By Cynthia K. Buccini
When a woman about to give birth enters a U.S. hospital — and 99 percent of them do these days — she probably will be strapped to an electronic fetal heart rate monitor and may also be tethered to an IV. She might be given drugs to induce or speed up labor, and she may undergo an unexpected cesarean section.
Despite these and a host of other medical procedures, the United States has one of the worst records in maternal and infant mortality among industrialized countries, writes Jennifer Block (CAS’98, SED’98) in her new book, Pushed: The Painful Truth About Childbirth and Modern Maternity Care (Da Capo Press).
“When women go into the hospital, they’re going to experience interventions that don’t necessarily have to do with their health and well-being and their baby’s health and well-being, but that have become routine because of liability concerns and malpractice insurers’ requirements and all of these things that have nothing to do with the medical evidence,” says Block, a Brooklyn-based freelance writer and a former associate editor at Ms. magazine.
She points to the electronic fetal monitor. “In the hospital, 95 percent of women, according to surveys, have to wear an electronic fetal monitor,” she says, “which is no better than a nurse coming in and listening periodically with a stethoscope or with an electronic Doppler monitor. The fetal monitor, when it’s on continuously, as it often is, really limits mobility. So women are now in bed.”
When did childbirth become a medical emergency? Block set out to write a magazine article about that and similar questions, but the subject proved too big and complex to wrestle down to a few pages. In Pushed, she explores the “intense medical management” of childbirth, the rising cesarean rate, and the difficulties some women face in finding alternatives to a hospital birth.
You say that in the United States Today, we don’t support the physiological birth process. What do you mean by that?
The physiological birth process is the automatic sequence of events that happens to a woman’s body during labor: the contractions start, many hormones start pumping, the cervix starts opening, and the baby starts moving down.
We know that the healthiest thing for both the mother and the baby is to support this process and to have a minimally invasive vaginal birth. That’s the optimal experience, one in which the mother goes into labor naturally, moves around throughout labor, pushes in an upright position ¾ standing, squatting, sitting — or on hands and knees. Most women, if they give birth vaginally, are pushing in very counterproductive positions, either on their backs or lying back. They’re being told when to push and how long to push.
More than half of women are receiving synthetic oxytocin, the drug Pitocin, to either induce or speed up labor. According to surveys, about four out of ten women are being induced into labor. Nearly a third of women are going through major abdominal surgery to give birth. For the women who give birth vaginally, a third of them are getting episiotomies. These practices, we know from research, contribute to all sorts of problems: incontinence, sexual pain, recovery pain. Cesareans can lead to major complications. We know that these practices don’t make for an optimal birth experience, yet most women are still experiencing them.
You write that we consider childbirth a medical condition that needs to be controlled. what’s contributing to this trend?
There is a lot going on, but I think the overarching problem is we’re not valuing physiological birth. We have this idea that a cesarean is just as good, that mimicking labor — inducing labor with drugs and instruments — is the same, and the research shows that it’s really not.
The process works much more efficiently when it’s allowed to take its own course. Babies benefit greatly from labor, and breast-feeding is much easier. I think there is a collective distrust of the female body and a lack of trust that it can do this work of labor.
We want the support and the medical technology if we need it, and that’s really important. Women and babies die when there’s a lack of emergency obstetric care available. But it doesn’t mean every woman needs the full-blown emergency obstetric care all the time.
But aren’t we just trying to protect the health of mothers and babies?
Yes, but what we’re learning from the research is that we’re actually doing them a disservice. When we treat every birth like an emergency, when we induce every woman who goes over her due date or over forty-one weeks, we see more cesareans, and when we see more cesareans we see more problems. This is partly to blame for the recent rise in maternal mortality. And a very large study of 5.7 million babies done by a U.S. Centers for Disease Control statistician found that babies born by cesarean were three times more likely to die within the first month of life. So what we really need to do is understand why that is and to reexamine the idea that cesareans are better for babies. They don’t seem to be, and they definitely interrupt breast-feeding.
You attended several births in researching your book. Why?
Before I even put together a book proposal, I decided I needed to see a birth to figure out if it was something I could handle. I don’t have kids. So I went to a birthing center in El Paso, Texas, to interview the midwives. They invited me to work a twenty-four-hour shift.
I spent the day shadowing a couple of midwives as they did their prenatals, and I talked to some of their clients. At about nine this woman came in, and she was in labor. She did not lie down once. She kept walking around the room. Within the hour her water had broken and she birthed that baby standing up. It was wonderful. It’s an amazing rush to witness that. I saw probably the most optimal birth experience you can imagine.
Is that the solution: more midwives?
I think one major piece of the solution is to create a maternity care system where midwives are primary maternity care providers. They support the physiological birth process and leave the emergencies and the problems to the doctors, because that’s what they are good at. And if a woman needs to be induced into labor, we have really good tools to do that.
One problem we have to solve is that physiological birth doesn’t seem to fit into our health-care system. Hospitals are businesses, and doctors’ practices are businesses. So many physicians said to me, “I have to pay $100,000 a year in malpractice insurance now, and I have to take twice as many clients as I used to just to make up my salary and keep the quality of life I had. That means I spend half the time with patients in the office.” It’s impossible to expect a doctor to wake up all hours of the night and stay with a woman throughout her labor. That’s not what they were trained to do; they have far too many clients to do that for everyone.
Once you get to the hospital, there’s a ticking clock. Nurses would say to me, “I can’t have them taking up beds. If you’re in early labor, you’re taking up a bed, you’re not taking any intervention, you don’t belong here.”
We need to create spaces like birth centers. Not every woman wants to have a home birth, and birth centers, where they exist, are extremely popular. They’re sort of that middle ground. They’re a place where women can get support for physiological birth from midwives and also have a connection to a hospital. Midwives are experienced at recognizing problems and transporting seamlessly. But birth centers are having a hard time staying in business, because they have malpractice insurance problems, too. Their insurance is also quadrupling.
I think that most women want to do what’s best for themselves and their babies. It’s not that they want a natural childbirth. They just want a normal birth.
