The Obstetric-Industrial Complex | Book Review | Chicago Reader

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The Obstetric-Industrial Complex

An expose on birth in America just emphasizes how little things have changed.


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If you go to a hospital in the United States to deliver your child, you will probably do so flat on your back--thought by many to be the worst possible position in which to give birth short of being hung by the feet. You have a one-in-three chance of having major abdominal surgery. If you don't, you've got another one-in-three chance of having your vagina slashed with a knife. And you will have a better chance of dying, or having your baby die, than do women in almost any other industrialized country.

All of these depressing details and more are available in Jennifer Block's new Pushed, an examination of American maternity care in general and the rising rate of cesarean births in particular. Block used to be an editor at Ms., and the book is loaded with interviews, statistics, and the kind of muckraking you'd expect from a veteran of the progressive media. But what's infuriating about her narrative isn't that she's turned up new evidence of incompetence and negligence, but that she hasn't.

Block cites the latest studies, but their conclusions simply bolster what the World Health Organization has been saying for years. Adjusting for risk factors, mothers are four times more likely to die after a C-section than after a vaginal birth--and babies are at greater risk as well. During vaginal births, episiotomies (slicing open the area between the vagina and anus in order to widen the birth passage) can lead to infection, incontinence, and sexual dysfunction and according to research available since at least the 1980s are almost never medically necessary. If you induce labor with drugs like Pitocin the chances of a hard labor and of fetal distress both go up. Being hooked up to a fetal monitor has no proven medical benefit, makes the mother uncomfortable, and increases the risk of a cesarean. Again, all information available to doctors for decades--and thanks in part to Jessica Mitford's wry, scathing indictment of obstetric practices, The American Way of Birth, published 15 years ago, available to the public too.

Despite all this, women like Block who question the efficacy of our nation's obstetric care, are often branded by doctors, acquaintances, and even family as recklessly matriarchal uberhippies--ranting ideologues in hemp maternity clothes. But there's little ranting in Pushed. Block's tone is dry, her prose full of scientific minutiae about cesarean rates, obstetrician attitudes, historical studies, and the legal status of midwifery. Those undaunted by the facts and figures are rewarded with some quietly deft storytelling. Block's description of a typical C-section, for example, is neither overtly judgmental nor outraged. Instead she calmly piles on details--the surgeon struggling to work around old scar tissue, the blood, the nurses choosing a radio station, the mother seeing her child for the first time in a digital picture. Anybody who's ever been in a hospital for a major procedure will recognize the studied depersonalization and the downplayed but lingering threat that something could go very wrong.

After reading this passage it's hard to believe that any woman would choose to have a baby like this, and yet more and more women do. Cesarean rates dipped in the mid-80s but they're back up from 15 percent of all births in 1980 to 30 percent today. Elective cesareans--when a woman has a baby surgically removed by appointment before she goes into labor--are also on the rise (though by Block's account exact numbers are harder to pin down). Doctors often claim the increase is a reflection of patient choice. Women, obstetricians suggest, are afraid of labor. Block reports that there's even a new word for it: tokophobia, the fear of giving birth.

Still, judging from Block's research, the popularity of cesareans is less about fear than about scheduling. Obstetricians are highly paid, highly trained, upper-middle-class emergency specialists. Their time is valuable and they want things to move along. Saint Louis University nursing professor Kathleen Rice Simpson goes so far as to say doctors encourage women to give birth during the week and during the day so they can maintain their own normal lifestyles, with regular sleep and weekends off. In a study of physician-nurse communication, Simpson found that during labor nurses often try to keep doctors away from mothers. Once an obstetrician gets involved, there are going to be interventions, even if they aren't medically needed. New York obstetrician Jacques Moritz notes that the prevalence of unnecessary inductions is the profession's "dirty little secret."

In part, this is because of liability. If something goes wrong during a birth, an obstetrician can become uninsurable. Block reports on doctors who, in a frantic effort to decrease their exposure, have begun to refuse to participate in vaginal births of twins, or of breech babies, or of babies who are past term, or of any baby born to a mother who has already had a cesarean. This last is the main reason for the increase in scheduled cesareans--once you've had one surgery doctors fear the scar will tear during a vaginal birth. But liability only explains so much.

Block says in fact that after a C-section a second C-section may be more dangerous than a vaginal birth After multiple cesareans incidents of placenta accreta--when the placenta attaches too firmly along a scar from a previous surgery--have risen alarmingly. Yet physicians and insurance companies haven't taken steps to decrease their risks in this area.

Why? The answer still seems to be that in American obstetrics surgery and intervention are what's seen as "normal," while labor is seen as dangerous. Block's interviewees point out that obstetricians are comfortable with drugs and knives and taking charge. When there's a disaster, they're great. But as the midwives Block interviews demonstrate repeatedly, labor requires a lot of sitting still and a lot of patience. Obstetricians, Block suggests, aren't trained to do that and aren't very good at it. So they try to move labor into their comfort zone--the surgeon's table.

This is why, for primary care, the WHO suggests that it's often better to have a midwife, who doesn't have to rush to be somewhere else and who apprentices by attending many, many vaginal births, rather than by learning surgery. In places like Scandinavia midwives can provide primary care in various venues, with hospital obstetricians as emergency backup, and you get extremely low fetal death rates. In much of the U.S., on the other hand, doctors have successfully lobbied to force midwives to certify as nurses, keeping the majority of them in hospitals. In Illinois, one of the most restrictive states in this regard, midwives without nurse certification can be prosecuted if they attend a home birth.

As a result, even if you want to have your baby in a safer, saner way--without the risk of unnecessary surgical intervention--you may not be able to. Perhaps someday that will change, but until then we can expect excellent books like this one to come along at regular intervals, reminding us that the United S

tates is a terrible place to be born.

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