who are past term, or of any baby born to a mother who has already had a cesarean. This last is the main reason for the increase in scheduled cesareans -- once you've had one surgery doctors fear the scar will tear during a vaginal birth. But liability only explains so much.

Block says in fact that after a C-section a second C-section may be more dangerous than a vaginal birth After multiple cesareans incidents of placenta accreta -- when the placenta attaches too firmly along a scar from a previous surgery -- have risen alarmingly. Yet physicians and insurance companies haven't taken steps to decrease their risks in this area.

Why? The answer still seems to be that in American obstetrics surgery and intervention are what's seen as "normal," while labor is seen as dangerous. Block's interviewees point out that obstetricians are comfortable with drugs and knives and taking charge. When there's a disaster, they're great. But as the midwives Block interviews demonstrate repeatedly, labor requires a lot of sitting still and a lot of patience. Obstetricians, Block suggests, aren't trained to do that and aren't very good at it. So they try to move labor into their comfort zone -- the surgeon's table.

This is why, for primary care, the WHO suggests that it's often better to have a midwife, who doesn't have to rush to be somewhere else and who apprentices by attending many, many vaginal births, rather than by learning surgery. In places like Scandinavia midwives can provide primary care in various venues, with hospital obstetricians as emergency backup, and you get extremely low fetal death rates. In much of the U.S., on the other hand, doctors have successfully lobbied to force midwives to certify as nurses, keeping the majority of them in hospitals. In Illinois, one of the most restrictive states in this regard, midwives without nurse certification can be prosecuted if they attend a home birth.

As a result, even if you want to have your baby in a safer, saner way -- without the risk of unnecessary surgical intervention -- you may not be able to. Perhaps someday that will change, but until then we can expect excellent books like this one to come along at regular intervals, reminding us that the United States is a terrible place to be born.

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Comments

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Christina O at 5:12 PM on 10/23/2007

I hope women read this book and we can ban together to change things before it is too late for our children.

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Diane Burke at 6:56 PM on 1/29/2008

Be very careful about negating the importance of having a knowledgeable person by your side and lifesaving tools available to you close at hand. I did not and now my child for the last 20 years has to live with brain damage. I gave birth to her in London where the medical opinion at the time was as little intervention as possible, let it be as natural as possible. Most of the time that is a wonderful experience but how do you know if you are going to be the one who needs your baby saved. I was a healthy 28 year old, my mother easily popped out 6 kids, why would I ever think it would be hard. Well because of the lack of monitoring, her heart stopped beating (probably because the cord got stuck between her head and my hip bone). The doctor was too relaxed and did not notice the emergency right away. They had to take me in an elevator to surgery, prep, put my under and all that time her heart was not pumping blood to her body and brain. She went from a complete whole baby to a quadriplegic and all it took was 10 minutes to take her life away. If I had been in the USA I believe the doctor would have monitored me more closely and I would have had a healthy baby delivered to me by c-section before her heart stopped pumping blood to her brain.



Be careful of being on this pedestal just because you lucked out this time and had a heavenly experience of child birth. It wasn’t in your cards this time to have my experience. Be careful of that, I would not want for you to feel guilty for talking someone like me into staying home and birthing a dead baby. When one has my random experience, that was very much unpredictable, one realizes that the inches away the baby’s head is to the open air is one of the closest times they will come to death too. The timeline is microscopic to a healthy baby and an unhealthy baby. A doctor has to see this microscopic timeline and make a call. When it comes out all is well, then you and many lucky mothers can take that line for granted. Be very careful you were given a gift that not everyone gets. When it comes out wrong, then we blame the doctor’s judgment. How do they win?



Please feel lucky, not talented or like it is easy. If a doctor performs a c-section and the baby is healthy maybe still feel fortunate because you really don’t know that perhaps time was of the essence and seconds could possibly have been ticking away. I was denied a c-section that would have been my best most wonderful gift in my whole life and more importantly in my daughter Lesley’s life. Get off your high horse and have GRATITUDE.



Please stop giving c-sections a bad name and realized they can be life saving. Electing not to have one can be a very selfish move on the mother’s part and a child could possibly have to live the rest of their life handicapped because of this selfish decision. Meanwhile my next two kids, 19 years old and 15 years old, were also c-sections because I did not want to risk the emergency of natural child birth that I experience with Lesley. They are healthy, intelligent children and I feel blessed that I had the courage to have two more after my first experience. By the way they were born in the USA.



Diane Burke

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Sarah Lancaster at 9:34 PM on 2/16/2008

Ms. Burke,

First, let me extend my sympathies to you and your daughter. I cannot imagine the sadness that you live with. In your position, I can well understand your fears regarding vaginal birth. However, stating that cesareans are overused and potentially dangerous for both mother and child does not negate the fact that they have a place and time. It is simply a medical fact.

As of 2006, the national CS rates had climbed to 31.1%. It is impossible that nearly one third of women are incapable of giving birth vaginally. The human race would not survive if that were the case. According to the World Health Organization, anytime a national CS rate climbs above 15%, more mothers and children are being harmed than helped. No one is denying that there are times when CS is appropriate. However, CS carry their own risk, and **that risk is what is being hidden from mothers.** Mothers who undergo CS are more likely to suffer complications, including death. (4x more likely than a vaginal birth.) These complications become more common with each subsequent CS. Considering that more and more hospitals are banning VBAC (vaginal birth after cesarean), it is a very real possibility that mothers who have a CS will be forced to choose between their own health and having more children in the future. Additionally, babies born by CS are more likely to suffer medical complications, including death.

Your situation, while tragic, is not statistically normal. Therefore, one cannot base medical policy or care for the majority of mothers on the tragic circumstances that afflict a few. The point of this book, and of the drive for more natural births, is not to villianize all CS. It is not to state that all women should deliver at home. The point is to acknowledge that most CS ARE NOT carried out for valid medical emergencies. Most CS are NOT a matter of saving a child's life or a mother’s. The countries with the lowest rates of infant and maternal morality are also those with low rates of obstetrician-attended births. These are not opinions. They are not propaganda. They are not personal judgments. These are medical facts that are well known to the medical community, but virtually unspoken to mothers.

Health care based on fear does not help. It harms. Keeping mothers ignorant of the risk of CS and the benefits of natural, vaginal birth is not only dangerous, it is ethically wrong. Doctors do not have the right to place a mother and child's life and risk for their own convenience, their fear of lawsuit, or their malpractic insurance carrier's demands. Women need to be given all the facts and allowed to make their own decisions about health care.

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Liz at 1:27 PM on 6/18/2008

Ms. Burke,
I am sorry for what happened to you in the birth of your child. My doctor threatened me into having a cesarean by telling me that my child could be born brain-damaged if I delivered vaginally. I do not know if this is what actually would have happened...but I can say that I was NOT informed of the potential consequences for FUTURE babies if I were to have that cesarean (which I did agree to). He did not tell me that I would have a higher risk of miscarriage, placenta previa, or uterine hemorrhage and hysterectomy during a next pregnancy and birth. He did not tell me that I would have a higher risk of dying myself during this or any future birth. He did not inform me of the risk of respiratory problems in my son if I were to consent to the surgery, and he did not inform me that I might be forced into another cesarean due to insurance issues. Of course cesearean births have their place, and should absolutely be used when the benefits outweigh the risks. I just think that often in lower-risk situations than yours, cesareans are performed due to overstatements of the benefits and ignorance of the risks. I hope women (and their doctors!) read this book and gain a fuller understanding of all the issues so that they are able to make informed decisions.

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Prachi at 4:26 PM on 4/7/2009


Ms Burke
Mine is a story on the other side of the spectrum where I almost lost my life after a c section.

http://coumadinbirth.blogspot.com/

US hospitals are broken, completely, and the entire emphasis is on generating revenue

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