Thursday, January 27, 2005

Let me start with a huge word of congratulations to our friends Katherine and James for the birth of their son, Seamus Patrick Harte. He was born yesterday at 2:00 pm, weighing 7lbs 5 oz, and was 19 inches long. Katherine and James found the Bradley method class we took, and we're looking forward to raising our kids concurrently (especially for what that means as far as babysitting duties and socialization of the critter). This news leads right into...

Book #3: Ina May's Guide To Childbirth by Ina May Gaskin



This one's going to be preachy, folks. Let me first say that I wouldn't have included this in a normal year because it's more self-help book than, say, a novel or book of essays. However, three reasons compel me to include it: 1) I have strong feelings on the subject, as I'll explain below; 2) although the first half of the book consists primarily of birth stories, the second half is a clear and concise screed about the wrongheadedness of modern obstetrics disguised as a guide to midwifery; and 3) considering that I probably won't have time to finish many books in the first few months of my baby's life, I will take all of the books I finish.

I'm a policy wonk in real life, so let me start with bias. Ina May Gaskin is the head midwife at the hippy-dippy TN recluse The Farm. Most of the hippy types I knew in Alabama eventually took a pilgrimage to The Farm (those that weren't brought up there, that is), and a few moved there and may still be there for all I know. I don't see how Gaskin's choice to live and work on the Farm makes her any less of an expert in childbirth, especially given her vast experience in the subject. Gaskin and the other Farm midwives have delivered over 2000 babies and have lower incidence of complications than the national average, primarily because, as Gaskin asserts, modern obstetrics is built around a cost-obsessed concept of convenience rather than common sense and health.

Gaskin doesn't have all of the statistics she needs. In fact, no one is collecting statistics on the entire population of U.S. childbirths. Most hospitals won't allow information on problem births to be released. Very few HMOs have a financial incentive to investigate hospital birth methodology because hospitals lean towards birth methods that are cheaper in the short-term. Let me repeat this: no one is looking at the long-term implications of current birth procedures, and no one is tracking the incidence or cause of problem births.

Most women talk about the pain of childbirth and the necessary recovery time. Many of our friends have told us to listen to the hospital staff because they are professionals and know what they are doing. Then we hear the horror stories about the difficulties they experienced after administration of the Pitocin or the epidural. Somehow, people have gotten it into their heads that childbirth is something that should be regulated with drugs as intrusive as chemotherapeutical drugs. Childbirth. An experience that, unlike cancer or most other life-threatening diseases, has happened to every single person (indeed, every single animal) who is alive and who has ever been alive. Why do obstetricians treat this process, the largest and most profound experience in the life of the parents and child, like a life-threatening medical procedure?

Take the Caesarian. Sure, there are some women who need major abdominal surgery to birth their child due to unforeseen complications. Out of mothers choosing natural, normal childbirth, the rate is less than 5 percent. In the world at large, the rate is closer to 8 to 10 percent. However, in the U.S. population, the rate is over 20 percent. Why is this? As with any odd behavior, there's a variety of reasons, but the policy wonk in me is swayed that cost is the primary factor. It is expensive to allow a women to have a long labor because the hospital (and HMO) must pay for the use of the room, the time of the staff, and there is a risk - albeit a small one - that the mother is having a long labor because of a complication that could lead to a lawsuit against the hospital. In the face of cost risks, hospitals and hospital staff prefer to go with the easier and cheaper option of major abdominal surgery, the Caesarian. After all, with the C-section, the doctor makes a small incision, rips the stomach and uterus open (ripped skin tends to heal faster than sliced), and removes the baby that way. A few stitches (and -- another digression -- it has become common practice in very short time [i.e. without any sort of long-term testing period] for U.S. hospitals to use a single-stitch repair for C-section birth because it takes only 5 minutes, compared to the safer 10- to 15-minute layer-stitch) and a prescription to a regimen of drugs later (and, oh yeah, don't nurse that baby for the next few months), and everything is finished. Medical schools institutionalize these rationales, and voila! high Caesarian rate.

There's more. Ultrasound has only been in use since the early 70s. No one knows the long-term effects of exposing a fetus to ultrasound. There have been very few studies on the effect to cellular development. It's ubiquitous because it's incredibly convenient. However, it would be convenient to simply kill subnormal children, too, but no one is recommending that. My point: convenience is not an acceptable rationale to propagate a process that has the potential for vast negative implications in the real world, but this method has spread like wildfire across the medical community. Say, why don't we just siphon nuclear waste into nearby water sources? After all, there would be no short-term effects!

Hospitals often use fetal monitoring machines that attach to the baby's head and monitor the heartbeat via electronic pulses. Yes, hospital attach a machine that transmits an electric pulse to the unformed and unprotected skin over the brain of a fetus in utero. Think about that. These machines are notoriously unreliable, too, often leading hospital staff to push for quicker delivery than necessary.

Episiotomies (that's the cut to enlarge the vaginal area, men) are commonly used in hospital deliveries, despite billions of years of evidence that the episiotomy is a mostly unnecessary procedure. With a little preparation and exercise, a women should easily be able to give birth without a cut.

Vaginal Birth After Caesarian (VBAC) is currently strongly discouraged in modern obstetrics because there is a small risk that the abdominal walls will tear (especially given the incidence of single-stitch repairs) and C-sections, as I pointed out above, are shorter and more convenient procedures for hospital staff.

Finally (although there's a lot more to talk about here, I would need to consult this book and the others we've read on normal childbirth beyond this point), epidurals cause the mother to feel more pain because she can't react to her body, lead to long back labor (and Gaskin's history of back labor -- which is a bad idea, as anyone with a conception of physics and gravity could immediately grasp -- is fascinating, too, now that I think about it, similarly built around convenience for hospital staff with a side dose of prudishness for good measure), and suppress both the infant's natural breastfeeding reflex and the mother's ability to produce milk.

Gaskin's book demonstrates how topsy-turvy childbirth in the U.S. has become. Modern obstetrics treats the mother like a patient with a life-threatening disease and treats childbirth itself like a routine medical procedure to shuffle through. What sort of brave new world is this? Doctors and HMOs would doubtlessly attempt to medicate crises of conscience away. Actually, that was supposed to be a joke, but what is the prevalence of purple pills if not just that? Maybe a better way of putting it is that doctors would give Buddhist monks happy pills. Science should never alienate people from their most profound experiences (and, honestly, I can't think of experiences more life-altering than childbirth or positive action [we could also call it satori] based on real, hard, sometimes depressing soul-searching), but we have come to the point that we treat these experiences as if they were problems, not solutions.

I want to encourage any expecting couples to look into normal childbirth options. Childbirth is one of the few definitive times in your life that you can embrace the sweet mystery of life. Don't give up that experience out of fear, especially when that fear is fostered by someone's desire for profit. If Ina May's book is too hippy-dippy for you (and, unlike her book Spiritual Midwifery, I seriously doubt that anyone would find the second part of this book hippy-dippy; it greatly pleased the meat-and-potatoes policy-wonk side of my brain), look into Bradley classes, talk to the La Leche League, meet with the midwives at your local birthing center. Childbirth tops the list of experiences too precious to let fear obscure your need for wisdom.

9 comments:

JBJ 2:09 PM, January 28, 2005  

I hope you'll revisit this post after the baby arrives (as soon as you get the time and energy!). I'm not saying you're wrong, and I get mad at the health care industry too, but our childbirth experiences (pretty conventional, in a hospital with an OBGYN) were good. Our OB doc was not exactly a warm human being, but he's very good at his job, and the OB nurses were awesome (you spend a lot more time with them).

To my mind, risk of complications and other bad stuff is mitigated by getting good prenatal care, "shopping around" for an OB you are comfortable with, and advocating strongly for your wishes during labor. (What little value there was in me being in the room with Angela was reiterating, in a loud voice, what she wanted.) I feel for women in rural communities or other situations who don't have much choice in who/what they get.

One anecdote: When our first child was born, the birthing center at Rex Hospital offered "suites" where the mother went through labor and delivery in the same room. They made a big selling point of this. By the time #2 came along, though, it was labor in one room, then they roll the mother into THE delivery room. The change was because "the doctors prefer it this way," though I wonder if there was a cost factor.

Hayden Childs 3:47 PM, January 29, 2005  

John, I agree 100% that informed parents can vastly improve their birth experience in or out of hospitals. However, how many parents do you think are informed enough to disagree with obstetricians over, say, C-sections? In my experience, many of the people we know who have encouraged us to relax and let the professionals work have been educated, intelligent people who just have faith in medical professionals. Lord knows I trust doctors and nurses to do the right thing when I need their advice or care on most issues. I could see myself easily reasoning: Why would a doctor lead me astray on childbirth? But apparently (and, again, this is the best part of Ina May's book: the statistics) a good proportion of obstetricians will do so without a second thought.

That said, the couple I mention at the beginning of the post had their baby in a hospital without the benefit of a doula or midwife. They took the Bradley classes with us, and they trusted their obstetrician to do the right thing. James felt that he could handle the situation if anything out of the ordinary started to happen. And they did fine.

JBJ 6:25 PM, January 29, 2005  

I'd bet the rate of Caesarians is higher, for instance, in Amarillo than it is in Austin. Middle-class parents who know their stuff can give the doctor certain signals in advance: that you know the downside to having a c-section and really want to avoid it, that you've studied Bradley or Lamaze, and (implicitly) if you have a bad experience with Dr. X you're going to tell all your friends about it and that they should go see Dr. Y.

I'm quibbling, though. Looking back, with Angela's deliveries they used a fetal monitor, and if the baby had been in distress & the doctor suggested a c-section, I'm sure we would have gone along. But we had communicated our preferences, and he would have had to communicate his reasons for going against them.

Marya 1:30 PM, January 30, 2005  

Actually the rate of c-sections is higher in higher-income women. I think it's a good bet that fear of lawsuits is a greater motivator than cost control for doing c-sections. Given that a c-section means three mandatory days in the hospital versus less than 48 hours for most vaginal births, that means that even if Gaskin's right about c-sections being done on the cheap, the cost of the surgery may be offset by the cost of the hospital stay.

I have lots more to say (and I am troubled by the whole idea of "normal" or "natural" as a description of childbirth without medical interventions), but I think finding a caregiver you trust has to be the most important thing. Whether it all goes absolutely by the book or not, birth is unpredictable; not an illness but a natural process that can, very naturally, end very badly. If things get interesting for mother or baby, you need to be listening to what your caregiver says you need, not quoting her the stats about failure to progress being a bogus diagnosis.

Yes, birth can be beautiful (our daughter's was, and hey, I was numbed from the chest down with my lower half hidden behind a curtain), but the main incredible thing about that day or two or less is that, whether it's grueling or thrilling or empowering or humbling, you get a healthy baby out of it. The unhappiest new mothers I've known were the ones who went in focusing on the glorious birth experience (and their detailed plans for how it would go), and then didn't get "the birth they wanted." What an awful thing to be brooding about when you could be enjoying your brand new person.

JBJ 11:48 AM, January 31, 2005  

I stand corrected about the c-section statistics.

No doubt, OB-GYNs are plagued by fear of lawsuits, and not without reason.

Hayden Childs 1:05 PM, February 08, 2005  

I haven't responded because I haven't really been up to it. Let me just say that I don't think any of us are in disagreement. The point I want to mainly hit is Marya's annoyance at me using "natural" and "normal" for drug-free childbirth (and drug-free, rather than medical personnel-free isn't an usual use for the term "natural childbirth"), which is, I think, a way of normalizing an increasingly unusual choice in childbirth. My larger point is not that either of y'all have had a diminished childbirth, because I don't think that such a thing is possible -- it's that U.S. obstetricians are too quick to choose convenience and short-term risk as reasons to push for medically intrusive decisions in childbirth, leading to untested results with potential long-term consequences.

Anonymous 7:57 PM, August 02, 2005  

Hi,
I saw this site while reviewing for my boards. I'm a physician (not an OB/Gyn). The medical school and residency program I attended has always taught that vaginal births are best. Even twin and favorable breech births are performed vaginally whenever possible. The perinatologists and OB doctors there are dedicated, highly trained individuals, and are not influenced by reimbursement issues or other non-medical reasons for C-Section.

Having said that,imagine my surprise when my adult step-daughter told me the community-based private OB/Gyn practice she works for actually asks the patient to indicate her preference for C-Section or vaginal birth at the first OB visit, apparently without providing information to the patient concerning the risks of Caesarian-section vs. vaginal birth! I was dumbfounded.

As physicians, we take an oath to "do no harm".
Educating patients about pros and cons of certain procedures, informing them of all their options, advocating for patients, and even protecting patients from their own bad decisions all fall under that umbrella.

28 years ago, my own son was born vaginally, with nothing but a saline drip in my veins, after 27 hours of labor. He was breastfed. He and I went home about 36 hours after delivery and he (and I) did fine.

I am one physician (and there are MANY) who think C-sections should be reserved for those women and babies who have a true indication, and that babies should be breast-fed whenever possible.

Hayden Childs 2:08 PM, August 04, 2005  

Thanks for your comment!

After the birth of our son (which I wrote about in a later post), I pointed out that the Austin Area Birthing Center also appears to have a vested interest in disinformation about birthing procedures. We're in a sad state of affairs when neither side of the issue is telling the simple truth about something so fundamental to all of our lives as childbirth.

I'm always happy to learn that there are many physicians (and perhaps this is "most physicians") who are committed to vaginal birth and to preventing unnecessary C-sections. But there should be a way to hold obstetricians like the one your step-daughter visited accountable for not discussing the risks of C-section births.

Anyway, good luck with your boards!

Anonymous 6:10 PM, May 04, 2009  

I used Ina May's book with my third child and wish I had had it for my first two, it would have saved me a lot of pain and trouble. Speaking of good reads, has anyone read the Vaccine Safety Manual by Neil Miller? I cannot recommend it highly enough.

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