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!