03 December 2008

Birthing Babies

My sister and I watched The Business of Being Born the other night. Between us, we've had two C-sections and two vaginal births (one of the former for me, the rest for her), and we're both busy firing off information to our pregnant sister-in-law, who is planning to use a midwife for her delivery. I like to think that we are reasonably enlightened women with a pretty good sense of the choices involved in pregnancy and delivery, but man, some of the statistics in that documentary are hair-raising.

  • Among 33 industrialized nations, the United States [has] the second worst newborn death rate in the developed world.
  • In the five countries with the lowest infant mortality rates -- Japan, Singapore, Sweden, Finland and Norway – midwives were used as their main source of care for 70 percent of the birthing mothers.
  • Cesarean section is the most commonly performed surgery in the US, at a cost of $14 billion per year.
  • Cesarean-delivery rates are now at an all time high in the United States, standing at 1.2 million, or 29.1 percent of live births in 2004. The increase represents a 40 percent increase in the past 10 years. (In 1970 the rate was 5.5%) In several New York City-area hospitals, the Cesarean-delivery rate is even higher – over 40%.
  • In one 1999 survey, 82% of physicians said they performed a C-section to avoid a negligence claim.
  • Overall, the cesarean section rate for hospitals with nurse-midwifery services was about 13 percent lower than the average cesarean rate for all hospitals.
  • Complications from cesarean surgery and anesthesia [are] the leading causes of maternal death in developed countries, including the United States.

The gist of the documentary is that women in the United States don't make informed choices about their births and that one simple medical intervention (induction) tends to lead to another (pitocin) and another (epidural) and so forth until the doctor says "we must do a C-section for the health of the baby".

I had that kind of interventionist birth, and I'm torn between rationalizing it as justified and wondering if it was avoidable.  I was induced a couple of weeks before my due date because I'd had a couple of bleeding episodes.  Inexorably, the one thing led to another and another, and then I was being wheeled down the hall for the C-section.  Did it have to happen that way?  I just don't know, and that's not the end of it. After the baby was out, I had a post-partum hemorrhage which nearly necessitated a hysterectomy. If I'd had a vaginal birth, and the uterus had done its thing, would that hemorrhage have still happened? Or not? If I'd hemorrhaged after a vaginal birth and not been in the OR, then what?

Halfway through the movie, my OB turned up. Yes, the very woman who cut me open and delivered my baby is interviewed in The Business of Being Born. She comes off squarely in the anti-home birth camp, but she does redeem herself when she says "the risks of a vaginal delivery are much less than a C-section and what most people don’t know is a C-section is major surgery."  Hell yeah, it's major surgery - and apparently it's often unnecessary major surgery.  

The whole thing almost makes me want to run off and become a midwife. But in order to become a midwife, I'd have to become a nurse, and before I can start nursing school, I'd have to do undergraduate work in microbiology and anatomy and statistics and psychology and I just don't think I've got that in me.

Instead, I'll suggest that all women of childbearing age watch The Business of Being Born and/or read Ina May Gaskin's Guide to Childbirth and make an informed decision. Please.

(Note - all those bulleted stats come from the press materials posted on the movie's website.)


FreshHell said...

Sigh. Don't beat yourself up over it. No sense pondering over "what ifs" at this point. I read what I could find and was fortunate to have two unmedicated vaginal births with no complications. I also hired (at some expense) a doula. The same woman both times. She is also a nurse practioner at the kids' pediatrician and its so nice to continue to see her - and she can see the products of her work. She helped me avoid one of those interventionist births. The doc on call thought I'd been in the "no progress" stage for too long and "wanted to use all the tools available to her" to move things along. Move them along for who? Did she have a tee time she was missing? The doula found out that her shift ended in 30 minutes and we waited for the next doc and had the same no-intervention discussion. She was much cooler about it and offered to simply break my water when I'd had enough. I'd been in labor all day. Eventually, I said, yeah, go ahead. She did and Red was born less than an hour later.

Mayberry said...

I had the same kind of birth you did (I mean the this, leading to the that, etc.) and I did waste a lot of time wondering and worrying after. My 2nd time, I attempted a VBAC. I didn't succeed, but just the trying helped me a lot. Oh, and is it a coincidence that my first birth was in NYC? Bet it was at one of those 40%+ hospitals.

She She said...

I have three kids -- C-section, vaginal, vaginal (those aren't their names...). I used midwives for all three for prenatal care and for the births of my second and third children. All of the kids were born in a hospital. Before my first was born, I told my husband that if all went well, we'd have our next baby at home. All I can say is, thank god we were in a hospital. Things can go wrong so quickly. I'm all for women making informed choices, but I hope they keep in mind whose experience the birth really is -- it's the baby's.

Anonymous said...

I wonder, who are these women going in to give birth uniformed? I read more than one book. I chose a midwife.

Not that any of it did me any good: my daughter was footling breech due to an unknown abnormality (bifurcation) in my uterus. I am lucky to have no doubts that c-section was the best course of action. However, the majority of my close friends have had c-sections after "prolonged" labor.

This makes me glad that's all behind me now.

RuthWells said...

With early labor and bedrest in my first pregnancy, I was inclined to do everything the doctors said without questioning, and ended up with a heavily medically managed (epidural, pitocin) vaginal birth. With my second (also high-risk) pregnancy, I went to a midwife practice at a local hospital. Having the medical establishment there as back-up was crucial to my peace of mind, and it enabled me to have the birth experience I wanted: guided by my midwife, it was drug free, episiotamy free, and I was totally conscious and awake for it all.

A few months after birth #2, my midwife practice closed -- the hospital felt they weren't bringing in enough patients to warrant subsidizing the practice.

Which bites.

Awesome Mom said...

I do have to defend that infant mortality statistic. In the US we are more likely to try and save the micro preemies and that really adds a lot of deaths to our infant mortality rate. I think the rate is a bit inflated due to that.

Jennifer (ponderosa) said...

My first child was induced and I've no doubt that it was the right thing to do. I mean, he MIGHT have been fine if I'd waited until term, but he had enough problems that I'm glad I didn't have to take that risk.

My 2nd was induced, too, and even at the time I thought my OB was overreacting. But who am I to question a woman with that much experience and education? I went with it. It turned out ok. (No c-sections.)

Julia said...

You will probably be unsurprised to find out that I have issues with the movie. I have issues with the whole movement. Meaningful birth my ass. And this is from a woman with three vaginal births, two of them without epidural. The one with the epidural was my middle son, who was dead by the time labor was induced. But because of the level of care I had in that pregnancy, I do not ever have to question if there was something that could've been done to prevent his death. I am lucky that way, much luckier than many other dead baby moms.

I love midwives at my practice. I have had more than one meaningful encounter with them. One even delivered my daughter (she came fast and the docs were all busy in the ORs), and she was great. But I hate it when people conflate these midwives, who went through years of schooling and are great at what they do with some of the homebirthing midwives who do not have to have any kind of medical training or certification. Because sometimes you get lucky, and sometimes you don't. And sometimes when you don't babies die. Or mothers die.

Hemorrhage is the leading cause of death among post partum women. This is why when you are in a hospital nurses come to check on you every so often. Your pad, your vitals, etc. Some women still die, but many are saved with quick action.

My youngest son was born at 36weeks 4 days. He had steroid shots when my labor first started at 33.5. In other words, he shouldn't have had breathing issues when he was born. But he did. We ended up in the NICU for a week, because he also had an infection that they found when they tested his blood. A pediatrician was right there when he was born. When it became clear that he was going to need help (about 5-6 mins after he was born), they called for the head pedi from NICU. 5 more minutes later he called for an incubator because it became clear that it wasn't going to be just a special care nursery thing. 15 hours of CPAP. That's what he needed. I wouldn't have had immediate access to it if I was at home, or even at a birthing center. I don't even want to imagine having to rush or transfer an infant. And what of that infection? He got his first dose of antibiotics less than an hour after being born. If he didn't have breathing issues, they might not have caught it that early. But I would've still liked to be in the same place as him when it did manifest itself.

Having said all that, my hospital really is an exception and pretty much an ideal. Only one OB practice, where MFMs, OBs, and CNMs all work together. Even OBs are non-interventionist for the most part. Nurses rock, and are great at supporting unmedicated birth. The other big hospital in the city? Not so much. I can imagine having a bad experience at that hospital, and then looking for a diametrically opposed setting. In case of my youngest, as I discussed above, that would've been unfortunate.

So my whole point, if I can find it with both hands and a flashlight, is that education has to go both ways. Yes, there are crappy doctors out there, but there are also crappy midwives. Yes, some interventions are unwarranted and suck, but some are necessary and save lives. Scare tactics on either side are unfair and dishonest. And also, all hospitals should work at being like mine. If they were, I truly believe a lot fewer people would have traumatic birth experiences, and the outcome statistics would be better (one piece of data that makes me think that is that at my hospital there is a higher rate of delivery by CNMs than the state-wide average, and my hospital is a tertiary care center, meaning that statistic includes transfers of high risk patients).

Unknown said...

I read Ina May Gaskin. I took a course in the Bradley Method. I informed everyone I knew during my pregnancy about the evils of intervention and drugs. I had midwife care and I pre-registered for our hospital's family birthing suite. I was prepared to have the birth of my dreams. I was going to nurse my baby right away and take her home as soon as possible so that I could swaddle her bum in cloth diapers.

What I got after being 10 days overdue, was a premature breaking of the waters, following by 19 excruciating hours of unmedicated, unfruitful labor. The nurses let my tired midwife sleep through my entire labor and by the time she woke up she was too late to help me. I tried to salvage a vaginal delivery with pitocin and an epidural, but Violet wanted nothing to do with pitocin and they had to stop the drip. I was out of time, (it had been 24 hours since my water broke) and they called for a c-section. As if things weren't bad enough, my body rejected the second dose of my epidural and I could feel my toes as I was being wheeled into the OR. I had to be put under general anesthesia and my poor husband was kicked out, with no explanation. No one but the OR staff saw my sweet baby come into the world. That hurt ALMOST as much as the hot, phantom knife that stabbed me for 20 minutes while I waited for my morphine drip in the recovery room. In the end, the doctor assured me that Violet would have needed a bone saw to get herself out of my narrow pelvis. The anesthesiologist apologized so many times, I couldn't be mad at the poor guy. I got a whirlwind tour of the entire modern birthing process. I was sad for a very long time.

Violet was born only a month before Hurricane Katrina happened and I remember seeing a story about a mother who died at the convention center because she went into labor and there was no one to help her. The image haunts me, because if I had been trapped without medical care, Violet and I would have died too.

I don't regret anything now. I met my best friend in that useless Bradley class. But, I do wonder if I should have requested a pelvic x-ray or a more thorough screening before being cleared for a low-risk birth.

I still agree with the whole natural birthing movement, but I'm not much of a poster-girl for it.


Unknown said...

The difficulty, too, is that many statistics are hard to even find on the whole vaginal verses C-section, because many doctors will now refuse flat-out to do a vaginal birth in certain circumstances.

With my third (a breech C-section after two vaginal deliveries), I had difficulty finding reliable statistics about which was more risky for a healthy mother who had had a previous vaginal delivery -- a breech vaginal or a C-section. My research led me to conclude that a C-section was actually still more risky, but by then my conclusion was pointless -- I couldn't find a single person, doctor or midwife, who would deliver a breech baby vaginally because of the fear of malpractice.

The Library Lady said...

I was induced with my first girl because they considered me a high risk pregnancy--which truthfully I wasn't. But the umbilical cord was half the normal length (rare but it happens) and I ended up with the c-section.

With JR they WANTED me to have a VBAC and I did. So I've done it both ways.

You know though, what I tell all the pregnant moms who come to the library is that it doesn't matter which way you do it or whether or not your birthing plan goes up in smoke. What matters is that you are fine and that your baby is fine. And THAT'S a successful delivery. Period.

Vodka Mom said...

I had three c-sections. THREE! Each time I had over 10 hours of labor (24 with the first; ten with the second...) with little or no progession. Yeah, the recovery sucked, but the results were three gorgeous healthy kids.

Anonymous said...

Yup. Excellent movie. Knowledge really is power.

nonlineargirl said...

As a woman who chose to use midwives (in a hospital setting) and who planned on a homebirth before learning about the twins, I feel compelled to say that this move drove me insane. I was really annoyed by the implication that there are two choices, and those choices lead inexorably to super medical intervention or happy, healthy birth. (I hate to say it, but thank goodness the film-maker shows there is sometimes a real need for medical intervention.)

I was annoyed that hospital birth with midwives is not discussed as an option, nor is the fact that the REAL issue is having an educated patient who can speak for what she wants and a competent provider that listens to the woman and does not jump the gun for convenience, etc.

I appreciate that Ricki Lake was moved by her own experiences to make this film, but it felt very heavy handed, especially near the end when the french doctor suggests that a baby born by c-section can not fully bond to her parents because the "love hormone" has not been released by vaginal birth. Um, what about women who use surrogates? What about women who adopt, can they not love their children fully or be fully bonded to them? Bleh.

certainly there was a lot of interesting stuff in the film, and some interesting facts, but oy. I felt as I do watching michael moore movies - something less heavy-handed would be more effective.

Yo-yo Mama said...

No matter what a woman decides, it's all in the preparation and the education.

Yes, it's major surgery and there are lot of people out there who think "opting" for major surgery(like a c-section) is nothing less than suicide with all their hyperbole. If that's so, then there are twice as many people, women AND MEN, who do it every day when they elect for plastic surgery, even if it's to correct a "defect" and for some reason, they aren't being preached to.

To each their own.

Debbie said...

I had my first (twins) by section, my third unmedicated in a Navy hospital, and my fourth in my bedroom. You have to be a strong and assertive woman to homebirth because the culture is opposed to it so much. But, I loved it.
Thanks for stopping by my blog because I am glad to find you.

kathy a. said...

my kids were born in 1987 and 1989. we are still having the same conversations now, and i don't know what to make of that.

my son was a frank breech -- 3 qualified OB/GYN's tried to turn him, pushing starbord, port, and subterranian, and it didn't work. i went into labor before the scheduled c-section, and it all went well, considering i was scared out of my gourd and my husband nearly fainted, not long after he said "your uterus is on your belly now." healthy baby boy! 6 weeks before i could drive -- when they say major surgery, it is.

daughter was a VBAC, and really that went very well, except for being in the hospital for a week while she got bigger after premature labor. and the fact it was at a navy hospital overseas, and the doctor who delivered her didn't believe i was in labor yet [hello! on oxygen for 6 hours, dude, contracting and dilating up a storm!], so i didn't get drugs. i told him to shove it, when he finally showed up after she crowned, and told me to "stop pushing." like i had a choice in the matter. jerk.

kathy a. said...

frank breech means butt down, legs up. there was no way i was risking a vaginal delivery with son.

the mama bird diaries said...

I've heard amazing things about that movie. I've wished a million times that I knew more during my first pregnancy. Excellent post.

shrink on the couch said...

I think the most telling statistic is the one about doctors avoiding lawsuits. Can't blame them really.

I took Bradley classes, was determined to have vaginal births, reduce tearing (husb gave me olive oil massages "down there"), the works. Had two C-sects anyway. Tried to deliver twins v-bac, even, at 40 weeks. No-go (their little feet were tangled together). I was informed, strident and determined, but it wasn't meant to be.

I was comforted by three healthy babies and refuse to dwell in coulda-shoulda-woulda land.

And now? Ten years later? well, no traffic thru the love canal has its advantages. Just sayin'

bernthis said...

I had no choice but to have the c-section. My daughter would have died in utero if I hadn't. That being said, it was a huge operation and a big recovery (I ended up with an infection in my incision) Shoulda, woulda, coulda- I think you're right that all women should have the access to this information.

Jenn @ Juggling Life said...

I had all my kids vaginally in a hospital and with two of them I had epidurals, but not with my younger son (he came very fast). I don't feel like the pain of that delivery added anything to my experience at all.

That said, I think some women really want and need to be more in touch with their bodies throughout the birth process and good information never hurt anyone.

I think the possibility that our infant mortality rate may be a skewed statistic is quite an interesting one. I'd bet that the high humber of uninsured women without prenatal care is a factor also.

Gwen said...

I've learned really interesting things from all the comments and your post, Maggie, even though this baby shop is closed.

I think there must be a little of the same kind of thing involved here that goes on with, say, medicating for mental illness. You hear about people who just want to be a "little happier" and then we feel like it's okay to be judgmental about the entire issue.

So some women make less than well-informed choices or doctors or midwives aren't great, and it becomes this either/or proposition, like Nora was saying above. The reality is usually way more complicated. But maybe that's the underlying problem with statistics: they attempt to find order where it can't numerically exist.

Or maybe the kind of people who need thoughtful education and information aren't the kind who read and comment on blogs of this caliber.

I don't know. I just think, as with most of these issues, we have to make our own best decisions for ourselves and then trust that others are doing the same.

cinnamon gurl said...

My sister hemorrhaged after a c-section and she told me that it's actually much less common after c-sections than vaginal births. In her case, she would have hemorrhaged regardless of how her daughter was born (she had placenta eccreta).

I had an emergency c-section too, after my midwives transferred care because my son was in distress. He had a very short cord so there was no way he could have been born vaginally.

Which has nothing to do with anything really... I do think that low-risk births are best attended by midwives. I think midwives need hospital privileges and women need to make their own choices about where they birth. The research on home birth in Canada is clear that in low-risk situations home birth is at least as safe as hospital births, with fewer infections.

Anonymous said...

That movie had the same effect on me -- I'm actually still considering the midwife thing. I had one birth center birth and one home birth -- and I will say that my homebirth midwife was so much more knowledgable than my more medically oriented birth center midwife. Home birth is amazing -- and keep in mind that midwives are not anti-hospital -- they will take care of you (and they know you better and stay with you throughout the entire labor -- how many docs do that?).

Anonymous said...

i have only one issue with the movement:

at my first birth, my docs assumed i wanted to avoid a section at all costs (although i never said that), and they let me labor for too long before recognizing that there was no other way. i think so many women were making noise about c-sections that they assumed i felt that way.

Maggie May said...

It's so good to get a convo going on this kind of thing.... there is a grey area, and, there are too many c=sections done that are not medically necessary.

Woman in a Window said...

I was induced twice. I would do it all differently now. (I'd have a mid-wife and pay her to have a baby for me.)

Seriously though, if I'd have known all I know now through experience I would do it differently. I'd wait for nature to take its course and get a better doctor.

Mama Cass said...

Thanks for sharing. I was given pitocen with both of my deliveries, as my water broke, and labor was not going quickly enough alone. I am also torn...what would have happened differently had I not been in a hospital? Then again, with my second, there was meconium in the amniotic fluid, and her umbilical cord was wrapped funny, so had I not been in a hospital, things could have ended very differently. I am grateful to have a doctor who helped me deliver vaginally, but also know that had a c-section become necessary (and we were close) I would have been happy it was immediately available.

Aurelia said...

About the stats: we rescue micro-preemies just as often in Canada, and we collect stats the same way they do in the US. (Diff.criteria in some European countries)

Anyway, in Canada we have lower neonatal death rates and a much lower rate of c-sections. Of course, we also have a completely different system of liability insurance, and because we have public health insurance we have lower awards for lawsuits. So docs don't worry about the same lawsuit issues. Plus the government and professional groups have endorsed certain criteria for things like VBAC, so it means Docs are more comfortable saying yes to less interventions.

So, yeah, the US has some way to go.

Just me, but your labour sounds like you did need that section. You likely would have ended up like me with a crash section and hemorrage if you had gone longer. So don't feel too bad. Really, I think you were in the medically necessary camp.

Furrow said...

I entertain midwifery fantasies, myself. For what it's worth, although I got the unmedicated birth I wanted, and had a wonderfully supportive midwife and doula by my side, I sometimes wonder if I might have been more successful at breastfeeding if I hadn't been so intensely focused on and ultimately wiped out from labor and the 2nd degree tear that resulted from premature pushing just to END IT ALREADY. Yeah, it's a stretch, but it's enough to make me contemplate an epidural next time. Which may lead to pitocin which may lead to a section, so maybe not. ARGGHHH!

Furrow said...

And I want to clarify that I had a hospital-based midwife delivery.

kathy a. said...

i have to believe that higher infant mortality in the US is because many, many mothers do not get regular prenatal care, because they are uninsured.

uninsured mothers are not generally going to know their options, or know of problems developing with their pregnancies, unless/until there is a medical emergency. they do not have professional midwives, and doctors dealing with birthing in the ER are not going to have the relationship with the mothers or the chance to fully educate them about choices under those circumstances.

i also think it is important to remember that throughout history, it was common for women to lose babies via miscarriage, birth accident, etc., and not uncommon for women to die in childbirth. the majority of births, perhaps, happen safely, naturally, normally, with everyone alive -- but that is not true for everyone, not even today.

my first cousin, born in 1965, has lifelong mental disabilities due to a birth accident -- his brain was deprived of oxygen because the cord was wrapped around his neck. that is an accident that probably would be preventable today.

my baby sister was born prematurely, also in 1965, weighing in at 2.5 lbs. she was not expected to survive, but she did, although she has lifelong ENT problems, resulting in hearing loss. i believe there are far better techniques for holding off labor now, and for boosting tiny babies.

a woman in my lamaze class died; she had a rare amniotic fluid embolism. her baby was a couple months premature and survived, but let's just say this freaked the hell out of the rest of the class. that was just one of those things, not preventable, but a reminder that "natural" doesn't always mean a good outcome.

i have concerns about the high rate of c-sections, and about poor infant mortality, and about the lack of prenatal care for many women. during my second birth, a vbac, i would have loved to have had better support. but i'm also a fan of prenatal and natal care that can prevent horrible things from happening.

painted maypole said...

i read similar stuff when I was pregnant and it is truly horrifying. i was pretty proactive in my care, but wish I had known more from the very beginning when I was picking a new OB - having just moved while pregnant.

Lys said...

Omg - now this is a post that everyone needs to read. Let me say that if and when I have a child, I will keep this in mind. My best friend had a C-Section and, due to complications (and physician 'alleged' negligence), she almost died a week after. Thankfully she and the baby are fine but you know there's something wrong when the hospital calls you up to tell you they are "waiving the bill". Yeah, I would think they should.

Mad said...

The one thing that I would add is this: women can only make informed choices where choice is available. As someone who lives in a rural area of Canada where midwifery is not and option, I can't help but read about these issues with a measure of disbelief. When I think about all the American women who have limited coverage or no health care coverage at all and must make decisions based on what is the most economically feasible option, I seethe.

For me it always about ensuring equality of access to health care for all. Only then, can any kind of choice be offered to women.

Anonymous said...

Every Mother does the best that she can. No matter how 'informed' you are, we are all within systems that influence our care. I was completely informed (extensive work with midwives in the US and abroad, attendance at more than a dozen natural births, etc., etc.) and still ended up with an unnecessary c-section for a breech baby that caused undiagnosed scaring and infection so extensive that my daughter's delivery 2 1/2 years later turned disastrous and very nearly tragic. Knowledge isn't always the answer and it can be a mute point in the end, as frustrating as that may be.

I am so, so sorry to learn of the outcome of your first delivery. The fact that you have doubts about it is evidence enough that the system is flawed; we should all be a part of a system of care that we can find trust and security in. Yours is the sort of outcome that is so very rare that I understand your doubts looking back to the situation -- I know what that is like from my own first delivery. At the same time, even if you were equipped with all of this information, it is no guarantee that any step would have been in anyway different.

If I may add to your list, Henci Goer (in my opinion) is one of the most informed reads on this issue -- she goes through the medical literature and explains what and why hospitals choose what they take as policy and how/where it conflicts with medical science. Her book "The Thinking Woman's Guide to Childbirth" is fantastic.

I also love Pam England's "Birthing from Within" -- particularly for women who have experienced traumatic labors and deliveries.

Michele said...

I just have to tell you that I love reading your blog! Very informative! I have 7 living children...they were all born prematurely (34 weeks), except for my twins who were born at 23 weeks May of 07. Sadly my son Nick passed away 2 days after they were born...Kenny is now 21 months old and has many problems. But we are dealing with them. My doctor is perfect, I had the first 4 babies vaginally, then I had a c-sect for #5 and the twins #6 & #7), and finally a VBAC2 for my 6 month old!