Debunking the Business of Being Born: Part 5

This part 5 in a series debunking the Business of Being Born. Descriptions of the movie are in bold, my commentary is in normal text. The other parts of the series can be accessed by clicking here.

A woman says “Its very easy to convince a woman that they need this procedure or that procedure, because there is a huge power disparity.”

There is an inherent power disparity in any situation with patient care. Doctors are trained in how to deal ethically with the disparity, while I have noticed a tendency in midwives to ignore the problem or pretend that it can be overcome by force of will.  There is also the issue of accountability- doctors are not very accountable for unethical behavior that does not result in bodily harm, but they are still much more accountable than midwives. The film makes it seem as though midwives are the solution to patients being given misleading information and coerced/forced treatments, but midwives are equally as capable of doing this to pregnant women. I know because it happened to me, and have since found many stories of women who have been through it, too.

There is footage of a laboring woman in a hospital  asking “What is the risk to the baby?” and a doctor replying “minimal”. 

Combining this footage with the previous statements gives the impression that the doctor is lying to the patient. We are not given enough information about the procedure or the patient to judge if it is true or not.  This scene is emotional for me- I feel for the woman who may be uneasy about what her doctor has told her (or maybe she is feeling fine? We don’t get to speak with her again so we cannot know, her face is blurred so its impossible to know if she was even anxious or not). This movie expertly manipulates feelings of helplessness that women almost universally experience in patriarchal society.

A woman says “So if you’re in labor and the doctor says, ‘wow, I think we need to do x,’  you’re gonna say ‘yeah we need to do x’. The doctor may think he is giving you an option, but you hear the expert advising you to do something. ” The woman making the statement is revealed to be a part of citizens for midwifery, a political group whose aims are to increase the access of women to midwifery. 

I agree that patient consent violations are an enormous problem in medicine. It isn’t just a problem for pregnant women, and so using homebirth midwives as a solution leaves out a wealth of people who could benefit from a more universal solution. Almost dying in an accident, or surviving cancer, or any other situation that causes a person to face their mortality is a major life event and transformative in the same way that giving birth can be. People who actually care about solving a problem are always looking for possibilities to better deal with the problem, they ask meaningful questions about what strategy is best. They do not push a single solution and fail to discuss any others. That is a sign of pushing an ideology or a belief system instead of practical solutions for practical problems.

(more footage from monty python)

Ricki Lake and Abbey Epstein are on the phone with an indiana midwife talking about her interest in their project. They discuss that Ricki Lake is the driving force behind the movie because she had 2 babies, the 2nd one at home. Ricki discusses how it was important for her to experience everything, to feel everything, to have the memory of pregnancy and birth. She notes how a lot of women she knows don’t care about any of it, they just care about a healthy baby. She wanted to explore it because she feels that so many women are missing out on an amazing life altering experience of natural child birth. The midwife agrees that it is hugely transformative. 

(footage of a happy unmedicated birth)

Something I really resent now is that someone like Ricki Lake can use her class privilege to push whatever agenda she wants, simply because it was important to her personally.  I would personally love to make a documentary about the dark side of midwifery in america, but I am not rich or connected in the entertainment industry so its unlikely that I would ever get the opportunity. My message isn’t less important than Ricki’s, but only one of us will be heard on a national scale. People who wield that kind of privilege have a duty to others to act with integrity and avoid misleading others. This movie is grating in its emotional appeals and telling omissions. Shame on you, ricki lake.

Several other women discuss how powerful having a baby was for them and the reverence the occasion deserves. There is more footage of a different woman during her home birth labor.

“A woman doesn’t really need to be rescued. Its not a place for a knight in shining armor. Its the place for her to face her darkest moment and lay claim to her victory.” Says Cara Muhlhahn

At the time that I fell for this movie this line of thinking seemed empowering. In reality, none of us have any real control over if an unmedicated vaginal birth is possible for any individual woman. When I was in a doula training I remember the instructor saying “the baby will come out if she is in a coma. The uterus pushes the baby out.” I felt a little confused- how was it an achievement (or a ‘victory’) if it can just happen while you are unconscious? I ignored the cognitive dissonance involved with that. I admired how amazing our bodies are instead of questioning the premise of NCB- that you can control how your birth ends up. You can’t. All you can do is make a bet based on statistics and hope you are in the majority.

There is footage of cara assisting a laboring mom at home in a birth pool. 

Another midwife talks about how birth can be empowering and wonderful or traumatic and scarring. They show footage of a woman being wheeled off to an emergency c-section who is obviously in a lot of pain. 

The implication is that her birth by c-section was traumatic. We can’t know because we cannot speak to her. We are made to feel sad for her when really, the reality for women without access to c-sections is much more grim.

“We are completely lost. And we have even forgotten to raise the most simple questions. What are the basic needs of women in labor? And the fact that midwives have disappeared is a symptom of the lack of understanding of the basic needs of women in labor.” says dr michael odent. 

He continues “Like a traveler who suddenly can realize that, he took a wrong way. The best thing to do in this case, is to go back to square one. The point of departure. And to take another direction. 

This isn’t necessarily true. The best course of action may be to find out what is working and what isn’t, and make revisions to the things that are obviously not working. He doesn’t ever get specific about the ‘basic needs of women in labor’, but makes it the basis for his entire argument to return to home birth using midwives. Another claim that is impossible to actually examine for validity. Its boring at this point to type that out.

There is footage of Cara looking at a map and planning a route to a patient, and discussing her credentials as a CNM. She says that her reasons for preferring home births is that the client gets to have their baby at home. Her secord reason is that she would prefer to be on their turf instead of the other way around. She discusses the philosophical underpinnings of “giving the power back to the woman.”

This mindset isn’t restricted to midwives, there are OBGYNs who believe in giving power back to female patients. There are midwives who believe that they know better than patients. It is so easy to exploit the human tendency to stereotype groups of people, and this movie is absolutely shameless about it. They never ask if there are abusive midwives or feminist leaning physicians. Its an obvious question that the film makers failed to examine.

(footage of cara during prenatal visits. She is very nice to the patients and their families)

“I do believe that women who choose homebirth, they do share something. It could be just a feeling that she knows how she wants to do things. And then I think when she’s in labor, she can interact with her labor in a different way than if everyone is doing things to her and making decisions about her.” 

Examination of the themes so far:

I think women who choose home birth may or may not share things. I do know that most of them are white, middle or upper class, and college educated.  Something women of that demographic share more often than other groups is anorexia or bulimia. Until there is research about this I can only offer my opinion, but I do believe there is a connection. Natural Child Birth has a lot in common with the twisted thinking of an eating disorder. There is a lot of perfectionism, judgment, black and white thinking, and the belief that your body will perform a certain way if you are Good Enough. Your body will be proof that you are Good Enough. Your body, its pain, its resistance, is a thing to overcome to prove to yourself, and others, that you are acceptable. If you accomplish it you will finally feel amazing, whole, at peace. There is only one ideal birth to chase, just like there is only one ideal body.  Craving an unhealthy level of control over yourself or your life is a feature common to many women with eating disorders, it may be because there is such a large proportion of eating disordered women who have survived sexual abuse. Midwives are not helping these women, they are preying on them for income. This is such a horrible, dangerous idea to give women who cannot control if they need a c-section, or if natural child birth is a meritless agony to them in retrospect.

The movie deceptively pairs footage of doctors with negative statements and midwifery footage with positive ones. Where are the women like me, like so many others, who had awful midwives? Where are the vignettes of births that women considered ideal that were not NCB?  I have a hard time believing that the film makers could not access anyone with a contradictory opinion, they simply chose not to show anything damaging to the image of midwives.

Something that really made me dig in my heels and adhere more strictly to NCB ideology was the way that anti-home birth advocates ridiculed the idea that women highly value the experience of giving birth. It was extremely personal to me. I identified with this movie a lot because of the value it placed on women and their experiences.  I was at a positive place in my life after overcoming a lot of adversity, and after seeing this movie I thought “Hey, why not me? Maybe I can have the best experience and a healthy baby. Why not aim for the best life can offer?” When other women ridiculed chasing the ‘ideal’ experience of child birth I felt very sensitive about it. Who were they to tell me what I should or should not want?  They always framed it as an experience vs safety, but it seemed like a false dichotomy to me. Why not both? I had to fight for so long to feel like I was worth anything, or that things might turn out well for me in the next chapter of my life.  It also made me think that anti home birth advocates were sexist. The ridicule of a woman who wants ‘too much’ from life is rampant, and it seemed to me that this was yet another example. The worst thing a woman can be is someone who takes more than their share- of food, sex partners, of a conversation, of attention, of decision making, of authority. We are constantly told to be happy with our lot, even when it is woefully inadequate. It is unfortunate that anti-NCB groups are not sensitive to the hopes of women in NCB. I empathize completely with those wishes and do not see them as selfish or narcissistic.  I am hoping that this blog will be a place to show sensitivity to the valid concerns raised by NCB advocates while also being critical of their message about the proper solution to these problems. Stay tuned for more.

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.

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!

in defense of unnecessary c-sections

I found a wonderful piece about unnecessary c-sections, from a mom that (maybe) had one. I am in the same boat as she was, though I did not labor as long. Here are some of the bits I really appreciated:

You know why my c-section was traumatic? Because I felt like it was my fault. Because everything I read about c-sections treated them as something that happens to women who are uneducated and don’t advocate for themselves. Because I had bought into the idea that, if you don’t give birth vaginally, you did something wrong.

I don’t know if my c-section was necessary and I never will. Maybe if I had been somewhere without access to modern medicine, I would have been in labor for a few days, vomiting, in mind-warping pain, increasingly weaker and more exhausted, and eventually her head would have turned and I would have given birth vaginally.

Would that have been better?

Would that have been the way an educated person gives birth?

I identified with this so much. I can’t believe how I spent time wondering what I could have done differently to avoid a c-section. I know that self-blame for things that aren’t controllable is a sign of an unhealthy relationship (or unhealthy self esteem). To me it signifies the way Natural Child Birth causes an unhealthy relationship between women and their bodies.  They teach you that you can control your child birth destiny by being Good Enough. Strong, trusting of your body, positive, self assured, etc. It is a part of why NCB is so alluring to so many people- birth can be scary and feel very uncontrollable, if NCB were true we could all have much more control over our own birth experiences. This is an especially alluring thought for women who maybe haven’t always been in control, like the 1/4 of women who have experienced some kind of abuse in their life.

Another bit that resonated strongly with me:

There are some births where c-sections (and other interventions) are clearly unnecessary. There are other births where c-sections (and other interventions) are clearly necessary.

But an uncomfortable percentage of births fall in that gray area in between, where it is simply not possible to tell if the c-section is necessary or not. In that gray area, there are four possible outcomes:

1. True positive: A c-section is necessary and performed
2. True negative: A c-section is not necessary and not performed
3. False positive: A c-section is not necessary, but performed
4. False negative: A c-section is necessary, but not performed

Now, think about the consequences of 3 and 4:

• A c-section is not necessary, but performed: Well-documented risks of complications increase.
• A c-section is necessary, but not performed: Death or permanent injury of mother, baby, or both.

So, obviously, we want to err on the side of more false positives than false negatives.

I wish I had thought about that before my pregnancy! This makes perfect sense.

Another difference between midwives and OBGYNs

…an OBGYN can’t just dump you from care in your third trimester without helping you find a new care provider.  Actual health care professionals have an obligation to do what is best for the patient, and that includes not leaving them to their own devices when they are unlikely to be accepted as a patient by someone else. I found an article about a woman who got abruptly dumped by midwives during her pregnancy, and they refused to help her find a care provider.

The funny thing is, my entire pregnancy had been riddled with series of let-downs and deflated dreams. Getting kicked out by the birthing center was just another hole in the fantasy I’d built about pregnancy. And I did not even end up having the blissful, natural childbirth I assumed I would. In fact almost everything on the well thought-out, seemingly mild birth plan we naively handed to our labor team, went out the window. But interestingly, by the end of it all, I did feel empowered.

 

They knew it was hard to find an OB in the last trimester, but did not do any work to help her.  Could they have dumped her the day before her due date? I’m sure they could have. The problem with this case is compounded by the fact that the mother was suffering from depression and other mood problems. She was extremely vulnerable and the midwives washed their hands of accountability for her care. She was able to stand up for herself and find an OB, but who knows if the next woman will?

started a petition

please share this petition if you think direct entry midwifery needs federal oversight:

 

https://petitions.whitehouse.gov/petition/review-direct-entry-midwife-credential-safety-and-accountability/hF2dcL6g

six reasons you shouldn’t listen to the healthy home economist

I was linked to this article today, titled Six Reasons To Say NO to Vaccination. Its a stretch to call these ‘reasons’, but they are great examples of the kind of emotional decision making that is rampant in Natural Child Birth circles. Reason number one:

#1:   Pharmaceutical Companies Can’t Be Trusted

She goes on to list a bunch of things that pharmaceutical companies have done wrong. I agree that there are many problems with the pharmaceutical industry. That is not as evidence that vaccines are problematic.

Last time I went to Ikea I noticed a recall notice for a tea cup. Apparently it can explode if you put something too hot inside the cup.  It would not be reasonable to believe that the entire company makes dangerous products based off the recall of the cup. It would be even less reasonable to assume the entire industry was guilty by association, or that I should be fearful of teacups in general. Each claim and product can be evaluated on its own merit.

#2:   ALL Vaccines are Loaded with Chemicals and other Poisons 

Everything is a chemical. Literally. Its a meaningless descriptor in this context, so is the use of the word ‘poisons’.  She lists ingredients in vaccines, then lists a non-vaccine usage of the ingredient to prey on the fears of people who are ignorant of chemistry.  An ingredient having multiple uses does not prove that it is harmful or poisonous. She also ignores the issue of dosage- the ingredients she is describing are in extremely tiny quantities.

#3:   Fully Vaccinated Children are the Unhealthiest, Most Chronically Ill Children I Know

I don’t really care if the healthiest people I know are vaccinated or not, because it proves nothing about the truth of the matter. I care about finding tangible evidence of vaccines causing ill-health. That is why studies are performed on large numbers of people and with accountability for results and peer review- its what people do when they are interested in finding out the truth.

#4:   Other Countries Are Waking Up to the Dangers of Vaccines – 

If Other Countries jumped off a bridge, would you???

#5:   A Number of Vaccines Have Already Had Problems/Been Removed from the Market 

Again, every vaccine can be evaluated on its own merit. A problem with vaccine A does not mean vaccine B, C, D, etc have the same problem. There is a lot of black and white thinking going on in the post.

#6   You Can Always Get Vaccinated, But You Can Never Undo a Vaccination 

…but vaccines are a preventative measure, so you can’t always get vaccinated in time. There is also the fact that a lot of vaccines wear off and have to be given repeatedly to offer protection. That is a vaccine being ‘undone’ in the sense that it is no longer effective.

 

These are the same people who are constantly telling women to ignore their doctors advice, calling it ‘scare mongering’. Believing that there is a vast corporate and government conspiracy in place to sicken children for profit is seen as a legitimate fear, but contracting a preventable disease is not.  There is considerable overlap between people who are anti-vaccine and pro-natural child birth. This should be a huge red flag to anyone considering using direct entry midwives for their birth. They may believe that vaccines are poison and that they don’t need to be vaccinated (despite working around pregnant women and infants, who could be severely negatively impacted by contracting a disease like influenza or measles).  A midwife at the birth center I went to was not informed about vaccines and seemed to be against them, it was a nagging doubt that I should not have ignored.  It is further evidence that lay midwives are not medical professionals because they are ignorant of and in opposition to preventative medical care. Some will outright tell their patients not to vaccinate their children. Recommendations about vaccines are way outside the scope of practice for a direct entry midwife, so they should really stop.

one difference midwives aren’t willing to sell you

I remember being totally sold on using a midwife for my birth. A direct entry midwive, specifically. They are very eager to tell you about how they are different from the hospital and other health care providers (in terms of philosophy, not safety- they claim they are just as safe). There are some differences that they never alerted me to that I believe all pregnant women should be made aware of.

What midwives won’t tell you is that they do not want to be accountable for mistakes, and that they regard any attempt at making midwives accountable as ‘persecution‘.  They only want their own midwife-run organizations to be in charge of accountability, mainly so that there will be no harsh consequences. Midwives with clearly dangerous practices can simply move from place to place, preying on vulnerable women who would otherwise never be candidates for a home birth.  MANA (midwives association of north america) isn’t even willing to define what “low risk” means, they prefer to let individual midwives decide what that means. Why would individual midwives be better at deciding ‘low risk’ than a panel of experts (even other midwives), based on proper research?

This maverick do-whatever-you-want type of practicing was the norm in medicine for a long time. This documentary is about that era in medicine, specifically about a doctor who was performing hundreds of ethically questionable lobotomies in the 1940s. One patient died because he wasn’t paying attention to what he was doing, he was trying to pose for a picture during the lobotomy. He invented an ice pick technique to simplify the surgery (you can guess that there were no controlled trials in the development of the technique, and that results were mixed).  In those days doctors did not publicly discuss negligence with non-doctors and there were not any real consequences for malpractice.  Luckily, outside organizations and legislators got involved to hold physicians accountable for the outcome of their practices.  Midwifery today is in the era of 1940’s physician accountability: the public has to fight for it, because midwives are unwilling to regulate themselves.

When professional colleagues work together there is a natural tendency to feel loyalty and assume good faith. I understand that, completely. No situation illustrates the tendency of professional colleagues to excuse the inexcusable more than sexual abuse scandals. The catholic church (and countless other religious groups). Jerry Sandusky (and other educational facilities). Teachers and doctors are often defended by colleagues when accused of abuse. And yes, midwives, too.  The dynamic can happen in groups as small as individual families, with one parent ignoring the sexual abuse of their child by another family member. This is why outside accountability needs to exist in professional organizations.

If you need more evidence of midwives banding together when they should be condemning negligence, just look for what midwives have to say about it:

The reality is that if Rowan Bailey is found guilty of murder in North Carolina, then a precedent will be set that a death in a midwife attended birth was found to be WILLFUL murder of a baby.

Don’t talk to me about “But she wasn’t legal” because we all know that midwives hedge their bets on legal. They all do some small thing that is maybe crossing a line or helping someone they shouldn’t “legally” because frankly, the legal system is full of discrimination against healthy women and we all know it.

She is saying that all midwives break the law. They all determine their own guidelines and if they kill a baby or a mother because of the line they decided to cross- oh well. The midwifery community will be there to support the midwife instead of the patient with a dead infant.

For the record, the midwife in question let a woman labor for four days without obtaining any help. Gloria Lemay had this to say:

Shannon, thanks for this important post. I’m always reminded of the words by Angela Davis, “If they come for you in the morning, they’ll be back for me in the afternoon.” We’re all in this together. If one midwife is being bullied, all midwives are being bullied. The bright light of overblown charges is that, of course, they will be reduced. The tragic thing is that it’s akin to taking a baseball bat to a butterfly.

Please everyone, no matter how small, donate as a show of solidarity.

Everyone seems to be ignoring that a baby is dead, and their parents are very much alive and still dealing with the loss caused by negligence.  They forget pregnant women completely when their colleagues are threatened with legal action. When the state is (understandably) angry about a needless death it is “bullying” to use the harshest possible charge against the midwife. What will a midwife call it if you have to pick up a phone and report her?

In defense of midwifery compels people to give money to the legal defense of the clearly negligent midwife. Midwives talk very differently on websites intended only for other midwives. The author has a warning that when YOU (a midwife) attend a perinatal death you don’t want a DA breathing down your neck, right? I mean, unless you have a sense of ethical responsibility and believe perinatal deaths should be investigated!  This is what midwives do when there is negligence- they help each other pay their legal fees, and prioritize each other over patients.

Valerie ElHalta is one of the worst cases I’ve ever seen. When she caused death or injury and the state found out, she simply moved to a state with fewer regulations. She went to oregon, and then to Utah, where she used cytotec and a vaccuum extractor without adequate training. A preventable infant death occurred as a result. The midwifery community did nothing to stop her or warn other people that she had a history of poor judgment. When she was arrested in Utah the community here decided it was persecution, and that a political watchdog committee needed to be formed. 

Midwives will talk your ear off about woman centered care, about respecting choice, and whatever you want to hear… but they won’t tell you that if someone hurts you or your child they will be donating money and time to help the person who wronged you. Its perverse. I am lucky to have ended up on the wrong side of Direct Entry Midwives with my baby alive, but it doesn’t make seeing the defense of needless suffering and death any less infuriating to me.