How to be Born

BORN IN THE USA
How a Broken Maternity System Must Be
Fixed to Put Women and Childen First.
By Marsden Wagner M.D.. M.S.
295pp. University of Calfornia Press.



Scientists, in order for their research to have any kind of statistical validity, need to be dispassionate and totally unbiased. Doctors are not scientists. We hire them for their opinions.

Surgeons, in order to be able to make that cut and sew it up right, need to be cool and decisive, even detached. In fact, many hospitals will not allow surgeons to operate on close friends or relatives. Yet it is continuity of care and a trusting relationship with the care provider that most consistently increases positive outcomes and experiences for women in labor and birth. Obstetricians are surgeons

Obstetricians, like all doctors, are trained in pathology (disease.) Their experience and expectations of labor are that it is risky, painful and needs medical intervention to happen successfully. Healthy laboring women need, more than anything, to be trusted, monitored, protected, supported and left alone.

Who can blame doctors who only see what happens in the hospital; who are expected to manage every possible reproductive health issue, ward off litigation, keep clinic hours for prenatals, post partum visits and non-pregnant women, AND go to births; if they try to make their lives a little easier by scheduling more cesarean sections, speeding up or inducing labor with medication, and cutting routine episiotomies to help move things along?

Marsden Wagner, for one. In his new book he offers a clear picture of how and why American obstetrics is basically out of control.

Throughout the world healthy pregnant women are attended primarily by midwives and give birth in out-of-hospital settings. Among industrialized nations, the rate of women reporting satisfaction with their birth experiences and positive outcomes increases with the rate of midwifery care. Although the US spends more per capita on obstetric technology and has a higher rate of medical interventions than any other industrialized nation, our rates of infant morbidity and mortality are among the highest and continue to rise. Many obstetric practices in the united states do not conform to world health organization (WHO) guidelines, or even the recommendations of the FDA. Womens' labors are often induced for no medical reason, putting mothers and children at unnecessary risk. This is often done using Cytotech, a drug that is known to cause uterine hyperstimulation, amniotic fluid embolism and uterine rupture. Not only is thie drug used "off-label" (for a different purpose than the one for which the FDA originally approved it) but it is actually contraindicated for use in pregnant women. The rate of cesarean section, which the WHO says should not exceed 15% is above 30% in the US (and higher than 50% in many hospitals) Many women are not informed that the drugs they are being given are being used experimentally, or educated about other, non-medical options in labor and birth.

Wagner describes the American College of Obstetrics and Gynecology (ACOG) as a "tribe" with all the unspoken rules and hierarchy you'd expect. He tells many stories of doctors refusing to make official statements that would lead to negative consequences for another obstetrician; of midwives losing their practices because they couldn't get physician back-up, of oversight committees and peer review boards who take turns justifying one anothers' actions rather than forthrightly grieving loss, learning a lesson and moving toward evidence based practice.

This book would be a heavy handed condemnation, were it not for the vision of what could be. In Dr. Wagner's perfect world, healthy women are attended by midwives at home or in free-standing birth centers. Obsetricians attend high risk births in hospital settings.
Perinatologists (scientists) get the funding they need to do substantive research that begins to shape the scope and direction of maternity care.
Women form neighborhood self-education groups and care for eachother during pregnancy with the supervision of a local midwife. They become educated about and intimiately involved with their own health care while forging the invaluable relationships that will aid them throughout parenthood.
Midwives and doctors are equals. They collaborate and value eachother's insight and experience.
A singlepayer, or socialized medical system provides quality care for all pregnant and laboring women; making it possible for midwives to make a reasonable living, while reducing patient cost.
All health care practitioners are accountable to their clients and to oversight within the system.
All kinds of people all over the country know about, have experience with, and trust the process of labor and birth.
Women becoming pregant have a clear idea of what their care will look like. They go into labor for the first time having seen their mothers, aunts, cousins and friends do the same thing; sensing their connection to the millions of mothers who have made thier lives possible, and with the determination to instill in their daughters the same trust and strength that will sustain them through one of the most profound experiences of their lives.

I find it truly inspiring that, for all his familiarity with very frightening statistics, the author really seems to believe that profound change is not only possible, but that it's coming. And that women - that's us, ladies -
will be the ones to bring it.