Drugs, Knives, and Midwives

The U.S. maternity care system is in crisis. A grassroots movement to save it is under way.

Content Tools

The woman, who is expecting her first child, is a week past her due date. Even though tests show that her baby is doing well, her obstetrician decides to induce labor with Cytotec. It's a drug that has not been approved by the Food and Drug Administration (FDA) for pregnant women, and it can cause contractions that are strong enough to lacerate the anatomical barrier that keeps amniotic fluid separate from the mother's blood vessels -- a situation known as amniotic fluid embolism (AFE). AFE is almost always fatal.

The woman's contractions speed up immediately, but the doctor continues to give her Cytotec until her contractions are coming so rapidly that the baby is having difficulty getting oxygen. The fetal monitor shows that the baby is in extreme distress, so the doctor sets to work to save it.

Shortly after the birth, the mother starts to hemorrhage and goes into shock. The baby dies 35 minutes after birth. The mother dies a few hours later from AFE.

This nightmarish scenario is one of many from Marsden Wagner's book Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First (University of California Press, 2006). A perinatologist and a scientist, Wagner is a former director of women's and children's health at the World Health Organization (WHO). He's also an old-fashioned whistleblower. By his lights, the American birth industry is in a crisis because we have turned a natural event into a medical condition. As a result, we've allowed obstetricians -- and not the midwives who safely deliver the majority of the world's babies -- to control maternity care. The ironic result is that in our efforts to make birth as safe as possible, we have saddled American women and babies with a system that, despite being the most expensive on earth, puts us in the bottom tier of care for wealthy countries.

Today, more than 15 years after Jessica Mitford detailed the potential hazards of obstetrical forceps, fetal monitoring, and diagnostic ultrasound in The American Way of Birth and more than a quarter century after Immaculate Deception, author Suzanne Arms' expose of high-tech birth, sold more than 250,000 copies, the number of American women who die around the time of birth is on the rise. According to WHO, 28 countries -- including Croatia, Ireland, Kuwait, and Portugal -- have lower maternal mortality rates. Forty-one countries have lower infant mortality rates.

It's not just the shocking mortality rates that trouble Wagner and other reformers. Childbirth Connection, a New York organization dedicated to improving maternity care, recently published Listening to Mothers II, a national survey of 1,573 women who gave birth in 2005. Its findings document numerous indignities and dangers, most of which easily could have been prevented. Of the 25 percent of women who were given episiotomies (a cut in the muscle between the vagina and the anus to widen the birth canal), a startling 73 percent were not consulted before having the procedure.

While an episiotomy is a minor -- albeit painful and often unnecessary -- procedure, a cesarean section is major surgery, and 32 percent of Listening to Mothers II respondents had one. That's a higher rate than the 29 percent cited by Wagner, itself a steep increase from the 21 percent reported five years earlier. Given that WHO has calculated that the optimal rate of C-section for saving the most women and babies is between 10 and 15 percent, what's driving this trend?

Certainly, in this age of rising malpractice insurance costs, obstetricians want to protect themselves from being sued. But Wagner also thinks that C-sections offer doctors a way to bring the most time-consuming part of their practice under their control. 'It means they can split their time between seeing patients in the office, doing gynecological surgical procedures in the hospital, and attending births, on a timetable of their choosing, and reduces the chance that they will be required to attend births at inconvenient times,' he writes. 'For some, it is perhaps their only chance to have a decent personal life.' Wagner also believes that our skyrocketing C-section rates are driven by the internal politics of the birth industry. By promoting cesareans, doctors are choosing a procedure that midwives cannot perform.

Even in an elective cesarean, a woman is almost three times more likely to die than in a vaginal birth. Beyond the immediate health risks, having a C-section decreases a woman's chance to become pregnant again and doubles the risk of an unexplained stillbirth in later pregnancies. In 2 to 6 percent of cesareans, a doctor accidentally cuts into a baby. Babies born from an elective C-section are twice as likely as babies born vaginally to end up in neonatal intensive care.

The widespread use of labor-inducing and painkilling drugs is another by-product of what Wagner sees as the rampant medicalization of American births. According to Listening to Mothers II, four labors in ten were started artificially. The most common method used (80 percent) was synthetic oxytocin, more commonly known as Pitocin. There is no disputing that induced labors can be medically necessary. But they also are done at the request of anxious mothers who are so exhausted by their pregnancies that they just want to be done with them. In theory, there is nothing wrong with trying to jump-start labor; since human life began, women have been walking, squatting, rubbing their nipples, swallowing castor oil, snorting sneezing powders, and having sex to give their babies a nudge. But nearly 20 percent of the women in the study who were induced said that they felt pressured by their doctors.

The problem with using Pitocin is that it makes contractions more painful and creates a snowball effect that often leads to pain medications such as epidural blocks, which spur their own set of complications. According to Wagner, a quarter of women who receive an epidural experience side effects such as fevers, urinary incontinence after delivery, headaches, temporary and permanent paralysis, and even death. Because a woman who has had an epidural cannot feel or move her lower body, she has to give birth lying on her back, which is less efficient than upright positions such as squatting or standing.

When Wagner challenges doctors who use Cytotec, he's told that if they were to wait for FDA approval, they would be stalling the medical progress of their field.

This arrogance, Wagner warns, is endemic in the practice of medicine. He urges his readers to push past unfounded fears about safety to realize that 80 percent of births don't need medical interventions. But while Wagner blames the medical establishment, a roundtable discussion in the journal Birth (Sept. 2006) takes a wider view that implicates our panicky, instant-fix culture. 'We are a terrified, risk-aversive society,' writes Michael C. Klein, professor emeritus of family practice and pediatrics at the University of British Columbia, who believes that we want the easy solution in all aspects of our lives. '[We] pop a pill and carry on being fat and out of shape, while [we] expect to die suddenly at age 90 in the middle of sexual intercourse. We demand it of society, the medical profession, ourselves.'

In their indignation, critics of the current birth system tend to overlook the fact that despite its myriad shortcomings, there have also been considerable advances in the way we give birth, and that birth fads and trends are products of their time and culture. Tina Cassidy's Birth: The Surprising History of How We Are Born (Atlantic Monthly Press, 2006) is a fascinating tour through the dark days of craniotomies (puncturing the fetal skull to remove babies who were stuck), cesareans without anesthesia, and 'Twilight Sleep,' a method developed in Germany in 1914 in which women were drugged into a semiconscious state, strapped to their beds, and then had their ears stuffed with cotton so they wouldn't be awakened by their cries of pain. Indeed, a fair number of women giving birth today were born to mothers who were unconscious. Fathers were routinely banished from delivery rooms until the 1970s, and newborns slept down the hall in nurseries and were fed formula on rigid schedules.

Most new families today spend the night together in the same hospital room because activists in the 1960s and 1970s demanded that birth become a more human, family-centered experience. Now, a new breed of agitators are starting to take matters into their own hands. In a December 2006 Boston magazine article, Cassidy details the efforts of Boston-area women who are fed up with unwanted C-sections, false positive prenatal screening tests, scant breastfeeding support, and incorrect predictions from doctors about dangerously large babies. The members of this 'mommy uprising' are hiring hands-on midwives instead of obstetricians and are insisting that they be allowed to have a doula -- a supportive labor coach -- present at the birth. Some are passing on the hospitals altogether in order to give birth in the familiar comfort of their own homes. But while studies have shown that home births are as safe as hospital deliveries for low-risk pregnancies, most doctors oppose them. In some states, attending a home birth is illegal, and home birth midwives and their clients (not 'patients') have been driven underground.

Wagner argues that midwives are key to fixing our broken maternity system and that they should be given the primary responsibility for women with low-risk pregnancies. (Obstetricians can be responsible for women with serious medical complications.) He envisions a system in which most maternity services are located in neighborhoods and not hospitals. If the United States had a national health care system, American obstetricians would no longer be able to maintain their monopoly on the birth industry. He also calls for doctors and hospitals to be more transparent, providing information about not only their C-section rates, but also rates of maternal and infant mortality, uterine rupture, and adverse drug reactions.

Of course, there are thousands of obstetricians who provide expectant and laboring mothers with compassionate, ethical, and medically first-rate care. And there are plenty of midwives who in their fervent belief in the rightness of their approach display the kind of arrogance Wagner ascribes to his fellow doctors. To make its way into the mainstream, midwifery needs to move beyond its earth mother image and take a more tolerant view of American women's fear of excruciating physical pain. In her book Misconceptions: Truth, Lies, and the Unexpected on the Journey to Motherhood (Doubleday, 2001), Naomi Wolf articulates this challenge. Describing the difference between the alternative birth center and the maternity ward at her Washington, D.C.-area hospital, she writes that 'the contrast between the two delivery floors seemed to sum up a failure to give women decent choices in childbirth. I did not understand why the polarity was so stark: the beautiful floor with its rigid set of options regarding pain, or the slaughterhouse atmosphere of the regular birthing rooms where I could receive medication for the body if I needed it, but nothing for the soul. My heart longed for the alternative birth center, its beauty, the openness. But could I stand the pain? And would my labor go so smoothly that no complications would arise to get me sent to the warrens down below?'

As anyone who has read Misconceptions knows, Wolf was indeed shuttled out of the birth center when her labor failed to progress according to her nurse's time line. After Pitocin and an epidural, Wolf was rushed into an operating room for an emergency C-section. It's a scenario, she later found out, that is all too common among American women giving birth. To paraphrase Wolf's critique of the popular pregnancy manual that in her view encourages women to passively accept overly medicalized births, she did not get what she expected when she was expecting.

Elizabeth Larsen is a freelance writer based in Minneapolis. She has given birth twice in a hospital assisted by midwives and is grateful that they didn't shame her when she demanded pain relief.