That summer was in the year of the seventeen year cicada. First, we saw only their shells haunting the trees and bushes and occasionally the children would find one of the strange moths on the driveway, breathing out its last bit of life after waiting under the ground for so many years. An entire existence in the dark for this one moment in the sunshine, this one moment’s claim on immortality.
With the warming days, swarms seemed to appear over night. As I peeled a sticky child from my chest with one hand, reaching with my other to silence the beeping phone that was causing him to stir, I heard their machinery-like love song over the hum of the window air conditioner. I tiptoed around the house, feeling the heat of the day beginning to sink in even at the early hour and, as I stepped outside, the full chorus of the cicada greeted me. For a moment, it sounded like an alarm sounding all around me. The heaviness of the air clung to me and every other living thing. The overgrown grass in our unkempt yard seemed to sweat. I placed my bags in the car and forced myself in, turning on the air-conditioning as quickly as I could. I took a long slow breath and felt a day’s worth of fatigue already overwhelming me. It was a bad day to be covering the labor floor.
My drive to the hospital was a quick one. We had bought our house several years before with the single goal of a very quick commute. When you spend as many continuous hours locked inside a brick building as I did, the thought of spending any significant amount of time getting there and back is unconscionable. Though, as far as hospitals go, it was a nice one. Set in the green suburban hills a short distance from New York City, it had a more serene ambiance than most. The grounds were always perfectly manicured with new seasonal flowers appearing each month. There were even beautiful gardens, ponds, and walking paths designed for the emotional well-being of patients, staff, and other guests, though I know very few staff who had ever seen them. The hallways in the main entrance were marble and friendly women greeted you upon entering. Each day, one of the local florists brought a fresh arrangement of flowers for the entry. It all made for a nice picture on the pamphlets and billboards advertising maternity services to the community. Only the creaking and stalling of the elevators revealed the building’s age and the administration’s reluctance to address bare bones issues. Compared to some of the more urban hospitals I had visited while exploring residency options, it was a paradise.
The morning started off quiet enough. After getting the morning report, I went to see a few patients who had delivered their babies with other physicians in my coverage group in the days before. The list was typical, fairly evenly split between women who had vaginal deliveries and the less fortunate women who had their babies in an operating room. Our labor and delivery unit was a busy one, where close to six thousand babies entered the world each year. The high risk care and neonatology unit were some of the most highly regarded in the country and most patients came for access to that level of care, should they need it.
The close to even split in mode of delivery had earned our hospital a place on the national naughty list of “bad” “high intervention” hospitals with unnecessarily high cesarean section rates. Occasionally, demonstrators would gather outside the hospital and hold a little protest to warn the public about all the supposed inappropriate things that went on inside. There was even a book that used our hospital as a central illustration of the many broken things about the obstetrical system in America.1 However, as I went from woman to woman that day and read the reasons for their cesarean, I did not find glaring examples of cesareans that should not have been performed. Most of the indications fell into the “shrug” category. Maybe if the patient had not received an epidural so early, maybe if they had not broken her water, maybe if they did not start this medicine, something could have gone differently, but who could know for sure? It was a big baby. The baby was in a bad position and the fetal heart rate tracing did not look good. Maybe no matter what the woman, the residents, her nurses, or her doctor had done, she would have ended up in the same place, with her baby born the same way just under a different set of circumstances. For myself, I could not think of a single cesarean I had performed as an attending obstetrician where, at the time I headed into the operating room, I did not feel I had exhausted every other option. It was a subject that frequently occupied my mind as I tried to keep my own cesarean rate low and as the hospital pushed for more and more reforms to improve their overall rate. Where did this very normal activity of having babies really all fall apart?
As the day wore on, the rooms on labor and delivery quickly began to fill. The heat brought them out in droves. Tired doctor after tired doctor entered the unit, sweat still dripping from their foreheads from the walk through the parking lot. Just as one room emptied, another belly, either in labor or simply wanting to be, occupied it again. Baby after baby rolled down the hallway. However, even by the afternoon, no patient had arrived for me to care for. I was the service doctor, there to provide care for any patient who showed up without a private physician to care for them, and I was feeling the nervous charm of my good fortune at having no work before me.
Every few hours, I emerged from my call room to inspect “The Board,” a listing of all the patients in labor that was hung in the center of the labor and delivery nursing station. Each patient was indicated by room number, doctor, number of previous babies they had borne, cervical exam, whether their water was broken, and what medications they were receiving. On most days, the entire patient list would have a “P” in the medication column, which indicated that they were receiving pitocin, a synthetic variant of the natural hormone oxytocin that brings about contractions. Nearly half the patients on any given day would have also been induced and had their membranes artificially ruptured. There was not a question of whether a patient was going to receive an epidural for pain management during labor, it was simply a matter of when the check appeared in the box to indicate that it was done.
My good luck came crashing to a halt twenty minutes after five, just as I was sitting down to my recently delivered nochi bolognese. One of the junior residents called, her voice urgent with concern on the other end of the phone.
“We just brought a patient to room nine. She is fully dilated but the baby’s heart rate is down.”
Unimpressed, assuming the patient was going to rapidly deliver, I reluctantly pushed back from my meal and asked, “Who is her doctor?”
“She doesn’t have one. She got her care with some midwife.”
Now I was interested. I briskly walked from my call room to the Labor and Delivery unit and entered the frantic room nine, where two residents were yelling at the woman to push while the patient was screaming and flailing out of control. Several nurses were slamming cabinet doors, quickly assembling delivery equipment, and preparing the infant warmer for a resuscitation. Multiple alarms were sounding over the methodical thudding of the fetal heart rate monitor, it’s slow sound obvious enough to make an actual observation of the heart rate unwarranted. As is my typical response to a crisis situation, I became very calm and quiet. I walked to the cabinet and retrieved a pair of gloves, while simultaneously questioning the residents.
“What number baby is this for her?”
“Second, previous baby was section.”
“She’s a VBAC?” I demanded incredulously. The situation now much more dire. The resident nervously nodded in assent.
“I am going to examine you,” I informed the patient. The patient’s labia were purple and swollen. I felt for the baby’s head. It was low in her pelvis, but molded and swollen. The realization of what was going on washed over me. I tried to get the patient to look in my eyes.
“How long have you been pushing?”
No response. I now noticed her companions for the first time. A middle aged woman in street clothes stood attentively at the patient’s side, along with the panicked father. I mentally went through the woman’s list of possible identities: mother, aunt, sister, friend, doula, or midwife. I decided it was one of the latter and now met her gaze.
“How long has she been pushing?”
She quickly looked back and forth at the patient and then her husband, the conflict raging on her face. Finally the patient’s husband responded reluctantly, “Two hours.”
I did the quick mental calculation to determine the quickest way to get the baby out, running through all the possibilities that got them here and the consequences of each decision I had before me. I decided in under five seconds.
“Vacuum,” I demanded and promptly applied the suction cup to the baby’s head, not bothering to instruct the residents and feeling my own pulse begin to rise. I took a moment to settle myself and then did what I had been trained to do.
The infant emerged pale and purple in color, not crying, with four little limbs hanging limply at it’s side. The cord that had been tight around the child’s neck had been quickly cut and the baby was handed off to the awaiting neonatologist. Once I gave it up, I felt my hands begin to shake, as the adrenalin finally had its effect, and heard the mother weakly ask as they were busy forcing air into the baby’s lungs,
“What is it?”
“A girl,” one of the nurses replied.
“Sophia,” the mother smiled to her husband, not grasping what our quiet, serious glances implied.
The woman at her side encouraged her with a forced smile, “You did it!”
“I did it, I’m so happy.”
Baby Sophia spent many weeks in the Neonatal Intensive Care Unit before being discharged home with a presumed anoxic brain injury. After the delivery, I saw the woman from Sophia’s birth in the hall outside labor and delivery. Initially, I meant to simply pass her by, but I could not hold back the question that had been plaguing my mind.
“Why did she try to have her baby at home? She was high risk.”
The woman shrugged and then replied unapologetically, “She wanted a natural birth. She wanted a vaginal delivery. No one would even let her try.”
The urge to blame someone for Sophia’s birth is strong in most people who hear her birth story. It is easy to blame Sophia’s mother. That blame is the natural conclusion that arises from the presumption that a pregnant mother’s first and foremost duty is to make decisions that prioritize the safety of the infant she carries, even if that is to her personal detriment. That presumption is so ingrained in our society that it is rendered incontrovertible and any perceived deviation from that norm draws criticism from even the strongest proponents of personal autonomy. The woman sacrificing herself on the altar of motherhood is female glorification in its highest form. The lines of sacrifice are repeated in movie after movie, television show after show, often spoken between couples clutching hands with emotional music playing in the background, “If you have to make a choice, to save me or save the baby, you save the baby! Save the baby!” The decision made by Sophia’s mother to pursue a “high-risk” vaginal delivery, in a way that may have put her child at increased danger, is deemed an inherently selfish act according to our collective moral consciousness, so conditioned by a subjective valuing of child over mother. Selfishness is the most damning judgment we can place on a mother and the gravest of insults.
It is easy to blame the midwife. Again, according to our modern viewpoint, by choosing to attend Sophia’s birth within the home, she presumably prioritized mode of delivery and her patient’s birth experience over Sophia. She failed to recognize fetal distress and arrange transfer to the hospital in a timely fashion. She was also clearly practicing outside of her scope of care and, according to some state laws, outside of the legal limitations of her midwifery license. Home birth, in and of itself, is not supported by the American College of Obstetricians and Gynecologists and a history of previous cesarean delivery is considered an absolute contraindication to delivery within the home.2 In 4 out of 28 states where Certified Professional Midwives, midwives without a formal nursing background, are licensed to practice, a midwife who attends an out-of-hospital VBAC can actually be arrested and imprisoned for providing this care.3
However, it is exceedingly more difficult for those within the medical community to consider that they may share in the blame for Sophia’s birth and examine the ways in which their own system creates the sequence of decisions that culminate in births like Sophia’s. In this case, the labeling of VBAC as “high risk” immediately restricted the options for Sophia’s delivery and created risk by offering only extremes of care. It is particularly interesting to note that in this circumstance, it was not the “high-risk” vaginal delivery after a previous cesarean delivery that resulted in Sophia’s compromise. It was simply a routine challenge that impeded Sophia’s blood supply, a tight umbilical cord around the neck, a complication which could have occurred in any “low-risk” delivery. The reason this problem was not detected and acted upon before it caused harm was because Sophia’s mother was not in a hospital. The reason Sophia’s mother was not in a hospital was because she could not find a doctor who would be willing to “let” her have a vaginal delivery after her previous cesarean section. The question I should have been asking was not why Sophia’s mother tried to have her baby at home, but why she felt she did not have the option of a hospital birth.
Women throughout the country are finding themselves with limited options when it comes to the delivery of their children. The cesarean section rate has remained steady at 32% for the last 2 years.4 While overall induction rates have decreased, one in five women still have their labors induced artificially and the list of medical indications for induction has expanded to include advanced maternal age, maternal obesity, and an ever-declining definition of postdates pregnancies. In a survey of over 2000 women, 14.8% of respondents felt pressured into an induction and 13.3% felt pressured into a cesarean delivery.5,6 In the same survey, 76% of women indicated that they were unable to walk in labor and 92% delivered lying on their backs. Nearly all the women who were surveyed, four out of five, had continuous fetal heart rate monitoring, received IV fluids, and had food and drink restricted.7 Of those women like Sophia’s mother, who had a history of a previous cesarean delivery, 90% had another cesarean delivery.8
The hospital, once a harbor of safety through an unpredictable labor process, has become an institutional representation of the battle being waged over women’s bodies and reproductive rights and the stage upon which women feel horrific atrocities are committed, not prevented. Obstetricians and nurses, rather than being viewed as guardians of women and infants through a tumultuous birth process, have been cast as central villains in a performance of unwanted cesarean sections, unnecessary medical interventions, and disrespect toward laboring women that plays itself out in countless labor and delivery units across the country and is recounted in tale after tale featured in various films, news articles, and mommy blogs. Births are managed in a machinery fashion under the guise of ensuring safety. Labor and delivery protocols, one of the last vestiges of a patriarchal medical system, tell women what they are and are not allowed to do with their own bodies and babies. Women are “not allowed” to walk, eat, or take off their blood pressure cuff or fetal monitor. They must labor in bed, deliver on their back, and often receive medications and episiotomies without appropriate explanations or even specific consent being obtained, beyond that of an all-inclusive consent they sign upon admission to the hospital but rarely read. Women are “not allowed” to remain pregnant past a certain gestational age and must present at the hospital for their induction. Many hospitals and physicians “do not do” VBACs.
In response to this over-medicalization of the birth process and the lack of autonomy experienced in many maternity wards, an ever-growing percentage of women have begun to speak with their feet and reject part or all of standard prenatal care and seek options for their labor and delivery along the fringes of the traditional medical establishment or outside it. It is not only women who want a VBAC who are fleeing obstetricians and hospitals, but also women who simply want to give birth without technological interventions, without epidurals, and without an increased risk of surgery. According to data released by the CDC, in the short time period from 2004 to 2012, there has been a 56% increase in out-of-hospital births and the percentage of births attended by midwives both in and out of hospital has more than doubled to represent 7.9% of all births in the United States.9,10
Multiple advocacy groups have arisen out of the current climate, working to combat the injustices and inappropriate care that are felt to be pervasive within the maternity health care system. The Coalition for Improving Maternity Services, the Maternity Center Association, Childbirth Connection, Choices in Childbirth, the International Cesarean Awareness Network (ICAN), ImprovingBirth Network, and VBAC Facts are some of the more prominent examples of these groups. An entire natural birth industry has formed as well, offering various products and services, including childbirth educators, doulas, and lactation counselors, that are meeting the needs of women that are being unmet by the medical community and with varying levels of expertise. DONA INTERNATIONAL, the leading doula certification program, has seen its membership grow from 750 in 1994 to over 6000 in 2012. Over half of women in the United States attend some form of natural childbirth education, with a wide range of options including Lamaze, the Bradley Method, BirthWorks, HypnoBirthing, or one of the many hospital-sponsored classes taught at nearly every maternity center in the country. Multiple natural birth promoting online communities, such as BabyCenter, TheBump, Mothering.com, have grown and flourished, where women offer support, share information, and discuss birth experiences. Countless books have been written describing the problems with US maternity system and offering natural alternatives to its norm.
Those that go by the term “birthworkers,” the midwives, doulas, childbirth educators, and lactation counselors in the natural birth community, advocate for a physiological birth model, defined as labor and birth powered by the innate human capacity of the woman and the fetus without medical intervention. Specifically, this model calls for the spontaneous onset and progression of labor, appropriate biological and psychological conditions to enable labor to progress in an unhindered fashion, a vaginal delivery of the infant and placenta, and skin-to-skin contact of the mother and newborn infant with no separation in the postpartum period and early initiation of breastfeeding. Proponents of a physiological birth model are often highly critical of obstetricians and hospitals alike and strongly call into question much of what has become standard in both prenatal and labor and delivery care, including ultrasound, antibiotics for prevention of group beta Streptococcus—related sepsis and meningitis, intrapartum fetal monitoring, vitamin K administration in the newborn for prevention of hemorrhagic disease of the newborn, antibiotic eye ointment for prevention of birth-related conjunctivitis, and cesarean birth for breech presentation or multiple gestations. They routinely raise the question of whether low-risk women should even be receiving care from obstetricians, who they view as surgeons first and foremost, who are without the knowledge or philosophy of care to be able to properly support a physiologic birth process. Most believe birth is safer in the home or in a midwife-run birth center because medical interventions, rather than the birth process itself, result in the greatest number of bad outcomes and what bad outcomes that do occur in homebirth or a birth center could not be prevented in a hospital birth to any large degree.
Most people within the medical community consider these positions to be dangerous anti-medical extremism that will ultimately result in the loss of more women and babies during the birth process. Some of the more vocal critics of the natural birth movement, such as Dr. Amy Tuteur, accuse these organizations of promoting an idealized vision of birth and shepherding women toward unmedicated deliveries in order to sell a product, in this case: midwives, doulas, childbirth education, lactation counseling, natural birth books, and birth supplies. Rather than answering a need, they are creating it by convincing women there is a perfect birth that they need to obtain, similar to the way the wedding industry sells the idea of the perfect wedding.11 From the medical perspective, the complaints of natural birth proponents and the women they support represent “high-class problems” in a world where real neonatal and maternal mortality still exist to a startling degree in underdeveloped countries and underserved populations. They argue that American obstetricians and the modern maternity system are merely victims of their own success; women only lament unpleasant birth experiences because they have no knowledge of or experience with the very real horrors that can occur in birth and are prevented by medical intervention. Any birth process that results in a healthy mother and a healthy baby is, by a medical definition, a success and any process that exposes mothers and babies to an increased real or perceived risk is rigidly avoided.
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