Debunking the Business of Being Born: part 4

This is part 4 in a series debunking the Business of Being Born. Descriptions of the movie are in bold.

A woman complains about the ‘intense interventions’ and claims that there is no medically justified reason for interventions in obstetrics.  She also says that there is no common sense reason for many things, such as the lithotomy position in labor.

Once again, no evidence is presented and the claims are so vague that they are impossible to investigate. Its an opinion, that is all. I cannot tell if she is saying that there is never a good reason for ‘intense’ interventions, or if there is never a good reason for any of the interventions OBGYNs use, or that there is not a medical reason the majority of the time.

There is a montage of hospital births and interventions that seem selected to make viewers feel uncomfortable. They cut to a home birth mother. She says “the more you can move with labor, the more you can move through your contractions, they don’t seem as intense.” There is footage of her moving during a contraction. “To lay still its like ‘who would want to do this? I just want to get up and move my hips!’ “

That was her experience during labor. I believed that it was the experience of women in general because of this movie and other NCB advocates. I believed it fully until I went into labor and tried it. I tried for hours to ‘move through’ my contractions. It didn’t do a god damn thing for the pain, it actually made it worse. I’m not saying the mom in the movie is full of shit, just that her experience isn’t shared by everyone. Even if every hospital pushed NCB on patients there would still be people like me who need something stronger than a butt-dance to deal with the pain.

The same woman as before claims “the lithotomy position is the most physiologically dysfunctional position ever invented for birth. Because putting a woman flat on her back literally makes the pelvis smaller. It makes it much more difficult for the woman to use her stomach muscles to push. And therefore makes it much more likely that an episiotomy will be cut or forceps will be used. Or the vaccuum extractor will be used. ” More creepy hospital footage and modern hospital deliveries are shown on screen. 

I could not find any real data about these claims, but (as I discussed in part 3) epidurals are the intervention most strongly correlated with instrumental deliveries. It makes absolute sense that moms who use epidural anesthesia would be positioned in a way that could facilitate interventions, because women with epidurals obviously cannot move around without assistance and any emergency interventions would be delayed by having to re-position her.

What is really strange is that I watched The MORE business of being born, and recall one of the super models talking about how being on her back was most comfortable for her during her unmedicated birth. If our bodies “know how to give birth” and all that I am not sure why her body would choose the most “physiologically dysfunctional position ever invented for birth”, which resulted in an uncomplicated vaginal delivery.

A man speaks a foreign language, he gestures towards a patient bed and references the lithotomy position. Subtitles read “this position here, it is easiest for the doctor. But its nearly impossible for the baby to come out alone in this position.

If its “nearly impossible” why does it happen so often? All the information I could find demonstrated that operative vaginal deliveries were 5% or less of all births in the U.S., and the vast majority of vaginal delivery patients were in the lithotomy position.

A woman uses a toy doll and a foam pelvis to demonstrate that babies need to turn after their heads engage in the pelvis in order to be born. She claims that shaking the pelvis and moving around helps. 

The same man as before (who we now know is an OBGYN) says Now if she was squatting I would have to be sitting on this little seat right here…

Footage of a birth where the mother is moving around on her own is shown, presumably not in a hospital. 

The dr continues: So the mother is active and thats very important, shes participating. As opposed to when shes laying down, the doctor is telling her “Push! Stronger now!”

Footage is shown on the screen of a hospital birth with a lot of people telling a mom to push. She is yelping in pain and there are hands all over her. Her face is blurred out.

This kind of footage freaked me out when I watched this movie. Peoples hands all over the mom while they barked orders at her really squicked me out as a person with an abuse history. Pretending that midwives are never grabby or never yell at women to push or that all doctors are aggressive in this manner is just nonsense. It is another attempt to put anecdotes in our minds instead of actual data. The degree a person obtains does not determine how much respect they will give you.

A doula/rn says: Women here have given up their autonomy about birth. Women are so afraid of birth. Because you do not have an image of what birth looks like. Women in america don’t know what’s normal about birth.

A CNM says “they watch A Baby Story and they watch Maternity Ward. They watch these programs. I think there is a lot of fear instilled in women around birth.”

The screen shows footage of terrified mothers in hospitals, presumably from the programs mentioned by the CNM.

A birth center owner says “Every birth that you see on television is women screaming and being rushed down the hallway and looking like an absolute dire emergency. So why should women feel confident about giving birth when the whole culture is telling them this is scary, this is dangerous? “

Those shows are the real stories of real women who really did have a terrifying experience. Why are women supposed to ignore the possibility of something terrifying happening? How are women supposed to make reasonable plans without contemplating what could go wrong? I am not advocating for anxiety or non-stop worry about complications, but the experiences of women who had emergencies in birth shouldn’t be ignored or buried in favor of the more positive experiences. I also know for a fact that they have shown unmedicated and home births on the shows mentioned. I remember being a teenager and watching a woman give birth in a kiddie pool in her home on the discovery health channel. I usually did not watch the birth shows, but she was screaming “CYOTEEEEEEEEEE” over and over again and I needed to know why she would yell “cyote” during birth so I tuned in. It was what she named her son.

Anyway.

Birth is what it is- why does it need to be portrayed a certain way?

NCBers know why- they believe, like many alt-med folks, that your attitude can determine your outcome. They believe that if you just aren’t afraid of birth it won’t hurt you. It sounds ridiculous when the theory is stated outright, so the movie does a good job of easing you into the idea that your attitude will determine the outcome of childbirth.  Several NCB icons like grantly dick reed and Ina May Gaskin state this theory in their books. They believe that giving birth while scared is like trying to pee with an audience- fear interrupts the process. It is a hypothesis, but it isn’t one that is testable. The hypothesis relies on the subjective inner experiences of women over a period of hours, it is something that can change dramatically in a matter of minutes. If a woman has even a moment of fear during childbirth any problem that occurred can be blamed on her. It is unspeakably cruel to blame women for something they have no control over. The movie accomplishes it very stealthily, and I believe that women are so used to accepting blame for things that it can be hard to even notice that its happening.

“Women expect to have traumatic experiences. Thats why women are having epidurals, they are all terrified of what this is.”

This is another subtle jab at women who chose interventions. She is implying that women chose epidurals because they are ninnies who were brainwashed by the media into believing they needed one. Women have epidurals because they are in pain.

A childbirth educator complains about the fear present in the depictions on television. She says that once the doctor plays the “your baby is in danger card” the battle is over. There is footage of a mom whose baby is having heart trouble during delivery, her OB is trying to avoid instrumental delivery but mentions it as a possibility. He tells her to push. 

“That’s one of the great manipulative techniques that are used, is when a woman starts to question, “wait, why do we need to do this? Wait, is there something else we can do? the first thing you turn to is ‘its for the good of the baby’.  Weather or not it is, you’ll do anything because if you go on to question it, well, then you’re a bad mom. 

There is more footage of a different OB recommending a vaccuum assisted delivery in a hospital.

As I stated before, there are very few instrumental deliveries. This part of the film gives the impression that it is much more likely to happen than it actually is, and they pretend that there is no danger in maternal exhaustion or pushing for a very long time.

Sometimes ‘its for the good of the baby’ is just the simple truth of the matter, or it is the truth to the best of the physician’s knowledge.  This film basically promotes paranoia about why your physician would recommend something. Why are midwives exempt from paranoia about non-intervention? The Business of Being Born very rarely questions the actions or recommendations of midwives, but constantly questions physicians. The physicians have the disadvantage of having many years of training based on a large amount of complicated data. Issues like that are hard to explain concisely. Midwives can usually explain themselves in a slogan. It is superficially more convincing to lay people. It is very much the same as creationism, where snappy lines are more compelling to people who do not know better.

Discussion of the themes so far:

Negligence is usually defined as doing something a reasonable person would not do, or failing to do something a reasonable person would do. Both can cause death or problems. The Business of Being Born makes it seem like only the first kind of negligence is dangerous, when in fact both are.  The movie, and NCB advocates, repeatedly suggests the second kind of negligence as desirable without explaining why. The fact of the matter is that many women find the risk of intervention preferable to the risk of not using an intervention, and its understandable. There is a certain percentage of the time that the intervention would not have been needed, but it is not possible to know until something bad has happened.

I got irritated with statements that I could not investigate in this portion of the movie. If you make a statement using dramatic, emotional language, but never get specific enough to actually have your statement investigated for validity then people will hear whatever they want to hear when they listen. Its something politicians are experts at. It is a red flag for dishonesty. I wish I had spotted it before I decided to use a midwife at an out of hospital birth.

why aren’t you breastfeeding?

There is a lot of buzz about this ridiculous question sent to The Alpha Parent recently:

“I feel awkward around formula feeders. I don’t know where to look. Is it okay to look at their baby? Is it okay to ask them why they don’t breastfeed, or when they stopped? What’s the etiquette? Any chance you could help with these questions? I’m not being weird, I’m genuinely curious.”

I would have linked her to a wikipedia article on “social convention” or “manners” or something else equally obvious, but a real discussion ensued about if its cool to ask moms why they aren’t breastfeeding. Of course that isn’t anyones damn business, so I am trying to come up with good combacks for sanctimonious NCBers who do feel compelled to ask:

HUMOROUS:

1. Well…honestly?  I lost my nipples in the war *stare stoically into the distance*

2. My pediatrician said a double dose of vaccines is just as good as breastfeeding.

3. If you read your bible you would know its a sin (if they ask which part, say Leviticus).

4. We do usually, but our wet nurse doesn’t like to breastfeed in public, so…

5. I would, but making cheese out of my breastmilk is so profitable…

BITING

1. I formula feed so that you can keep feeling superior.

2. I wanted to ruin the bond I had with my baby, and this was by far the easiest way.

3. Well it is insanely easy for everyone, and never painful, so I guess I don’t have a good reason.

4. I hate my baby, obviously.

Counter with another inappropriate question:

1. I need to know if you are on your period before I tell you. (can sub any condition or disease here for period)

2.  How much money do you make?

3. When was your last bowel movement? How did it go?

 

Direct

1. How dare you question how I feed my child!

2. None of your business. Ever.

 

These are the best I could come up with. Add your own!

Justice for Vylette

Justice for Vylette

These stories are everywhere- it seems like the only recourse american women have after suffering from midwifery related negligence is to tell their story online to prevent other people from being hurt by specific midwives. It is damage control, not prevention. I am planning on pulling together a state-by-state resource list for concerned citizens to try and organize around the cause of holding midwives accountable to the public. Here is the beginning of Vylette’s birth story, available on the facebook page:

my absolutely perfect baby from my perfect pregnancy was murdered by the negligence of my midwives ASYA PORTNAYA & YULIYA MILSHTEYN of The Brooklyn Birthing Center ( http://www.brooklynbirthingcenter.com/ ). also doula London King ( http://www.pushlove.com/ ). they delayed me for hours so much so that my baby was trapped in my birth canal and suffered lack of oxygen to her brain. they did not believe me when i told them my contractions were 2 min apart for HOURS.

I took a look at the brooklyn birth centers webpage, and they still recommend the doula involved in this preventable perinatal death. I sent them an email asking why, considering the information available online about what happened there. You can email them too at info@brooklynbirthingcenter.com. My heart aches for this family.

The midwives in this story were a lot like the one I dealt with- it seems like when midwives just don’t want to deal with a patient they say whatever they can to get out of being responsible for the births they agreed to attend. The mother of Vylette believes that since it was thanksgiving weekend she was blown off by people who agreed to care for her during her labor. It is shameful. Do you think the midwives were even sorry? Of course not. They just moved on like nothing happened and had nothing to say to the woman who had to bury her daughter:

 her name is Vylette Moon and though she was here for such a short time she was very loved by all who saw her. except the midwives.. they never spoke to me again. stopped all contact and ran me in circles when i tried to obtain my medical records they are evil.i was supposed to birth at the Brooklyn birthing centerthe midwives were ASYA PORTNAYA and YULIYA MILSHTEYN. i believe they are currently still delivering babies. it makes me so sick.

The organizer of Justice for Vylette (Vylette’s mom) encourages people to share this story with anyone who is interested. I looked up her midwives on healthgrades, and neither Yuliua Milshteyn or Asya Portnaya have any record of a sanction or malpractice suit available online. Vylette’s mother did a very good job of publicizing these events so that anyone researching these midwives will find the story of what happened, but again that isn’t what I would call “justice”. I admire her strength in telling her story despite the pain of the loss of her daughter.

I am not sure if Vylette’s mother tried to report these women to the licensing board or not (both are CNMs) but I am going to contact her to see if I can help get anything done for her case. Please share or like her facebook page to show support.

UPDATE 1-16-14

I contacted Vylette’s mother through facebook and gave her the contact information for the complaints department of the new york licensing board. It was weirdly hard to find. Hopefully she will be able to put a mark on these women’s records (or perhaps cause them to lose their RN licenses).

Debunking the Business of Being Born: Part 3

This part 3 of a series attempting to debunk claims made during the business of being born. The descriptions and quotes in the movie are in bold

 

dr jacques moritz (abby epstein’s OB) discusses how birth is 98% waiting and 2% sheer terror, and you never know when the scary stuff is going to happen. He says “It goes from being completely normal, to 2% terror. When you’re at a hospital- and I don’t like hospitals in general, The idea that theyre not healing places in general. But they are good for when you have that terror.”

Ricki Lake responds “My issue is for those women that have the normal, the 98% that have no complications, they come to the hospital, and they’re put through these, you know, its like this system where they’re flat on their backs. They want a natural birth. Or they want to have a vaginal birth, and all these things are stacked up against them.”

Ricki Lake understands the “2% sheer terror” comment to mean that only 2% of births have complications. It seems that on average about 16% of births involve complications. The physician was clearly stating his opinion of childbirth and not quoting an actual statistic, and probably meant that his estimate is that 2% of the time there is a threat to life of the mother or baby, or their functionality. 

 

Anyway, the other main concerns expressed are a lack of options for women who do not want interventions. These are valid concerns to have. I worked in a variety of hospitals and clinics for a number of years, and this portion of the film really resonated with me because of that. I did not work on the maternity care floor very much, but I saw these same problems in other areas of the hospital. People are more or less put on an assembly line, asking questions can get you branded a trouble maker by staff, many patients agreed to procedures or drugs that they did not fully understand, etc. These are things I am very concerned about. 

However, there isn’t much reason to think midwives are the answer.

The Business of Being Born constantly implies that midwifery and out-of-hospital birth is the solution to the problems with maternity care systems, but I beg to differ. I found out the hard way that midwives can be just as aggressive and uncaring as any physician. There is not much accountability for physicians on this front, but there is even less for midwives. Since I had my difficult experience with multiple midwives, I found that many other women have had experiences like mine, with midwives and OBGYNs. The setting of your birth has nothing to do with if your provider actually cares about you, or just pretended to. 

Tina Cassidy, journalist says “They’ve told women ‘Come to us, we’ll take care of everybody’s birth. Doesn’t matter what kind of birth you want. We’re open to anything. And then you get there, and you realize, No, the hospital system is really set up one way, to handle one kind of  birth, and you just get put through that system. And its a fight to try to not get put through that system.

next is a montage of physicians ordering pitocin for patients and nurses providing pitocin and other drugs on a maternity floor 

The ‘one kind of birth’ they are referring to is actually a complex set of recommended interventions based on the physician’s assessment of the situation and protocols that the hospital has created to deal with any complications in the (statistically) most successful way possible. I do know that treatment happens without patient agreement sometimes, and that is absolutely wrong, but again- that isn’t restricted to hospital birth experiences. The pitocin scenes are there to bolster their point that the hospital won’t respect your birth plan, but demonstrated that poorly. We are not given any opportunity to speak to women who agreed to the pitocin or shared what they thought of it- ditto for pain relief and induction. We are given the impression that these women are duped into something they don’t really need, but aren’t given any opportunity to investigate if that is true or not. The nurses state that most patients (she says 90%)  use some kind of augmentation during their labor- its just the word of one nurse, so its impossible to verify if it is true, or if it is true outside of this one hospital. The use of personal statements by medical professionals in lieu of actual data is problematic- individuals are prone to misunderstandings and sometimes they lie for whatever reason. This portion of the film leaves me wondering why they don’t present data instead of anecdotes. 

Patricia Burkhardt, an NYU midwifery professor says “Hospitals are a business. They want those beds filled, and emptied. They don’t want women hanging around in the labor room.”

 This is a criticism of capitalism, not hospital birth. This is especially true since midwifery is a business too! I also know for a fact that a lot of hospitals aren’t businesses. Not for profit hospitals are the opposite of a business- any surplus at the end of their fiscal year is used to improve the facilities. 

someone else says “you get this feeling in the hospital that theres like a limit to how long you can be in labor.Like ‘oh its been 12 hours, now you need pitocin’

ricki lake says “I did know the pressure was on, you know, as we got into like 20 hours, 21 hours, 

cut back to the other woman “at the hospital I had pitocin, which made me itchy. So they give you something else for your itching.”

A third woman says “I knew once they gave you that pitocin, you need the epidural.”

cut to a scene of a nurse asking “feel better now that you had the epidural?”

the patient replies “OH GOD YES.”

There are several different women talking about how they felt there was a ‘domino effect’ of interventions. 

The ‘limit’ on how long you can be in labor is there for a reason. Again, it is because statistically there are problems if you let labor go on for x amount of hours without any progress. Will you be in the minority of people who has no problems after a prolonged labor? There is only one way to find out- labor a long time and see if your baby is okay or not. Each patient needs to weigh that against the risk of augmentation, something that should ideally happen as an agreement between a patient and their doctor. I believe most women are uncomfortable waiting and seeing if things are going to go wrong or not, and that is a valid choice to make. I also believe most women get pain relief because labor is painful.It is inhumane to let women suffer when they ask for pain relief. 

I am aware that unethical things happen in the hospital (forced treatments, lies about the treatments from drs or nurses), but again, midwives do unethical things at home too. There hasn’t been any adequate study of what setting is more likely to respect patient autonomy. There has been adequate study of what setting is more likely to facilitate a better patient outcome. Hospitals have been shown to repeatedly have better patient outcomes. To pretend that the better outcomes have nothing to do with the interventions is hard for me to accept, especially when we all know that c-section is the treatment responsible for saving many babies from many different complications.  There is also a lot of objective evidence that you are less likely to find justice if your midwife does something unethical vs a hospital or doctor. 

A cartoon plays about the snowball/domino/cascade of interventions theory at a hospital. The first thing they say is that epidurals interfere with dilation if you get one early in labor.

There is conflicting information about if epidurals slow labor. There is not a consensus on this issue. If it does slow it down, then the effect seems to be small- the studies I found that reported a prolonging of the 1st or 2nd stage of labor both reported that it prolonged it 30 minutes or less. The main thing that seems to be associated with epidural anesthesia is instrumental delivery.

The cartoon shows an upset baby inside a woman while she is given pitocin. The narrator says the epidural has to be turned up to deal with the pain of pitocin contractions. She says the increase of medicine in the epidural slows labor down more so they add more pitocin, which in turn makes the baby go into distress and then a c-section is ordered.

if this were true, there would be an association between epidurals and c-sections, but there isn’t one. While the length of labor associated with epidurals is controversial, the rate of c-section in women using epidural anesthesia is not.  

In the middle of the cartoon/montage of people talking about the cascade of interventions theory, an obgyn says “there is clearly an association with induction of labor an cesarean delivery.”

This was not what the previous cartoon was arguing- they were arguing epidurals and pitocin cause c-sections. Induction of labor is a whole different ball of wax, but the doctor’s words are put in the middle of the repeated statements about *any* intervention leading to c-section to try and give credence to the unsupported claims made. 

examining the themes so far-

I can empathize with women who had a bad experience at birth in a hospital, completely. I had a pretty awful time in the hospital too, but there is a reason I am an ex natural childbirth advocate and not an ex hospital birth advocate.

It is horrible when you have an expectation that is shattered, when plans change because something might be going wrong. That does not mean that these women made the wrong choice or that the hospital was bad for recommending the interventions that they did. NCB leaves women constantly wondering what they did wrong to ’cause’ problems during the birth. The reality is they did nothing wrong, and if they did somehow cause a problem it doesn’t mean it was ‘wrong’. We do our best based on the information we have at the time, and there is no reason to beat yourself up about how things ended up if everyone is healthy and happy. 

There is nothing to ensure that you will be in control in your birth. Birth is a very vulnerable time for that exact reason. I think that people with a healthy faith in humanity are okay with a bit of unpredictability, they may even find it exciting.This is part of why I believe women with abuse, OCD, or eating disorder histories are drawn to natural child birth. NCB advocates prey on women with these vulnerabilities to sell home births and midwives. They sell a very alluring fantasy of control, of perfection, if you are just good enough or try hard enough. It is a cruelty to do this to women who cannot actually control things to such an extent. 

 

Debunking The Business of Being Born: Part 2

This is part 2 in a series attempting to debunk the claims made in The Business of Being Born. Descriptions of the movie are in bold, my commentary is in normal font.

“most obs have no idea of what a birth can be like.” says Dr. Michael Odent.

“very few doctors have ever observed a normal birth, in medical school or in the hospital. Its almost an oxy-moron.” says the president of citizens for midwifery

cut to ricki lake asking 3 ob residents how often they get to see a fully natural birth. Two of them respond. One says ‘rarely’. One says “almost never”. 

A ‘fully natural birth’ is a matter of opinion. It is a laundry list of requirements that may or may not have anything to do with how humans have given birth in the past (for instance water birth is an entirely new idea, but is considered natural in NCB circles).  If a woman has an IV line, its not a fully natural birth.  If she had a shot of pain medication, that later wore off, it is not a fully natural birth. These distinctions seem pretty trivial to me.

I am sure that I could take all the possible choices in birth, make a list of the ones I thought were the best, and then ask OB residents “how often have you seen this kind of birth?” They would probably say the same thing, because the range of choices available makes for a large number of possible birth scenarios. I also do not think that 3 peoples opinions are the best way to demonstrate this point (if it is even true). They are in the same residency program at the same hospital- it could be evidence of that specific hospitals practices, or of what women in the region want, etc. We are not told how far these women are into their residency or how many births they have seen. Again, these factors are never explored, and hard numbers are never given.

This argument for ‘natural’ birth also invokes the naturalistic fallacy. Ditto for calling spontaneous vaginal delivery ‘normal birth’. I would imagine ‘normal’ birth is whatever kind of birth most people have, and they have already said that NCB is not the norm.

“well I always think that midwives do a better job at the normal deliveries than we do. For a normal, low risk woman, its overkill going to a doctor. The doctors not really excited about things when theyre normal.” says dr jacques moritz. 

“because OBs are socialized to search for pathology, they often see pathology where it does not exist. They find pathology because then they have something to do.”  says a medical anthropologist

“an obstetrician is a trained surgeon, and usually very, very good at what he or she does. And thank goodness we have them! Im so greatful that we have OBGYNS.” says a midwife

“They’re surgeons! They should be doing surgery all day, every day. When its needed. They should not be doing normal births. cause they’re not trained in it. They have no idea how to do it.” says another.

These are opinions, and they are impossible to prove or disprove because they are subjective judgments about the services of OBGYNs. The movie sticks to this kind of rhetoric a lot, mainly because the objective measures of safety for women and infants in out of hospital birth are pretty damning. If OBs are not well suited to spontaneous vaginal births then why are their outcomes so much better than midwives? You have to dress up the argument with a lot of flowery rhetoric, or just plain lie, to get people to ignore the evidence.

Cut to dr marsden wagner repeating the same stuff about how other developed countries use midwives more than the USA. He claims a lower rate of maternal and perinatal death in countries that use more midwives.

Correlation does not equal causation. There are a million reasons that differences could exist in rates of perinatal and maternal deaths. Attempting to attribute it solely to midwives is not warranted by the evidence available, and since the film is making the claim of causation it is up to them to demonstrate it. They fail miserably to provide any evidence outside of “two things happened at the same time, so one must have caused the other”.

I am always reminded of this exchange when someone mistakes correlation for causation:

Lisa: Dad, what if I were to tell you that this rock keeps away tigers.
Homer: Uh-huh, and how does it work?
Lisa: It doesn’t work. It’s just a stupid rock.
Homer: I see.
Lisa: But you don’t see any tigers around, do you?
Homer: Lisa, I’d like to buy your rock.

Text appears on the screen that reads:

The United States has the second worst newborn death rate in the developed world.

No source is cited, so I don’t know what year they are discussing or what countries they count as developed or not. I can’t even investigate the claim because there is not enough information given. Not only that, but they don’t talk about how close we are to the top ranking country. What if all the perinatal death rates in the developed world were excellent, and very close? That is what I found when I took a cursory look into the data for 2004-2008.

A Phd in public health says “the united states is ranked poorly in infant mortality.” 

That is true, but infant mortality is different than perinatal mortality (which is deaths that occur 0-28 days of life). Infant mortality rates aren’t pertinent in a discussion of home birth.

“one of the arguments made is we have different women. We have more high risk women. But this blaming of women is farcical, its not about mothers. Its about the way we treat care in the united states. ” he continues.

If it is true that the US has more high risk women, I am not sure how hospitals are supposed to magically compensate for that. He should have demonstrated that the US has equivalent rates of high risk pregnancies or lower rates of high risk pregnancies in his comparison. I am betting that he avoids talking about the numbers because they aren’t in his favor.

text appears on the screen:

The US has one of the highest maternal mortality rates among all industrialized countries. 

I looked into what counts as a maternal mortality, and it is anything pregnancy related that causes death within 42 days of pregnancy being terminated (either by birth or miscarriage). I am not sure why lack of insurance and socialized medicine is ignored as a factor in the difference in health outcomes. It is a factor that worsens health outcome statistics for the entire country. Why would there be surprise about this?  I am sure that someone with access to data could give the film makers information about the causes of these deaths, and then they could investigate if midwives are a solution to the complications that are resulting in these deaths. If they could demonstrate that, why wouldn’t they?

“This is the outcome when you are a century or so post-midwives. You lose a lot of knowledge. We are the one country where, when birth went into the hospital, the midwives didn’t go there with it. ” says Ina May Gaskin.

The cultural anthropologist talks about smear campaigns against midwives in the early 1900s to explain why they weren’t accepted in hospitals. They discuss the racism of some of the campaigns.

An author talks about the cultural shift in the USA away from midwives. She says that during that time it was more dangerous to give birth in hospitals than with midwives because physicians did not have adequate training in labor and delivery.

creepy footage of old hospitals and pregnant women about to get c-sections are played over an ominous soundtrack while this same narrative gets repeated. 

This has nothing to do with how safe home birth is NOW vs hospital birth, considering that a lot has changed in medicine since the 1900s. The film carefully avoids comparing direct entry midwives outcomes to physicians today. If midwives have such a superior outcome, why won’t their professional organization (MANA) release its death rate statistics?

This part seems to only be there to reinforce the narrative that midwives are good, hospitals are bad. The footage does a good job of instilling a sense of unease in the viewer. Old hospitals are indeed creepy, but do little to prove that anything was lost by moving birth into hospitals.

text appears on screen:

In 1900, 95% of births in the united states took place at home

In 1938, half of all births took place at home

by 1955, less than 1% of births took place at home

It remains at that rate today.

With all the talk about mortality rates before, you would think they would talk about the rate of perinatal and maternal fatalities in the times listed.  If their analysis is correct, then as hospital births increased the rate of maternal and perinatal death would increase as well. Here is what I found when I looked into it:

At the beginning of the 20th century, for every 1000 live births, six to nine women in the United States died of pregnancy-related complications, and approximately 100 infants died before age 1 year (1,2). From 1915 through 1997, the infant mortality rate declined greater than 90% to 7.2 per 1000 live births, and from 1900 through 1997, the maternal mortality rate declined almost 99% to less than 0.1 reported death per 1000 live births

You can see the graph here, that shows an over all decline in maternal mortality that coincides with births being done in the hospital (with an uptick in 1920). Even the increase in 1920 is not as high as the 1900s numbers. The increase in 1920 caused government oversight, which then changed the common practices in hospitals, and resulted in a mortality rate much lower than the pre-hospital era. It is worth noting that this is exactly the kind of government oversight that midwives are currently resisting.

Most of the information on that site is for infant mortality (up to one year), but there is a table demonstrating the reduction of neonatal mortality and the results are the same- a consistent decrease in the death rate over time, which quickly became superior to the pre-hospital era. The article has a lot of information about what technologies and techniques are responsible for the decrease (and the increase of maternal mortality in the 1920s).  There is thoughtful discussion of the history of labor and delivery in the united states. You’ll note that using a midwife is not listed as a strategy associated with decreased mortality, because it simply isn’t supported by the available evidence.

Discussions of the themes so far:

This movie constantly frames the argument as natural birth being in direct opposition to medicalized childbirth,  but I don’t see ‘nature’ and ‘technology’ as opposing forces at all. I would argue that science and technology is absolutely a natural thing for humans to do. Science is a very organized form of what is innate human behavior- to try to understand the world, to experiment, to test our theories about the world. Technology is an application of what is learned through science. It is entirely natural for human beings to work together to invent solutions to problems, like excrutiating labor pain or fetal distress.

These sorts of opinions are aimed at providing empowerment to women who are pregnant or planning on having children. I get that, it certainly appealed to me.  Pregnant women usually experience some fear of childbirth, and these messages from the natural birth community aim to exploit that fear for profit. It is so comforting to hear midwives say that everything is okay, and so frightening to hear doctors talk about what can go wrong. It is a case of your real friends telling you stuff that you don’t want to hear.

Debunking The Business of Being Born: Part 1

This is a series on The Business of Being Born (TBBB), a powerful film that has influenced many women to give birth outside of a hospital. I’m going to do my best to point out the factual problems with different aspects of the film.  The descriptions of the film are in bold.

The film opens with a montage of a midwife, Cara Muhlhahn, packing various medical supplies at 3 in the morning (IV kits, oxygen, towels out of an oven, etc).  Scenes are spliced in where people describe their thoughts about midwives, most of them are from people who either dislike the idea of using midwives or who are ignorant of what midwives do.   

The midwife drives to a clients house. They fill up a birth tub. She says she will just stay out of the way and advises the client to pretend she isn’t there. We see a woman coping with a contraction, and the screen fades to white and says:

“Midwives attend of 70% of births in Europe and Japan

In The United States they attend less than 8%”

This is intended to make you question why the United States is so different than the rest of the world. What they left out is that most of the midwives featured in TBBB  are not considered actual midwives in places like Europe and Japan. Most of them are direct entry midwives or ‘lay’ midwives, they are not nurses and do not have anywhere near the training that a nurse does.  On page 8 of this document from a Japanese Midwives organization you can see that midwives in japan must either first become nurses, or be proficient enough in nursing to pass the national nursing exam, before being able to apply for a midwifery program.   The European union’s midwifery standards are very similar. Their document is pretty confusing, so I’ll just point out one part that makes it clear that European midwives are also either nurses, or equivalent to nurses in training and education. You can see on page 8 of this document that one condition of being a midwife in the European union is carrying out treatment prescribed by doctors, something direct entry midwives are not capable of doing (because they aren’t nurses).  The american equivalent of european and japanese midwives are Certified Nurse Midwives (CNM), advanced practice nurses who got midwifery education after being a registered nurse for a number of years.  In some states in the US you can simply claim to be a midwife and you are legally qualified to be one. It is that way in Utah, and the midwifery community here pats itself on the back for having “one of the best” midwifery laws in the country.  Since direct entry midwifery is legislated on the state level, a dangerous midwife can just pack up and move somewhere new if they cause an injury or a death, or if they do anything else unsavory that they would rather not take responsibility for.

There isn’t any mention of the radical difference between Japan, Europe, and America’s health care systems, either.  There are many differences between the care people receive in different countries, and it can sometimes be attributed to a public vs private health system. There could be many contributing factors to explain the difference in the % of births attended by midwives, but the only one they explore in The Business of Being Born is ignorance about midwives, discrimination against midwives, and greed from OBGYNs and hospitals.

The next scene is Dr. Marsden Wagner exclaiming that “maternity care in the united states is in crisis. It’s, in many ways, a disaster.”

A provocative statement like this should be supported with some kind of explanation, but its not. They are planting the seed that hospital birth is problematic without explaining why exactly. Its a technique used by advertisers and scam artists all the time- they appeal to some feeling, in this case, fear or curiosity, and then don’t provide enough information to examine it for validity. You are left with whatever gut feeling is evoked by the imagery.  It is good film making, but it is a very poor way to educate anyone.

Another person says “Medical decisions are being made for monetary and legal reasons, not because they are good for the mother and the baby.

“Monetary and legal reasons” meaning avoiding a lawsuit. The unexamined assumption is that preventing a lawsuit is different than preventing a bad outcome. In reality, bad outcomes cause lawsuits against hospitals and physicians. The film talks about how doctors are trying to prevent lawsuits, but did not feel it was important to discuss what patients go through when they have to sue for malpractice. It is a glaring omission.

A doctor says “Technology is technology, its not stopping. This is what life is all about. So if you’re gonna have good stuff you might as well use it to get the best outcome. ” with a grin. 

Someone else says “We should constantly be asking ourselves, ‘is this an improvement, or are we making things worse?’

This contrast implies that the doctor quoted beforehand has not thought about this, or that there is no one constantly asking if technology in birth is an improvement or a hindrance. In reality, scientists and doctors are asking these questions.  The protocols in hospitals aren’t developed out of preference, they are developed based off of hard data from physicians and researchers about outcomes. They are reviewed, based on the data, at regular intervals. Changes are made based on the reviews. It is not a perfect system, so there are things that aren’t needed or cause problems, but it is a system that constantly aims for improvement of outcomes. The same can not be said about natural child birth.

“if we don’t quickly take ahold of this, we’re gonna lose normal birth” exclaims a woman.

A doctor says “I call it feminist machosim, you know, when you’re pushing your baby in a stroller three months later to say ‘I did it naturally.’ Personally, I don’t think its important.”

Anyone who has worked with physicians knows that its really not hard to find a mean one to cast the profession in a bad light. It doesn’t really reflect on if the care protocols in a hospital are better or worse than at home with a midwife. Ideally, a system of maternity care would have a level of accountability that would ensure that even the most sociopathic practitioner would have to try and ensure the best outcome. Malpractice lawsuits and medical licensing accomplish this (to a certain degree), but midwives do not carry malpractice insurance so they are not subject to these rules. There are also states where licensing is not required, or penalties are small for illegally practicing midwifery.

A woman says “There is so little understanding, of how incredibly important this process is to women.

A man says “Theres something going on in the nature of care in the united states thats troublesome. Women, they’ve been told for years now, that they’re not responsible for their own birth process.”

“Basically what the medical profession has done over the last 40, 50 years, is convince the vast majority of women that they don’t know how to birth.”

These are all slight digs at women who needed interventions in their birth. What is wrong with women who don’t know how ‘incredibly important this process is’? Are women who choose a doctor or a c-section less ‘responsible for their own birth process’ than someone who doesn’t? If a woman has an intervention, is it because she has been convinced that she ‘doesn’t know how to birth’? What actual women would prefer and why is left out of the equation, there is a strong implication that natural childbirth is The Best Way to have a baby.

There is a discussion of new york women scheduling their births because they are so busy. The discussion takes place at a photo shoot with a pregnant model who is planning a home birth. There is obvious disapproval of scheduled birth, though it is not stated outright.

Cut to a pregnant woman discussing how she prefers midwives for well woman care. Her husband discussed his feelings about doctors and how they can change your birth plan with seemingly no medical reason.

I am not sure why we get to hear so much from people who prefer natural child birth and so little from women who do not.  The clips of women talking about preferring a c-section or an epidural are usually used to demonstrate that they are ignorant somehow, or that these methods aren’t preferred by most women.  This is such a crappy message for first time mothers, because they cannot know what type of birth they will prefer. You can guess what you would prefer, but you cannot know for sure until you’ve experienced it. Women who have had babies can’t prepare another woman either, because her labor will be different than yours This film attempts to make one type of birth seem ideal for everyone and all others inferior, regardless of what individual women have to say about their non natural births.

Cut to footage of Ricki Lake on her talk show while pregnant, and then an interview with her about her birth experience with her first child. She wanted NCB, and ended up having a lot of interventions that she felt were not needed.  She felt cheated, and decided to do things differently next time. She reccomends Ina May Gaskin books for educational purposes. She states the aim of the documentary- to explore the birth system in the US, and ask if they are benefitting mothers & babies or not.

Cut to a monty python sketch about birth. 

The monty python sketch represents how some patients feel in a hospital, but there is no way to know how commonly women feel like that during their hospital births. There are endless complaints in this movie about doctors and hospitals, but there is no data (not even surveys) presented about how common these problems are at the hospital vs at home.

An analysis of the themes so far-

There are a lot of feminist dog whistles in this movie- things that would seem innocuous to people not involved in womens rights movements, but very note worthy to feminists (like myself). I instantly became interested in hearing the NCB side of the story because of the use of feminist themes in the film. The way that the majority of pro-NCB people in the film were women also made me more willing to believe their side of the story- after all, women are the ones having babies, not men.  Feminist women who are interested in NCB need to be aware of the way that midwives treat women who have been wronged by other midwives. The will support the midwife instead of women who lost their children because of negligence, or women who were abused or mistreated by midwives. The line that they support women’s choices is a good way to sell the services, but is it actually true? In my case, a midwife with decades of experience testified in court that doing exams against a patients will is the ‘standard of care’ in midwifery.   Either she is willing to lie in court to help her colleagues, or she is willing to lie to patients when she tells them that the midwifery model of care is about dignity and respect.  This was after the one midwife did the exam against my will, and the owner of the birth center said it was my fault. I reached out to prominent members of the community for help, and there was none. That is when I started to find out that a lot of midwives won’t refund a fee or even apologize after they cause a death by negligence, and that the same lack of help existed for women who had suffered much more than I did at the hands of negligent midwives.  Midwives are not more or less likely to be feminists than anyone else, but they present themselves ambiguously to appeal to feminists.

Feminism has helped me immensely in dealing with misogyny (including internalized misogyny), I now find it very offensive that Natural Child Birth has hijacked something I care about so deeply in order to sell midwives. I was lied to. The regard for women and their choices that is sold by midwives is only practiced if your midwife feels it is important. You can’t tell if she actually believes it is important until its too late.

I should have seen their political appeals as a red flag- If natural child birth is better, even just psychologically, then data will reflect that clearly.  An Inconvenient Truth managed to be a data-heavy documentary that gained popularity because it was so educational and concise. The Business of Being Born is more geared towards playing on the emotions of women to convince them of the inherent merit of natural child birth. It is the only way that I can make sense of the content of the film, knowing what I do now, and knowing what Ricki Lake must have discovered when she did interviews and research for this film. I would love to know what interview footage ended up on the cutting room floor.

stay tuned for the rest of the series!