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Bringing Up Baby: Reagan's Cesarean on Up All Night and the Issue of Control in Childbirth

Reagan and Chris in the delivery room on Up All Night

Dr. Joseph DeLee, the grandfather of modern obstetric medicine in the United States, believed that childbirth is a dangerous disease that must be managed and controlled. "It strikes physicians as well as laymen as bizarre," DeLee wrote in 1920, "to call labor an abnormal function, a disease, and yet it is a decidedly pathological process." DeLee taught 11,000 nurses and doctors during his prestigious career, and institutionalized "The Prophylactic Forceps Operation" as the gold standard of American obstetrics.

According to DeLee's model, women were knocked unconscious (or, sometimes, semi-unconscious) with morphine, scopolamine, and ether. The doctor then performed a generous episiotomy (cutting the vagina and perineum), removed the baby with forceps, and sewed the incision. Variations of this routine were standard into the '70s. DeLee's guiding principle was that OBs shouldn't respond to emergency childbirth scenarios; rather, they should prevent these scenarios from unfolding by controlling birth from the outset.

Today, new methods have replaced DeLee's, and yet popular obstetric interventions (cesareans, amniotomies, labor-inducing drugs, episiotomies, epidurals) are still designed to transfer control from the woman to her labor assistant. 33% of births in the United States are by cesarean, a rate that has grown significantly during the previous decade, in tandem with increasing rates of maternal injury and death. Yet representations of childbirth in television and film rarely show cesareans. Which is why I was so grateful for Reagan's recent childbirth episode on Up All Night.

Recap: At 12:36pm, Reagan goes into labor. She and her husband Chris take a limo to the hospital and chat casually; the sense of fear and urgency that is so typical of childbirth on television was, thankfully, absent. Reagan is dismayed to discover that her female OB isn't available for the delivery. A handsome young male doctor arrives, and Reagan requests a female doc. "Do we even have a choice in this matter?" Reagan's husband, Chris, asks. "No," the doctor replies. Shortly thereafter, Chris plus doctor poke fun at Reagan's detailed birth plan. As Reagan's labor progresses, Chris pressures her to get an epidural, but she repeatedly declines. Her attachment to a drug-free birth is framed as irrational. She takes an epidural at 7:10pm. At 11:29pm, the doctor says, "Pushing's not working, Mrs. Brinkley. The baby's head may be too big. I'm recommending a c-section," to which Reagan says, "No thank you." The doctor says, "Actually, it's not optional." Reagan's disagreement with her OB is framed as a control problem. "Babe, you gotta let go of the plan," Chris says soothingly. "We have to listen to the doctor, OK?" At 12:37am, Reagan has a cesarean.

The story arc emphasizes Reagan's eventual relinquishing of control and surrender to the unpredictability of childbirth. This episode was similar to the Murphy Brown childbirth episode, during which Murphy finally learns that she can't control childbirth.

It's true that childbirth is a deeply unpredictable experience that requires emotional strength and versatility. However, pop culture's chronic portrayal of laboring women as "control freaks" who must be persuaded to submit to medical pressure reflects the problematic assumption that the women's requests are misguided or silly. The concept of control holds an inherent judgment of the circumstances. The "control freak" giving birth is the one who is wrong.

"The baby's head may be too big" is one of many reasons doctors give when pressuring women into cesareans. Cephalopelvic disproportion—in which the baby's head is too big to clear the mom's pelvis—is extremely rare. Or was he referring to macrosomia (a big baby), another vague diagnosis? The "big head" is cited by doctors in cases when there has been no confirmation whatsoever of actual cephalopelvic disproportion or macrosomia.

Increasingly, "emergency" cesareans are performed in the absence of an emergency. "Failure to progress" is the most commonly cited reason for an emergency cesarean, and yet the time cap on labor varies from hospital to hospital. Some doctors say eight hours of labor necessitates a cesarean. Others say ten, twelve, or eighteen hours. Failure to progress now accounts for as many as half of cesareans in first-time moms.

Meanwhile, many elective cesareans aren't actually elected. It's true that some moms request a cesarean early in their pregnancy. These "maternal request" cesareans—which are by far the safest type—are frequently reported in the media yet account for a tiny number of "elective" cesareans. Many women who have a "repeat elective" because they had a cesarean with their previous delivery and are never given the option of a vaginal delivery. Many hospitals and doctors won't assist vaginal deliveries for women who previously had a cesarean. In states where midwives are illegal or legally barred from assisting women who previously had a cesarean, women who desire a vaginal delivery must locate a hospital that will perform one, or travel to another state with different midwifery laws. Those who can't travel are essentially forced into "elective" cesareans, despite mounting evidence that repeat cesareans actually increase the likelihood of maternal death when compared to a vaginal delivery, even for women who previously had a cesarean.

Meanwhile, first-time moms are told that if they pass their due date, they need to either be induced or schedule an "elective" cesarean. One woman who I recently interviewed told me that her doctor informed her—two days before her due date—that she should schedule a c-section. His reason was that if she passes her due date, she will need to be induced, and if she's induced, there's a 75% chance that she'll end up having an emergency cesarean (a totally made-up number), which he explained are dangerous. Frightened by this hypothetical scenario, the woman agreed to schedule a cesarean—before her due date, and with absolutely no medical indication. "I didn't question the doctor's recommendation; I just assumed there was a good reason for it," she told me.

In "The C-section Boom," a recent article in Boston Globe Magazine, obstetrician Adam Wolfberg wrote that, "the truth is, an obstetrician can persuade almost any patient at any time that a caesarean is the best choice," and that "some cesareans are done for the wrong reasons: a fear of litigation or a doctor's convenience."

OBs are more likely to be sued after a poor infant outcome than after a poor maternal outcome, and cesareans are more likely to prevent various types of infant outcomes while upping the risks to mom. "The statistical translation of this fear (of litigation)," Dr. Wolfberg wrote, "is the rise in the number of caesareans done for 'fetal distress'—20 percent in seven years ... Babies aren't having more 'distress'; doctors are just more likely to make this diagnosis and operate because of it."

In many situations, cesareans are safer for baby and more dangerous for mom. Does anybody tell mom about this? No. Are women told that an epidural will increase the likelihood that they'll undergo an emergency cesarean? Not usually. Are moms told that if they're given an epidural, they'll almost certainly get an episiotomy as well? Not always. Indeed, some OBs perform episiotomies without warning, and there are stories of doctors who tell mom there was "tearing" instead of disclosing the episiotomy.

Up All Night's birth episode was realistic. Reagan and Chris' acceptance that an emergency cesarean was necessary reflects real-world attitudes about control and childbirth. Informed consent during childbirth care is not a well-publicized issue, and complaints about treatment during childbirth care are met with the same response: well-educated white women—women like Reagan—have a control problem, and if they complain about their experience, it means they're unappreciative of modern medicine. Few seem to notice that those who aren't like Reagan (people of color, queer people, people with disabilities, uninsured people, etc.) also face problems (far worse problems) in childbirth care; they're just not in a position to complain about it. Perhaps the biggest challenge in fighting injustices in childbirth care is that women themselves have accepted the prevailing attitudes toward maternal complaints, and very serious problems in childbirth care have rather successfully been ignored and deflected by our culture's glee in casting women as control freaks.

For comprehensive, evidence-based information and resources for planning labor and birth, visit http://www.childbirthconnection.org/—and spread the word!

Pushed: The Painful Truth About Childbirth And Modern Maternity Care is an excellent resource if you want to learn more about contemporary problems in childbirth care, as is The Business of Being Born .

Click here to support the Maternal Health Accountability Act of 2011.

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Comments

43 comments have been made. Commenting is set to read-only for this post.

Thank you! This is just what

Thank you! This is just what I wanted to say while watching the episode ;) It's so frustrating watch someone act out what I'm sure so many women have gone through & have them play it as though it's "normal" & "what's best" :(

great analysis

Great post. It's amazing that in this day and age, a woman in control of a situation is just too scary to deal with for what (I assume) are the mostly male writers who come up with this stuff.

Up All Night Writers

This episode was actually written by a woman, and the series is created by Emily Spivey. I think the uncommon inclusion of a cesarean section plot was due to the women behind the scenes---the control issue is ubiquitous in childbirth scenes, it seems, not matter who does the writing. Overall, this episode was actually notable (in a positive way, I think) for its complete departure from formulaic portrayals of childbirth.

Katherine Don

Could you elaborate on what

Could you elaborate on what you think was a "complete departure from formulaic portrayals of childbirth"? It seems many parts of the episode (disgust at watching a birth video/looking at the mirror, the hospital environment itself, poking fun at a woman's birth plan, 'you don't need to be a hero' dismissal of natural birth,'doctor knows best' attitude, and eventual c-section) seem quite typical in the portrayal of childbirth in the media. And that "too big of head" was portrayed as the reason for her c-section with no mention of the influence of the epidural is just perpetuating a "women's bodies are broken" attitude. As noted in the post, actual cephalopelvic disproportion is quite rare, though it is often used to justify a cesarean. While I appreciated that Reagan had a pretty relaxed attitude for most of the episode, I think an episode portraying a woman who gives birth naturally with a doctor or midwife as an assistant and support person and not a "rescuer" would have been much more "notable (in a positive way)".

KimBG---you're right.

KimBG---you're right. "Complete departure" was too generous. I've watched so many childbirth scenes (in tv/movies) during the past two months that anything that's even a little different from the typical formula (water break, rush to hospital, screaming vaginal birth, cursing at the father) seems like a departure. The main differences with this episode were 1) no rush to hospital, screaming etc, and 2) cesareans are shown very very infrequently. But all the other stuff you mentioned it totally in line with typical media representations.

Katherine Don

I actually read somewhere

I actually read somewhere that the actual birth experience was based on Christina Applegate's own experience. ? Which makes almost...Worse. That she could possibly have been treated that way by a spouse & medical staff.

Right on, could we say more?

I really appreciate this post as the issue of birth choice inevitably effects all people at least once in their life. I took a class last semester, in the spring of 2011, entitled Birth and Becoming which was a Special Topics class in Interdisciplinary Studies. At least half of the class was focused on the history and practice of birthing from a primarily anthropological perspective. It was made abundantly clear that the patriarchal overtaking of birth and the ingression of biomedicalized birth actually increased the rate of maternal and infant death from 1920 on. Overwhelmingly when left to our own devices, women's bodies give birth without inclement health risk (not to say having a practiced and knowledgeable midwife, nurse midwife, or whomever you trust with your bodyhood present is in any way unnecessary). Likewise each time I menstruate, digest food, or drive a car (other common bodily happenings) I do not find it necessary to make my way to the nearest E.R. or M.D. However much biomedicine-as-guru of the body (AS A WHOLE) is the "norm" today, Let it be said that the first person responsible for their health is the individual. Period.
A second point I would like to highlight is that anyone looking to inform themselves about birth practices would eventually access literature espousing the health benefits for mother, child, and family as a whole (humanity) of home or natural birth with a midwife. And thus, the portrayal of intelligent women and their families choosing on-your-back medical birth is not congruent with the character's persona, nor reality at large. This came up for me during Michaela Conlin's character Angela Montenegro give birth on Bones last season. A character that is portrayed as relatively empowered, free thinking, and, dare I say, feminist. WTF.
Lastly, the psychological implications of cesarean birth on the child are anything but healthy or safe. The literature around birth trauma, which many of us are unconsciously affected by for our whole lives, is rather enlightening as to the effects of medicalized birth. One way or another, you are usually separated from your mom and washed, pricked, and labled before you can return to the one thing most usually inclined to greet you with love and affection upon your first take of the world. I'm not sure how it is now, but I had to be isolated from my mom for an hour while she recovered from the surgery. In any case, it is something to consider.

Yes. Great article. Birth is

Yes. Great article. Birth is a natural process. Western medicine has a limited place in that; yes, it is capable of saving lives but it is malpractice insurance rates and the fears of being sued (as mentioned in the article) that have doctors cutting women open left and right - in any typical for-profit hospital in the U.S., the real need to perform a c-section is rare.

I was raised by a midwife and had two natural homebirths. My first daughter was born in 4 hours and my second daughter was born in 2.5 hours. I strongly believe that because I was raised outside of the culture of fear surrounding birth that this led me to be confident in myself and in my body, which allowed me to have fast and normal births. I even resisted my own mother's attempts to break my water, wanting zero interventions. She did not break my water and labor proceded according to my desires and instincts.

Women are taught to supress and question their instincts. It is time to reclaim our instincts and our bodies, and take them out of the male-dominated medical model of Western medicine. It is time to start asking questions, pushing back when we are told we don't have a choice, and requiring support of of the people in the birthing room.

Used up like salmon

Great, Katherine!
In some of my reading about Dr. Joseph DeLee, I found that he once pondered whether or not human women giving birth were meant to "be used up like salmon" during spawning. As a former assistant to a homebirth midwife and a soon-to-be nurse, I will say that Dr. DeLee's attitude persists in the hospital model of birth: the unpredictable course of natural labor must be taken control of--they don't know how to handle it otherwise.

I really love this series on

I really love this series on childbirth!

You should watch the most recent episode of Being Erica ("Please, Please Tell Me Now"). Erica's sister had her baby at home and it was really wonderful! The only person who was panicking was grandpa, who thought it was ridiculous that his daughter, a doctor, wasn't having her child in a hospital.

I am so addicted to Being

I am so addicted to Being Erica. Are you in Canada? They don't have the new season on Hulu yet!

I am so tired of watching

I am so tired of watching women succumb to their OB/GYNs. I hear so many stories of "I needed to have this done because of..." when, I suspect, the because of is nothing more than a medicalized system that wants to control labor/delivery.

I had a doctor tell me that 90% of first time mothers REQUIRE episiotomies. I had the vagina (as Ms. White would say) to walk out of her office.

Being 7 months pregnant, living in a rural area and having no doctor, I found midwives. I had a healthy, natural delivery of child one. Five years later, I had a healthy, full-term delivery of twins -- again with my midwives. The doctor (who had to be on hand) was told to keep his ass out of the way and he could sit at the other end of the room.

Having him on hand "just in case" wasn't a bad thing, but like so many other things we women have to multi-task. We can't just, in many situations, relax and focus on giving birth. No. We have to give birth with an eye towards protecting our bodies and fighting for our bodies as well as our children.

Thank you!

I honestly think I may die of excitement over seeing such a perfectly accurate, passionate, and well-informed piece on maternity care in this "mainstream" feminist zine. I think I now LOVE Bitch Magazine. My peers and I have been writing about these issues for YEARS, and have almost never seen any other feminist zine address the actual problems without immediately throwing out some sort of childish "but birth is grody" kind of comments. These are REAL issues, and very serious feminist issues, yet most young feminists will not touch the subject without making it out to be the woman's fault for having children to begin with. That attitude is why my blog was born nearly 5 years ago, and (presumably) accounts for its popularity. We're missing real discussions about the maternity care crisis from most feminist discourse. THANK YOU.

Feminist/Activist/VBAC Mother of 2 Boys and a baby girl, born at home.

So important to note that

So important to note that your baby girl was "born at home".

I agreed with ALMOST

I agreed with ALMOST everything in this article, but this right here: Are moms told that if they’re given an epidural, they’ll almost certainly get an episiotomy as well?.

I have no idea if an epidural increases your chances of getting an episiotomy but it sounds like this is a doctor's call that has nothing to do with the actual epidural. Out of everyone I know that has had an epidural, and that is the vast majority of the people I know with children (let's say 15 people), only two of them got episiotomies. I had an epidural, I did not have an episiotomy and I didn't even have a single freakin tear. My doctor let me push for 2.5 hours and did nothing but cheer me along the way. Doctors need better training. Women have the right to pain management if they want it, and medicine needs to be better equipped how to coach these women to have a baby without anyone expecting a totally pain-free birth. It's BIRTH for crying out loud.

Not true at all

Episiotomy rates have been dropping like a stone. At major hospitals, it's now more like 15% (despite epi rates of 90% at the same hospitals!) The idea that everyone's going to get cut is out of date (and any OB who still does routine episiotomy is also not with the times).

Episiotomy rates vary

Episiotomy rates vary significantly in different hospitals and different states. This chart from Jersey shows how incredibly the policies at specific hospitals affect rates: http://www.icanofnj.com/hospitalepisiotomyrate.htm Episiotomy rates "dropped like a stone" in the '70s; the numbers have been fluctuating around 25% (average with strong regional variations) since that time.

Katherine Don

Episiotomies -- notes from the author

I apologize for saying "almost certainly;" that was an irresponsible and (unintentionally) misleading use of words. Receiving an epidural DOES NOT mean that you'll "almost certainly" get an episiotomy. The likelihood of both depends very much on the practices of your individual health provider, and the specific polices at your hospital. However, studies show that an epidural DOES increase the likelihood you'll also have an episiotomy. Here are links to several relevant studies, and coverage of these studies: http://www.jabfm.org/content/16/1/1.full ---- http://www.ncbi.nlm.nih.gov/pubmed/10432139 ---- http://www.aafp.org/afp/2003/0615/p2595.html ---- http://jama.ama-assn.org/content/293/17/2141.abstract ---- http://health.nytimes.com/health/guides/surgery/episiotomy/overview.html --- http://www.ncbi.nlm.nih.gov/pubmed/11392600.

Receiving an epidural makes it more difficult to control one's pushing. Thus, after a woman receives an epidural, it's more likely the birth attendant will judge an episiotomy to be necessary. Further, an epidural acts effectively as the analgesia for the episiotomy procedure itself. For this reason, some providers do the two together as part of their routine practice. I want to clarify that I'm not "against" epidurals. Indeed, over in the UK, there's a big problem with women being denied epidurals. Rather, I'm "against" the absence of informed consent. I also think a greater variety of pain relief methods should be available for women in childbirth.

Unfortunately, there isn't reliable national data on the connection between epidurals and episiotomies, because there is no federal requirement to report this information. And there have been very few studies. I've found the lack of information downright scandalous. The rates of epidural and episiotomy -- as well as the connection between the two --- vary WIDELY from state to state and hospital to hospital. It's best to ask your healthcare provider about their own individual episiotomy rates and preferences in practice. If you'd like better data collection on episiotomies and other procedures during childbirth care, please support the Maternal Health Accountability Act -- http://blog.amnestyusa.org/women/tell-congress-pass-maternal-health-acco...

Katherine Don

Thank you for this. It

Thank you for this. It bothers me how aware many women are becoming of situations where they are being undermined and controlled, but even many strong, loud feminists will surrender to a doctor without second thought, even though if you look at the research, in most cases of normal birth, they tend to be full of shit in this country. I hope more women see the control for the doctors sake for what it is and stand strong and know ahead of time what their options are and in what cases interventions would truly be needed.

What happened to natural childbirth???

24 years ago when I had my first child, there was never even a mention of an epidural.I took care of myself, ate well (no worries from my OB about gaining weight) but when I went into labor, he tried to give me something to speed it along! I had been at the hospital for an hour and apparently he had another engagement, because he wanted me to get that baby out! I absolutely refused - to the point of threatening to go to another hospital in their gown. End of argument and 2 hours later my healthy son was born. YES 3 hours total labor and delivery for my firstborn. No epidural, no episiotomy. I always believed this is what all those lady parts are for...so do what nature does and let it happen. My second child was attended by another OB (best decision I made was firing my other OB...and yes, you can do that!) Again, no drugs, no drama -- unless you count the mad dash to get to the hospital 22 minutes before he was born. THAT was a bit dramatic. Should have stayed home.

Now I see my young friends having babies of their own and ALL of them just assume they will have an epidural. No natural childbirth in this generation. Why? As this article points out, doctors making decisions for the mother. NOT for the mother's health, but to protect the dr. I've even seen an Easter Seals billboard urging mothers to wait until their babies are ready to be born rather than scheduling the delivery to fit into their lives! What is wrong with people??? The height of selfishness is to hurry your due date because you have an event coming up! And what OB would agree to this? Take responsibility for your own health and the health of your baby. Natural birth, no drugs, and breastmilk. Just 3 things you can do to start your child's life. Seems like very little to ask...but you need to fight for it.

Thanks for the article!

Another good resource

Henci Goer's The Thinking Woman's Guide to a Better Birth, which is basically a digest of medical literature and divided by topic (breech, induction, IV, EFM, and so on). From an anthropological perspective I recommend Robbie Davis-Floyd's Birth as an American Rite of Passage.

It is very frustrating how childbearing women are treated in most hospitals. They are subjected to many interventions and the resulting risks as a matter of routine rather than for a true medical indication. The culture's deeply held beliefs about mothers, doctors/authority, superiority of technology over nature, etc make it hard for a woman to demand and receive evidence-based care. I wish there were a simple, quick answer. For me it was to pay out of pocket to birth my first (and so far only) child at home attended by a Certified Professional Midwife, but I realize my privilege and know that's not possible for everyone. Despite the enormous cost savings my insurance and husband's employer refuse to cover out of hospital birth services.

Natural childbirth advocates obsessed with TV shows.

There's a new meme in the world of natural childbirth and it is getting a great deal of play. Childbirth is not inherently dangerous; its depictions in popular media like TV shows and movies tricks women into believing that childbirth is has significant risks and extremely painful. Hence the otherwise inexplicable preoccupation by natural childbirth (NCB) advocates with how childbirth is portrayed in specific TV shows and movies.

On the surface, it sounds intriguing, cutting edge and thought provoking. In reality, it is the same dreary sexism masquerading as midwifery theory. You know those silly women! They can't be trusted to understand the risks of childbirth or to perceive their own pain. It's all in their heads. They're all hysterical ... and we know that hysteria, a form of emotional reaction based on distorted thinking, starts in the uterus.

No one would suggest (or would dare suggest) that benign prostatic hypertrophy is a problem created by the media, or that men's pain is an illusion fostered by the media. I haven't seen any theories that preventative care for men at risk of heart attack is scaremongering, but I've seen a lot of articles like this denying the very real risks to babies and women posed by childbirth itself and insisting that the preventative care of modern obstetrics is nothing but a fiction created by doctors to enrich themselves.

The author of this piece seems entirely unaware that childbirth is and has always been, in every time place and culture, one of the leading causes of death of young women or that the day of birth is the most dangerous day of the 18 years of childbirth. The author seems entirely unaware that in the past 100 years, modern obstetrics has lowered the neonatal mortality rate by 90% and the maternal mortality rate. The author doesn't get it at all: childbirth seems safe to her BECAUSE of the interventions of modern obstetrics, not in spite of them.

Dear Dr. Amy: I don't believe

Dear Dr. Amy: I don't believe I made any statements about whether childbirth is or isn't "inherently" safe, inherently dangerous, etc. etc. Nowhere in this article did I align myself with the natural birth movement. Nowhere did I say that all obstetrical interventions are bad. Indeed, as I'm sure you are aware, some countries with very high cesarean rates have excellent maternal and infant outcomes. Unfortunately, when I write about this topic, folks have a tendency to project their own issues onto it and put words into my mouth. I am not "for" or "against" obstetrics. But if you think that the field of obstetrics, by sheer virtue of being a medical profession, is immune to criticism, then we have a very, very, very, very serious problem. There are good practices and bad practices. There are trends in practice. There are societal forces that affect outcomes. I hope you'll not automatically dismiss everything that you think might be aligned with NCB advocacy. That would be rather short-sighted. Clearly you have an issue with this "is childbirth inherently safe or dangerous" thing, and I hope it doesn't influence your practice of medicine.

I take great issue with the fact that you wrote "childbirth seems safe to her because...." when you know nothing about my personal beliefs about the relative safety of childbirth. In this article, I discussed specific practices that are often performed in the absence of informed consent. If I had more space, I would have elaborated upon how the overuse of these practices is making childbirth less safe. I would have given statistics and cited studies, which I'm sure you're found of.

I also discussed practices that are contributing to the rising maternal mortality and morbidity rates in the United States. These rates change over time. They don't exist in a vacuum. Obviously they don't. When they change for the worse, it's important to examine why. It is YOU who responded with irrelevant ideological arguments.

Katherine Don

Dear Bitch Readers

If you happen to have caught the above exchange between myself and Dr. Amy, check out her website: http://skepticalob.blogspot.com/
This is such an explicit example of an advocate unable to read what is before her eyes or process information that is not black and white. Her response was clearly not to my actual article or the content of the article. It was to some composite "natural birth advocate" person that she's arguing with in her head.

Katherine Don

Your empirical claims are false

Ms. Don,

Your article is filled with a series of empirical claims that are flat out false, and that come directly from the NCB movement. You provide no scientific evidence for any of your claims. I'd be happy to debate any of your specific empirical claims and provide the appropriate scientific papers to demonstrate that your claims are false.

Please don't presume to tell women about the risks of childbirth interventions when you have not read the scientific literature and instead are relying on websites and publications produced for lay people by special interest groups such as the Childbirth Connection.

I didn't realize that the

I didn't realize that the National Institute of Health, Amnesty International and the World Health Organization are all in the pocket of the "NCB movement." The "special interest groups" (ahem, ACOG) that tend to champion your particular interpretations of the data have all the money, lobbyists and legislation on their side, so don't worry about me and my truth-telling here. And I don't know why you presume to know what I have and haven't read (me no understand science). Frankly, quibbles about the scientific literature grow very tiresome, but I see on your website that this is your specialty. I like your headline about the Birthplace Study: "Homebirth increases the risk of death." I really enjoyed which findings you chose to include in your write-up. Folks on both sides of the debate are coming to very curious conclusions based on this study. I love how it's so much easier to lie with numbers than with words.

Katherine Don

I have my issues with Dr.

I have my issues with Dr. Amy, but you did make some errors in this piece.

Factually: There is no state where "midwives are illegal." In some states, non-nurse midwives are not licensed. ALL states license Certified Nurse Midwives. As I mentioned above, an epidural does not guarantee an episiotomy. The stats simply don't bear it out. (NYS includes episiotomies in its maternity statistics; you can check them if you like.) "Emergency" CS does not mean, and has never meant, life threatening emergency. It means unscheduled. (By the same token, elective means scheduled, not medically unnecessary.) My first section, which wasn't performed in the US, was coded emergent even though I wasn't even in labor.

More fundamentally, you've conflated obstetric interventions with control and lack of empowerment, and natural birth with making empowered choices. I've had two Caesarean sections (one horrible but medically necessary, the second much better) and I can tell you this: Empowerment comes from working with your providers and making informed decisions. The interventions themselves are neutral. I had the same outcome in both pregnancies, but my first was horrible because my providers (OBs and midwives, by the way) treated me as ignorant and did not lay out the facts. I would have chosen a CS willingly, knowing what I do now, if only they had actually explained what was going on. Your piece would have been a much more powerful statement on feminism and birth if you had focused on the power dynamic, how that is navigated, and how women can become genuinely informed and able to participate in their own care. Instead, you looked at interventions, with the assumption that they should be avoided, and how they're foisted on women. Obstetricians these days are increasingly female (something like 80% of OB residents are women). OB is no longer simply the patriarchy imposing its views on women, and I don't think we can dismiss this change as women buying into the existing culture.

Birth isn't all that safe. I've got two complicated pregnancies to prove it. I'm sick of the argument (in these comments) that natural birth is empowered, while women who have Caesareans are simply sheep who give in to pressure from their obstetricians. Yes, it's wrong that in many areas women are not offered the choice of whether to have an RCS or a VBAC. That doesn't mean that everyone who has an RCS did so under duress. My OB was completely willing to leave it up to me unless I required early delivery. I started the pregnancy planning a VBAC, and I changed my mind. I was the one who decided that in my particular scenario, with my particular risk factors (high blood pressure and a history of severe preeclampsia) I was not willing to continue the pregnancy past 39 weeks. I made an empowered decision to have a section, and some people can't accept that that's what I did.

The specific reference to

The specific reference to midwives in my article was clearly -- in context -- a reference to direct entry and CPMs. I was, after all, talking about women who are seeking an out-of-hospital birth because their hospital doesn't do VBAC. And yes, CPMs are prohibited by statute, judicial interpretation, or stricture of practice in several states. For a state-by-state breakdown, look at this chart: http://mana.org/statechart.html. Also, in Nebraska and Alabama, it's a felony offense for CNMs (the NURSE midwives) to be present at a home birth.

I take great offense at your accusation that I conflated "obstetric interventions with control and lack of empowerment." I was writing about specific interventions, the possible overuse of interventions, and the absence of informed consent. We have a huge problem when ANY critique of obstetrical practices are conflated with being against ALL obstetrical practices. A huge problem. The recent attempts to reduce iatrogenic deaths in intensive care units, for example, were never, ever met with accusations of being "against intensive care units."

I also did not -- once -- mention the natural birth movement in my article, nor did I voice any support whatsoever of natural births. Nor did I say that everyone who has an RCS does so under duress. I advocated for CHOICE and policies that ALLOW CHOICE. Many individual hospitals and doctors allow for choice, and that is good. I am talking about those that don't allow it. I understand that there can be a problem with the natural birth movement making women feel guilty or disempowered for having a C-section. I suspect this is something you have experienced, and that sucks. I think this is a big, big problem. But please don't react to that by putting words into my mouth or disallowing me to discuss the specific problem that, as you yourself wrote, "it's wrong that in many areas women are not offered the choice of whether to have an RCS or a VBAC."

Katherine Don

Did you see the part where I

Did you see the part where I said "in these comments"? If you read them, you'll see some deploring women who are simply led on by their own OBs, or (my favorite) that our children are psychologically traumatized.

Your phrasing was not at at all clear that you only meant non-nurse midwives. In some states (including my own) CNMs perform OOH deliveries (I'm familiar with the legal status of midwives in various states, BTW). This deliberate confusion is something Dr. Amy herself has been called out for.

And you're right: you didn't

And you're right: you didn't mention the natural birth movement in your post. And, I may have been slightly cranky when I posted because of some of the comments. However, indirectly, you did. Your sources are NCB based: Pushed, Childbirth Connection, The Business of Being Born. You're using the talking points of natural birth. This is, in some ways, an unfortunate consequence of how childbirth is discussed. It's polarized. The NCBers are the ones using the language of choice and empowerment, and the ones claiming to help you make informed choices. The "pregnant woman being manipulated by her OB" has become a cliche of natural childbirth--as some of these comments show. If you go looking for pregnancy information, you have two types: the execrable What To Expect et al (scaremongering) or natural childbirth--Henci Goer, Ina May Gaskin, et al. If you don't want to just take everything your OB says at his or her word, you're pretty much left with the latter, unless you want to do research on your own--and good luck with that. Either you're told OBs are out to get you, or you should just trust that they know what to do and why are you upset as long as you have a healthy baby? Real empowerment isn't on the agenda.

You said above that you don't understand science. You're not alone. Most people don't, and while I've become significantly more scientifically literate, I'm no scientist. When we want to know why, we rely on others to break it down for us. If you want to know why and be an active participant, what's more attractive? A book that gives you statistics, explanations, and citations, or one that simply tells you what the doctor might do?

I am in favor of choices. I am in favor of empowerment. I think that the natural childbirth movement was part of a necessary process whereby women became more than just passive participants in the birth process. But I think we're stuck in a rut with how we discuss birth. Either people don't understand why RCS vs. VBAC was a real dilemma for me, or they think I got suckered. Pretty much every birth discussion I've ever witnessed online has turned into NCB vs. Everything Else. I think we need a third option. It's why I don't like NCB and I'm not really a Dr. Amy fan either.

On Source Accusations

Alexis: You wrote that my sources are "NCB based," whatever that means. In my article, I linked to the following sources: 1) An LA Times article on the (scientific) findings of the California Pregnancy-related Mortality Review,
2) The Medscape.com article on macrosomia, 3) The about.com article on "what to do if you're denied a VBAC, 4) The National Institute of Health's (scientific!) findings at their VBAC conference, 5) A Boston Globe Magazine article written by an obstetrician, 6) The Childbirth Connection page on VBAC (CC, incidentally, is decidedly not part of the "NCB movement." Indeed, it's been around since 1918, before the movement existed), 7) '"Pushed" is a book of investigative science journalism overbrimming with scientific studies and interviews with OBs, 8) The Business of Being Born (this is the only one that vaguely fits your theories about my "NCB" allegiance)

Also, I was being sarcastic with the good doctor Amy when I wrote "me no understand science." I agree with you that the public is at the mercy of scientific literate folks to break things down, and that the polarization of talks about childbirth is very problematic, because the folks breaking it down are often advocates who want to force women to give birth in a certain way. And Dr. Amy is the worst example of intentionally "translating" the scientific literature in misleading ways. If you think I did that, I apologize, but I approach this issue as a journalist and an essayist, and I do my best to provide my readers with what I consider to be good sources.

In the end, I think we're probably in agreement with each other. Comments sections aren't the best venue to hash things out. I'm sorry that ideologically-driven folks have caused you woe and made you feel bad about your decisions. VBAC versus section is indeed a difficult decision; I am arguing that women should have access to both, should be better educated by their healthcare providers, and should not ever, ever, ever be subject to situations in which their own health is jeopardized in the name of efficiency and litigation avoidance.

Katherine Don

Anecdotes

I can't help but point out that you give much weight to anecdotal evidence, exactly what is so often criticized in childbirth choices debates. You assert that "Birth isn't all that safe" because you have had "two complicated pregnancies". Two complicated pregnancies prove nothing. Even a large study sample with adequate statistical power would not "prove" or "disprove" that birth is safe.

What it comes down to, is that no matter how small the risks or percentage of women and babies affected by adverse health outcomes, it is awful for the individual (the woman, her family, her health providers). No one wants adverse outcomes and everyone wants to be in the safest environment. For some women, that is a hospital. For others, it is a birth center or their own home. I am sorry your pregnancies and births were difficult. And I think it is wonderful that you felt knowledgeable, respected, and empowered to make informed, consensual decisions.

Safety

You're right, n=2 is not statistically significant. I personally have issues with the assumptions that women will be low risk and can plan her pregnancy accordingly. Pretty much every other high risk woman I know was left feeling completely alienated by that, and it only takes a single contrary case to disprove a blanket statement like "birth is safe." However, the mantra that "birth is safe" can be pretty conclusively disproven by both historical mortality and conditions in countries that lack access to modern maternity care. Birth is safe enough today because we know how to manage complications and don't assume that it will go perfectly by itself. Sometimes it will, but often enough, it won't. Mother Nature doesn't always demand perfection. She's satisfied with "good enough." If some mothers and babies die in childbirth, the species is still perpetuated. Being smug about birth is a privilege we're lucky to have living in the 21st century developed world. I know too many women and babies who would be dead without the care we have available today. (I'm not playing the fear card; one of the things about having a complicated pregnancy is that you meet a lot of other women who did.) That doesn't mean we all need the care I've had--I'm not disagreeing there! I'm genuinely happy when women have easy pregnancies. I would have been happy to have them myself. People just need to have a little humility and perspective, and not blame women for trusting their doctors or not taking responsibility for themselves when things don't turn out to be simple.

The studies on home birth state that at best, with the lowest risk women, home birth has comparable outcomes to hospital birth, with lower rates of intervention. The oft quoted claim that "home birth is safer" (some right here in this post) isn't true. If someone wants to plan a home birth with a qualified attendant knowing that, and aware of the real possibility, however slim, that a genuine emergency may arise, I have no problem with that. What I have a problem with is the mindless spouting of "birth is safe, and you should just avoid doctors" that's cropped up in these comments.

Childbirth is safe natural and not all that difficult

There will always be some, like the poster above, who is well known to be against the idea of birth being a natural normal event. Those who try to frighten women about the dangers of childbirth are not doing you any favors. Don't buy it. The reason we are somewhat safer today than 100 years ago is that we know more about germs and have antibiotics to treat them. When a Cesarean section is truly necessary, they can be done more efficiently and safely than formerly. The interventions considered normal today, are actually often dangerous to mother and baby. Our statistics are terrible in the United States. Birth, which is a natural event, not a medical emergency, has become MORE dangerous to mother and baby in the last few decades. It is not that BIRTH itself has become more dangerous, it is our system that is causing the problem. The C-section rate (32%) is outrageous. Women must fight for their right to have their babies without interventions starting with induction. Actually, going out the door to head for the hospital is the first intervention to be avoided. In healthy women with no specific risk factors, staying home to have your baby with the aid of a midwife is safest. Do your own research. The information is out there and it is easy to find. Stay away from alarmists who tell you that childbirth is the most dangerous thing you will ever do. Find people who TRUST Birth and read everything you can on the subject from that point of view. Some women are simply terrified of birth. They probably won't want to try a home birth. Fine. No one should be coerced into birthing in a way that frightens them. Birth is individual. Accept that every birth is different, don't worry about what your neighbor or friend did. Educate yourself and allow your body to do what it knows how to do instinctively.

"In healthy women with no

"In healthy women with no specific risk factors, staying home to have your baby with the aid of a midwife is safest. Do your own research. The information is out there and it is easy to find."

Tell that to the loss mothers.

http://hurtbyhomebirth.blogspot.com/

"Find people who TRUST Birth and read everything you can on the subject from that point of view."

Because if you read something that doesn't share that point of view, you might make up your own mind and do something incompatible with natural childbirth ideology.

I see the MD after your name

I see the MD after your name and then it makes sense. Your perspective is skewed, your bias evident. Have you had children in a hospital? Have you been a patient in a hospital? Not the one in charge? I hope you don't ever have to have the type of experience that causes so many women (that's sweet you have an acronym for us "NCB") to feel disrespected, pressured, traumatized and yes- angry- about the hospital system of medicalized birth. And the declining MORTALITY around the time of birth coincided with many other developments in modern life at the start of the 20th century, it was NOT due to women moving to the hospital to have birth. Correlation is not causation. However, since birth has become a "disease" and a circus of technology and interventions MORBIDITY has increased and women are being marginalized and mechanized and sliced and diced
.
And those "silly women" you refer to, in the context of TV and media, are characters written overwhelmingly by MEN.

And lastly, you're argument has a gaping flaw. "I've seen a lot of articles like this denying the very real risks to babies and women posed by childbirth itself and insisting that the preventative care of modern obstetrics is nothing but a fiction created by doctors to enrich themselves." Now here again is where your bias shows, this article (and most of this nature by "NCB''s) are not speaking of the "preventative care" of obstetrics, because that's absurd. That actually made me laugh. Do you mean incessant ultrasounds at every visit? Every diagnostic test known to man given to every woman regardless of her history, health, need or desire for them? The 5 minute visits where no questions are asked or answered answered? Or the 5 minute visits when C-section's are scheduled at 39/5 because the mom is "overdue"? The only thing standard obstetric care prevents is actual human caring between the OB and expectant mother.
Or are you saying that C-sections are "preventative care"? That is the ultimate destination of the view that accepts childbirth as a disease and as a set of risks rather than as an event in a woman's life which 90% of the time goes just beautifully without anyone doing anything, or would if it were allowed to.
Your own emphasis on the pain and risk gives away your fear of birth. No one said those things don't exist, but they are not the defining facts of birth.

Yes, Dr. Amy has had 4

Yes, Dr. Amy has had 4 children, all in the hospital. Two of them were even natural births. What difference does it make?

And CS is preventative care: " Preventive medicine or preventive care refers to measures taken to prevent diseases, [1] (or injuries) rather than curing them or treating their symptoms." There are many injuries from childbirth, for both mother and baby, that can be prevented by CS, thus it is preventative care.

I thought the whole premise of the show was that she *is*

a control freak and that this baby is going to change that but good.

So the angle is consistent with what I would expect to see for this character. She is described in all the info junkets as a "type A personality" character that will get her holy comeuppance once the child is born. It would start at labor and delivery, no? Childbirth and our resulting care is out of or control, no matter how much we would like to script it otherwise. Forces work to have us bend to their will. This is the lesson this character is supposed to learn based on the idea for the sitcom.

From Dr. Amy, and attributed

From Dr. Amy, and attributed from natural birth advocates to TV characters(?!):
"It's all in their heads. They're all hysterical ... and we know that hysteria, a form of emotional reaction based on distorted thinking, starts in the uterus." It seems she is implying that natural birth advocates are sexist ("the same old dreary sexism") because they "deny that childbirth is painful" or has any risks at all. Other than not knowing where on earth she's getting that from (the composite foe in her head), in her vitriol towards this vicious, crusading "NCB" she, herself, is resting on the same dismissive paternalism she accuses others of. Apparently, supporters of non-medicalized birth are utterly hysterical and out to get you.

The Dr is Out

Just thought I would point out that (Dr.) Amy hasn't actually practiced medicine in over 10 years (or otherwise been involved in obstetrics/health/childbirth research, etc.). It is also a bit of a mystery as to whether she continues to renew her license to practice medicine or use her MD title. I've tried asking through her website, but no answers. She literally spends her time picking fights anywhere childbirth choices are brought up. It is quite sad.

Yes I saw her website last

Yes I saw her website last night. I was really taken aback by the level of aggression! It's a seriously hateful website. It's a shame because she does actually have a few valid points (on the website, not in these comments) but they are buried in a bunch of really vile name-calling and condescension. She literally thinks anyone who has ever chosen homebirth is a complete idiot, a latent baby-murderer or possibly both. OB's are heroes and midwives are monsters. It's like Katherine Don pointed out, if you think that obstetrics is beyond any criticism at all that is a serious, serious problem.

Not sure what letting her

Not sure what letting her license lapse has to do with anything. She's no longer practicing medicine so there's no use in paying to renew it. She is still able to use the titles "Dr." and "MD" without a current license because she has successfully completed her education. She does keep up on current research on her own....don't need a license for that either.

For me, personally, I would

For me, personally, I would feel most in control if I can find an OB willing to give me a maternal request cs. No worrying about how the baby is tolerating labor, no worrying about damage to my vagina or perineum, no labor pains to bother with. I can deal with the recovery from a cs (not to mention my postpartum pain would probably be taken more seriously and handled better after a cs) for the predictability and control of a cs. Also, as you mentioned, they tend to be safest for baby.