Beyond the Birth Wars

The Grieving Parents by Kathe Kollwitz

Since writing two essays which address the natural childbirth movement (first in 2011, then again last week) I feel a bit as if I've been sucked into the tunnel vision of the Birth Wars. 

Taking a step back, I see it all as a paltry debate among those of us who are lucky enough to have quality and choices when it comes to our health care.

Don't read me wrong; it's clear that there is a whole lot of natural childbirth woo out there that is distinctly anti-science, anti-medical establishment, and anti-feminist. It is clear that lay midwives attending high-risk births in homes instead of hospitals has resulted in the preventable deaths of babies and women. 

It's just that in reading about the broader picture of birth in both America and across the world, I see a much greater concentration of death and harm among the economically disadvantaged, and especially women of color. I feel compelled to check my priorities. It's not that every woman and baby doesn't matter. It's that every woman and baby does matter.    

The Widow II by Kathe Kollwitz

For many pregnant women and their newborn babies, the difference between rich and poor is the difference between life and death. For instance, according to Save the Children's State of the World's Mothers 2013, in Cambodia, babies born to the poorest 20% of parents have a 144% elevated risk of death compared to babies born to the richest 20%. More than a quarter million women die every year because of complications from childbirth.The dead babies (and consequentially the grieving mothers, many of whom must endure their grief without sufficient social or mental health support) number over a million every year. Without question, most of these deaths are preventable, connected to, and exacerbated by the conditions of poverty.   

America's GDP doesn't make Americans immune to the deadly disadvantages of poverty. In 2011 the World Health Organization reported that the USA had a higher newborn mortality rate than 40 other nations. And a 2010 publication by Amnesty International reported about the high rates of maternal deaths and complications associated with pregnancy and birth for American women. 

In addressing these issues, natural childbirth advocates cry out about overused medical interventions and unnecessary c-sections. But it seems apparent to me that the problems for women and babies at higher risk begin long before a woman becomes pregnant. Food insecurity, poor nutrition, unsafe and/or highly stressful living conditions, and inconsistent access to preventative health care set women up with issues such as high blood pressure, diabetes, and obesity, all of which can easily lead to complications in pregnancy, which then may very well require all those interventions and c-sections. 

Then there's the elephant in the room that nobody wants to talk about, and often if anyone does, they are shut down: racism. Race is the strongest predictor of outcomes for birth in America (with black women and babies suffering the worst outcomes), and yet when these huge disparities are reported and discussed, the focus tends to stick exclusively to economic disadvantages and ignore the *gasp* possibility that black women are treated differently by doctors, nurses, and other health care workers (not to mention employers, teachers, social workers, or anyone else they encounter and who might impact their lives.) But is it so hard to imagine that pervasive and damning stereotypes of pregnant black women, especially poor, young, pregnant black women, could have at least a subtle impact on the way they are handled and advised by medical professionals during prenatal care, birth, and postpardum care? 

Authors of the 2010 article Closing the Black-White Gap in Birth Outcomes: A Life-Course Approach, outline a 12 point plan which includes suggestions which seem indirectly connected to pregnancy and birth, such as "Invest in community building and urban renewal", and "Reduce poverty among African American families." People who enjoy strong communities and financial security often take their huge benefits for granted and fail to see how they dramatically impact a person's overall health, behavior, and choices. 

Of course the broad suggestions in this 12 point plan need to be refined into specific programs, many uniquely tailored for particular communities, but the overall point is sound. 

The issues that result in dead or injured women and babies at birth can't be solved by either warm and fuzzy homebirth midwives or even a well-trained OB with a scalpel. The physical, emotional, and social needs of impoverished women not being met are far too great. 

My Failed VBAC Attempt

I attempted VBAC (vaginal birth after c-section) for all the right reasons. 

To run down the list: under 35, not overweight, no gestational diabetes, had only one previous c-section, more than 2 years ago, with a transverse incision. I went into labor before my due date and my daughter was only 7.1 pounds. 

My prenatal care was with a well-trained CNM (Certified Nurse Midwife) with 15 years of experience delivering babies, including VBAC babies, in a hospital setting. The hospital was welcoming to appropriate VBAC candidates, and the staff even had a recent experience with uterine rupture which thankfully had a healthy outcome. I felt confident in their ability to handle an emergency situation. 

My midwife told me not to frighten myself by looking up a bunch of uterine rupture stories, but of course I was going to at least do some looking into the issue. Uterine ruptures are rare, but not that rare - about 7 in every 1000 births. They are a life threatening complication for both the woman and especially the baby. Even for the survivors, it is common for a woman to end up with a hysterectomy, and for the baby to suffer brain damage. 

If you Google "uterine rupture stories" you can find plenty with happy endings (I imagine the people with sad endings don't like to share their stories as much), but they all happen in a hospital and after a terrifying ordeal for everyone involved. 

Of course having another c-section carries its own additional risks, so I decided that as long as I remained low risk throughout the pregnancy and did my VBAC with a CNM (opposed to a non-nurse midwife) in a good hospital, I'd be okay. 

The hospital didn't stop me from keeping Bee in my room.

Thank goodness I took the necessary precautions, because I did have a uterine rupture! After almost two hours of pushing and the baby almost coming out, the OB told me, my husband, and the CNM that she "strongly recommends a c-section." That was enough for me; just show me where I sign the consent form and get this baby out. 

It wasn't until after they opened me up that she saw the ruptured uterus. Apparently my daughter's body was blocking the opening, thus preventing anything from coming out or in. Had I managed to push her out vaginally, everyone at the hospital would have gone into red alert mode trying to save both our lives. 

Mom, Dad, big sis, and baby Bee, all healthy and together.

After they whisked my daughter Eulabee, my husband, and the CNM out of the room I closed my eyes. Thinking I was asleep, the staff went ahead and expressed their shock over what had happened. 

OB: So.... when I opened her up, the baby's shoulder was sticking out of the open scar. 

*a couple soft gasps and some awkward silence* 

ANESTHESIOLOGIST: She's not going to try this again, is she? 

No, siree, I am not! I'm quite happy as the mother of two, and this birth scared the bajeebers out of my husband so bad that he ran out and got an vasectomy as soon as he could. 

I attempted VBAC for all the right reasons, and it failed. 
Because I took all the precautions recommended by the medical establishment, I'm fine and Eulabee is fine. What about those who don't take such precautions?  

I have only ever written about birth and the Natural Childbirth Movement once before. It is still my most frequently read post, attracted the most comments, many of them attacking me for criticizing aspects of that movement. When I wrote that post, I had not yet delivered Eulabee. But I was pregnant, and wrote: 

When I found out I was pregnant again, I immediately called the Birth Center. I found out I couldn't have my second baby there, so I asked for recommended options. I was given a short list of CNMs who work at or with hospitals, which was great. 

But then the person on the phone said, "I can also give you the names of midwives who do homebirths." What!? If it isn't considered safe enough for me to attempt VBAC at a top notch Birth Center across the street from a hospital, why the hell would it be safe for me to try it in my home that is a 20 minute car ride (not accounting for traffic) from the nearest hospital? If the Birth Center is responsible enough to not take on clients with higher risks, why would they be so irresponsible as to recommend alternatives which are even less safe? This is the influence of natural childbirth, a movement that is more motivated by crackpot theories and warm-and-fuzzy feelings than science and evidence.

That evaluation stands. To promote a VBAC for women who fit all the low-risk criteria and who are giving birth in a hospital with staff poised and ready for an emergency is fine. 

But there are lots of people out there promoting HBAC (Homebirth after c-section) and HBA2C, HBA3C, and even HBA4C. Since the increased risk of HBAC is relatively small (although I imagine in hindsight it seems huge for the parents who watch their babies die or suffer brain damage) there are, of course, far more success stories than tragic ones, and these happy endings are blasted all over the Internet as if they are proof that HBAC is generally as safe as VBAC in a hospital. 

On MotherBloom, midwife Christy Tashjian tells the story of one successful HBA4C, frames it as a women's rights issue (opposed to a health care issue - as if the mothers are the ones who would be held accountable for malpractice), and emphasizes feelings over medical facts.

Holly on Homebirthers and Hopefuls tries to downplay the risk of uterine ruptures by saying: 

The main risk that midwives and consultants are concerned about with VBACs is uterine rupture, however, this is a much misunderstood and extremely rare occurrence. The vast majority of uterine ruptures will not result in mortality for mother or baby. Rupture can also occur in an unscarred uterus and can happen before labour begins, which means that it can happen whether you plan a VBAC or an elective caesarean.  

The majority of uterine ruptures do not result in mortality for mother or baby because of treatment that is only received in a hospital! More importantly, if treatment is delayed even by minutes, that severely increases the chance of death or brain damage. 

Also, extremely rare? The overall rates are 7 uterine ruptures for every 1000 births. Given how many women are giving birth every day, that's a lot of uterine ruptures! 

The CNM attending my prenatal care and birth had already done over 1000 births (I'm not sure how many VBACs) by the time she got to me, and she boasted that she'd never seen a rupture. After mine, I jokingly apologized for ruining her stats, and she jokingly said, "no it's fine, now I've had my one so I hopefully won't see another before retirement." But I could tell she was really shaken up. Uterine ruptures are no joke. When they happen they are serious threat to the lives and health of the mother and child. 

What this means is that midwives who attend HBACs have resigned themselves to needlessly endangering the lives of seven woman and their babies for every thousand, for the sake of giving the other 903 women a more pleasant birthing experience. That hardly seems ethical.  

Vicki Williams, a "Birthkeeper, Doula, Breastfeeding Specialist, and Lactation Consultant" (so no medical credentials), goes so far as to encourage a homebirth after a uterine rupture. 

Some women, such as Aneka who managed a successful HBA3C, are portrayed in the media as rather heroic. After watching Ricki Lake's documentary The Business of Being Born, she said she realized:

I'd been robbed of the birthing experience. If possible, all women should be allowed to birth naturally.

Aneka wasn't robbed of her good health and success in having three healthy children by c-section. Yet she expresses only disdain for the medical establishment that delivered those healthy babies. Had she been one of the minority who experience uterine rupture and lost her fourth baby because of the time it took to get to the hospital, would that have been worth the "birthing experience"? 

Then you just have this sort of insanity on website such as MamaBirth, which really hypes the "pride" and "empowerment" and how it "feels" to give birth naturally at home, and just outright disregards the increased risks of complications such as breech, as well as VBAC. 

Really, I've just touched the tip of the Natural Childbirth iceberg when it comes to advocating homebirth for VBAC and other higher risks pregnancies. Surf around the Internet for an hour and discover gobs more crazy for yourself. 

Since so many people seem to be moved by personal birth stories, Dr. Amy of Skeptical OB writes a lot about the unfortunate and grieving minority whose babies die or experience brain damage because they attempt high risk homebirths. HBAC examples include baby Vera, whose mother attempted an HBA3C, just like Aneka, baby James, baby Liam, a baby whose mother was hoping for an "awesome HBA2C story", the mother who attempted a VBAC at a birth center without continuous electronic monitoring, the mother of 6 who attempted an HBA2C, a mom who bragged online about her HBAC, despite the fact that her baby suffered brain damage, and many more. (I can only stand reading so many of these before I want to crawl into a closet and cry.) 

In his article Ten Thoughts On VBAC, Nicholas Fogelson of Academic OB/GYN - who favors VBAC attempts in hospitals and under the right circumstances - writes: 

VBAC should not happen at home.   I have recently referred to that as a game of Russian Roulette, and defend that view here.   In this case the gun has 100 barrels, but the bullet will kill the baby just the same.  If a woman can honestly say they are willing to take a 0.5% to 1% risk of disaster, then fine, but to me that risk is way too high.  I think home birth is an acceptable option in many cases, but VBAC is not one of them.

HBAC? Please! I could have died, mama!

Note the lack of touchy feeling bullshit. 

I attempted VBAC for all the right reasons, and it failed, because birth is inherently risky, even more so after having a c-section. 


To any women out there thinking about VBAC, I strongly advise only doing so if you are low risk, and then finding a OB or CNM working in a hospital that is totally supportive. 

For those planning an HBAC, I urge you to reconsider. HBAC is simply not safe enough. Had I made such an attempt, my spunky toddler Eulabee would not be here to make funny faces as she grabs for my cellphone. 

As any adoptive parent knows, welcoming a new son or daughter isn't about the birth experience. It's about bringing them home. 

On Some Liberals' Distrust of Doctors

Baby Gaga is in for a checkup.

I make no secret of the fact that I'd be thrilled if one of my kids grew up to be a medical doctor. Doctors have job security and respectable status in society, which would please any parent concerned about our kids' futures. But another part of the appeal to me is the ethics. A doctor's job is to use knowledge obtained through science to try to heal people. What could be a more noble profession from the secular humanist perspective? 

The medical field isn't for everyone. Not only does it require a strong ability to study difficult subjects such as organic chemistry. There is also the gross factor: blood, guts, tissues, fluids, horrible smells, and basically being able to look at human bodies just as a mechanic looks at a car. I couldn't even handle dissecting a frog in high school (I got light headed and ended up being excused to the library. Oddly enough, I'm okay cooking a chicken.) 

Monkeys need doctors too!

Given the rigorous training and noble objectives, it surprises me that not everyone shares my deep respect for the medical profession. 

Some of my friends are dismayed that I would encourage my kids to be doctors. It's sort of the bizarro version of adults who discourage kids from taking an interest in the arts for fear they'll grow up to be impoverished, drug-addled bohemians. In this case, the fear is that as doctors the kids will grow up to be arrogant automatons, brainwashed by scientism and serving the corporate greed which supposedly drives the medical establishment. 

These are the sort of liberals - mostly highly educated, middle class, and white - who drive today's Anti-Vaccination, Natural Childbirth, and other Alternative Medicine movements. 

I was reminded of this sort of contempt toward doctors while reading/viewing New Mom's Uncensored Photos Reveal the Beautiful, Messy Reality of Homebirth. It includes an interview with writer Ruth Fowler followed by the live documentation she and her photographer husband did of her son's birth on Twitter and facebook. 

Right off in the video, the interviewer refers to the "intrusive" nature of modern "technology", and it is clear that this story is framed as a human interest story about the beauty of a natural childbirth in contrast to the sterility of a conventional hospital birth. 

Ruth Fowler describes herself as not the extreme. She says to the interviewer, 

I'm not the kind of crunchy, granola mama who's like "Women who go to hospitals are bad mothers" I'm somewhere in the middle. My birth experience kind of reflects that. I'm somebody who had a natural, un-medicated home birth, but then I had to go to the hospital afterwards to get treatment that probably saved my life. And so I'm not an anti-hospital person. I just wanted to birth at home with my husband, with the people I care about, in the environment I care about. 

Doctor Lysi and Nurse Bebe get to work.

I found this statement puzzling. First of all, her birth experience doesn't reflect a moderate position. She had to be transferred to the hospital because she had a postpartum hemorrhage and would have certainly died otherwise. So according to Fowler, she isn't extreme because her distaste for the medical setting isn't so severe that she's willing to die to avoid it. That's a pretty low bar for extremism. 

She makes a point of saying she chose an "un-medicated" birth, but then used a whisky sour to help ease the pain. So in her view drugs designed to ease the pain of contractions and dispensed by medical professionals are undesirable, but hard liquor is just great? I'm not faulting her for the whisky sour (I've been in labor without pain meds for 24 hours, I know what that feels like), only the hypocrisy. 

Even though the headline of the Huffington Post article includes the word "messy", nothing messy is actually shown. The series of photographs show a beautiful, pregnant woman enduring great pain with dignity and ending up in a naked embrace with her newborn son. Then, suddenly, there is a jump to a couple of photos of mom and baby (hauntingly gorgeous) in the hospital, and the statement: 

… Nye was occidental [sic] posterior. He flipped to come out but shoulder dystocia ripped me apart. Then the placenta wouldn’t come out – some medical termI don’t know – which basically mean, it tried to detach and ripped more of me out! So I lost over half my blood and got transferred by great emt’s [sic] after the birth.

Felt awful but now recovering in UCLA Santa Monica on a TON of fentany1 (it kicks ass!) and blood transfusions and will be back home with Jared and Nye Soledad Iorio tomorrow. This mad experience Just reiterated how goddamn crazy birth is…

I don’t want to be an ass but this experience has taught me birth is beautiful and primal and mysterious and painful as ****. Thanks to my amazing midwife Racha Tahani Lawler for getting me through that, and her assistant Tanya and my brilliant doula Allegra Hill.

At this point my mind is screaming, what the fuck!? Does Huffington Post not realize that the messiest (and also terrifying) part of this birth experience has gone completely undocumented and downplayed? On her blog The Skeptical OB, Amy Tuteur lists crucial elements of this experience that have been omitted from any photographic or written documentation, including: 

Where is the photo of the postpartum hemorrhage with the blood pouring from between your legs?

Where is the photo of your husband’s face, horrified and frightened, as it dawns on him that you may bleed to death and leave him as a widower with a new baby?

Where is the photo of the EMTs hustling you out the door, racing against time to save your life?

What I find also concerning (and is noted, too, by Amy Tuteur) is how Fowler makes a point of thanking all the people who made her feel warm and fuzzy, but then neglects to thank the doctor/s and other medical staff who literally saved her life. Just as she wanted to give birth at home because that environment was one she "cared about", the midwife, her assistant, and doula are people she cares about, and the medical staff are to be treated as cogs in a machine. 

Little sis tries on big sis's lab coat.

A lot of people complain about the poor bedside manners of doctors as if the rift of contempt and distrust that often exists between doctors and patients were all the fault of one side. And as if things like a jolly bedside manner are worth a damn when one is lying on a table bleeding to death. 

This really gets me on a personal level since I am someone who attempted a totally natural childbirth with my first kid and vaginal birth with a CNM. (Neither were homebirths. I view homebirth as a reckless choice.) With both labors I experienced complications which ended with necessary surgeries. In the case of my second child I had a uterine rupture that threatened the lives of myself and my child. 

And I'll tell you what, while I appreciate the care I received from the very professional CNMs who did my prenatal care and were there with emotional support while I was in labor, I damn well feel immense gratitude toward the skilled obstetricians - both stern, serious-looking women - who opened me up and got my babies out safe! 

Sure, Fowler's not saying other people should do things the way she has chosen to do them. But she is romanticizing her experiences and then allowing that prettied-up narrative to be presented as reality. For a writer using documentation supposedly to better understand her own experiences, she seems utterly oblivious to the irrational prejudice she has against the medical establishment. 

My daughters may grow up to enter any number of careers. Right now my four-year-old wants to be a ballet dancer and painter, either of which would be amazing paths to follow. I certainly don't discourage those interests. But if either of them happen to grow up to be a stern, serious-looking obstetrician who saves the lives of women and babies, I'd be as proud as if they were Martha Graham or Louise Bourgeois. 

"Highest form of art"? I don't think so.

This is an addendum to my last post about Marni Kotak's performance art piece The Birth of Baby X. The artist successfully gave birth to a baby boy in the gallery this morning to an audience of maybe 15 people. I'm not sure why this is news. Most of us have known or will know people who are pregnant. A huge number of us women will some day be pregnant and experience birth. A huge number of men will have a partner who gives birth and be able to play a supporting role in the birth process. People can read about it, find books and videos that show all the details. Those who want to have a more intimate understanding of the process of birth can discover and attend gatherings of women who tell their "birth stories". This isn't exactly something shrouded in mystery anymore, as some would like to pretend. Which probably explains Kotak's small audience.


Really, what was the point here?
Rhetoric that attempts (and fails) to give higher meaning to this performance abounds. One spectator was quoted saying,

I feel like the entire audience accomplished this together with Marni, using the commonly created positive energy. 

Obviously the artist would have accomplished giving birth whether the audience was there or not, so I'm not sure what their supposed "positive energy" contributed.

The artist herself contributed more empty blather:

Kotak has said she hopes people will see that giving birth is what she calls "the highest form of art."

Forget Michelangelo's Sistene Chapel ceiling, the compositions of Mozart, the plays of Shakespeare. Doing something that only women can do, but which requires simply a fully functioning reproductive system and being sexual active is not just art, but the "highest form" of art. Huzzah for womanhood! Who knew surpassing Picasso could be so easy!

Forget the caves at Lascaux and the creative explosion, a time when modern humans evolved beyond all other species in a flurry of creative activity never seen before on earth. According to Marni Kotak, there is nothing that special about us humans. Apparently, something that just about every female of every sexually reproducing species on the planet, including roaches, rats, and worms can do is not just art, but the "highest form" of art.

No. Art is a response to our life experiences, not the experiences themselves, and not the mere documentation or witnessing of those experience. Art is creative. It transcends our experiences, gives them meaning.

As far as I can tell, all this performance was made up of was the artist documenting and engaging in aspects of her regular life on display for an audience. Maybe that would have been cutting edge stuff that pushed the boundaries of what is considered art many decades ago, but these days, who cares? What profound meaning comes out of this that didn't already exist without it?

Bad Art: Marni Kotak's "The Birth of Baby X"

Majoring in fine art and having to form an opinion about it, I long ago concluded that anything presented as "art" is appropriately categorized as such. Found objects such as Marcel Duchamp's Fountain (literally a urinal) or the rock and driftwood sculptures on view at Mokseogwon on Jeju Island: art. Chris Burden crucified on a Volkswagen, Marina Abramovic starring silently across a table at total strangers for over 700 hours: art. The scribblings and clumsy drawings of millions of children hanging on countless refrigerators: art.

Not to say all (or even most) art is good art. Just that it is art.   

So now that I have that out of the way, I can write about some crappy art. Specifically, artist Marni Kotak's latest performance piece: The Birth of Baby X. For this piece, the artist has transformed Microscope Gallery in Brooklyn into a sort of home-birth space to give birth to her baby in view of the public. 

Women turning aspects of their births into public affairs is nothing new. Numerous women have allowed video footage of the birthing process to be used in documentaries and educational films, viewed by high school students in biology classes and couples in birth classes around the world. The "Feminist Breeder" Gina Crosley-Corcoran turned her birth into a live blogging event with updates, photos, sound clips, and more. Chiropractor Nancy Salgueiro recently invited the public to view the live stream of her giving birth. For anyone interested in the progression of the natural childbirth movement, a performance such as Marni Kotak's is hardly ground-breaking. On the contrary, it was inevitable.   

While Kotak cites established performance artists such as Vito Acconci and Carolee Schneemann as her inspirations, her work is not nearly as creative or provocative.  In an interview with The Village Voice, Kotak says, 

I am driven to hold onto an authentic personal experience in a world that has essentially become consumed by an unreal hyper-reality.

But the performances of Acconci, Schneemann, Burden, and Abramovic aren't public displays of their real, day-to-day lives. They are creatively tailored. Certainly both the artist and the participating audience have an "authentic personal experience", but so does an actor playing Hamlet on stage, or a theater goer moved to tears by his performance. From what I can tell, there is as little creativity as possible in Kotak's performance. Instead, in her attempts to make the piece as "authentic" as she can, she has turned it into little more than a live documentary. 

The Birth of Baby X seems to be more an extension of the natural childbirth movement than the performance art of her claimed inspirations. In The Village Voice interview she also states:  

In "The Birth of Baby X," I will be completely engrossed in the act of giving birth before a live audience. I will be focused on delivering my child into the world in the healthiest manner possible, rather than on how I look or what the audience may think. Everything I have learned about the birth process is that the more you surrender your mind and don't try to control the event, but let your body do what it naturally knows how to do, the better your labor progresses. 

Here Kotak seems to be taken in by some of the unscientific claims and rhetoric of the natural childbirth movement. There is no evidence that surrendering your mind results in a better labor process. Letting your body do what it naturally does will not prevent abnormalities in the size or position of the baby or in the pelvis or structures that support it. It will not help if the cord is wrapped around the baby's neck or if the placenta does not have enough oxygen stored to supply the baby during labor. It won't prevent infections that pose a danger to the child. Women surrendering to their bodies isn't what has drastically reduced the number of women and babies who die in childbirth. Indeed, the places in the world where access to modern medicine is limited, women and babies continue to be at great risk.   

The more I read about Kotak's motivations, the more it seems to be a self-aggrandizing political stunt rather than a challenging or transcendent work of art. In an article published in Hyperallergic, we see more typical pro-natural childbirth rhetoric: 

Childbirth is treated like an illness,” Kotak said. Hospitals are often a sterile place to have a child, with multiple rules and regulations forbidding visitors. “You get the sense that people are afraid of birth and female sexuality.” In other cultures outside of the United States, having a baby is more integrated into the culture and having supportive friends and family around is the norm.

The natural childbirth movement began in reaction to conventional practices in medicine that often were sexist and which typically did make the process of childbirth more stressful and isolating for women. However, it isn't the 1960's anymore. Today, a growing number of obstetricians are women, certified nurse midwives working in hospitals are on the rise, partners play an active role, and breastfeeding is encouraged. Not to mention the countless books written to educate women on childbirth and the ample Internet resources available at the click of a mouse. 

In popular television shows and movies, hospital birth is most typically presented as painful, but endurable, safe, and resulting in a sweaty-but-smiling woman holding a healthy newborn in her arms moments afterward. Such was the case in one of the latest episodes of the television drama Parenthood when the character Kristina Braverman gives birth to her daughter Nora. Unable to get a hold of her husband, a nurse takes charge and is the one to pressure her brother-in-law to stay in the room with her to provide a supporting role. Meanwhile, the rest of the extended family soon gathers outside to congratulate her and welcome the new child into the world. I don't really know how the experience of childbirth could be painted in a more positive light without glossing over the very real physical pain, exhaustion, and perfectly realistic fears parents have about complications that routinely occur in a minority of cases. 

Kotak claims that "... the ultimate creation of this life performance will be a living being!" No. The ultimate creation of this life performance will be a bump to the artist's career and ego, and further dissemination of some more foolish sentiments of the natural childbirth movement. The living being will be the result of a biological function that most human women are capable of for most of their adult lives. 

The most authentic experience is not a performance of any kind. When real life is presented to an audience as art, both the viewers and performers end up having an experience that is mitigated by the self awareness and analysis invited by it also being a performance. The performance aspect does not elevate the experience. Rather, it cheapens and objectifies it. 

Natural Childbirth: Under the Skeptical Movement's Radar?

People in the skeptic movement are well acquainted with a great deal of common quackery due to articles in publications such as Skeptic Magazine, Skeptical Inquirer, bloggers such as Harriet Hall, the SkepDoc, and speakers at conferences like James Randi's Amazing Meeting. On topics of how irrational, anti-science thought impacts health, these skeptics-at-large regularly touch on homeopathy, anti-vaccine activists, chiropractic nonsense, acupuncture, detoxing, and even repressed memory.

But one rapidly growing and potentially dangerous trend in alternative medicine has largely been ignored by big name advocates of skepticism and skeptic organizations. In general, it is the natural childbirth movement, and specifically, the increasing popularity of homebirths.

Googling "natural childbirth skepticism" produces some revealing results. At the top is an article which is in fact skeptical of natural childbirth, although not published by any organization focused on the promotion of science and skeptical inquiry. It is Skepticism of the Natural Woman by Amanda Marcotte, published last year in Slate, and is a sassy, feminist counter to the idea that natural childbirth is better for women. The next two links are to articles posted in a blog called The Healthy Skeptic, which is in fact run by an acupuncturist who promotes a good deal of woo.

A search of Skeptic Magazine's archives for "natural childbirth" produced no relevant articles.

A search on skepdic.com of "natural childbirth" produced no entries on the practice and a search of "homebirth" produced only one story about a "homeopathic homebirth" buried under a number of examples of harm done by "occult, paranormal, pseudoscientific, and supernatural beliefs."

Nothing about Natural Childbirth made its way into Dr. Harriet Hall "the SkepDoc"'s 2009 article Top Ten Things You Should Know About Alternative Medicine and a search for "natural childbirth" and "homebirth" produces no entries on her blog.

In eight seasons of Bullshit!, Penn and Teller find room for whole episodes on lawns and cheerleaders, but the closest they ever got to criticizing natural childbirth was when they reached for the low-hanging fruit of dolphin-assisted birth.

I must give credit to Skeptical Inquirer. Searching their archives online, I was able to find one article on this subject: 'Natural' Childbirth by Ben Radford, published in the March/April 2006 issue.

The absence of much attention on the natural childbirth movement and increased advocacy and demand for homebirths in skeptic circles begs the question: is this actually something to be concerned about, or does natural childbirth have a sound basis in science and are homebirths just as safe as hospital births? After all, even the Wikipedia entry on natural childbirth makes no mention of any criticisms. So is there really a problem?

I would answer, skeptics should be concerned.

In 2009 I got pregnant and had a baby. What became an epic journey began at a prestigious but humongous hospital, moved to a small birth center, and ended up back at a large hospital. At the start I had lots of fear and few opinions or knowledge of pregnancy and birth, then decided to attempt a totally natural childbirth (efforts which included 24 hours of active labor with no pain killers), then had an epidural, a pitocin drip, and finally an emergency c-section. Involved were several obstetricians and other doctors, many certified nurse midwives, a couple of doulas, a psychologist, and an army of nurses. The long version of the story isn't necessary. Sufficed to say that I experienced almost every typical aspect of childbirth in America today.

Now I'm pregnant again, and the options are more complicated since I had a previous c-section. This and all that happened in 2009 has motivated me to learn as much as I can about childbirth, and it is during these inquiries that I have become fully aware of what has been dubbed by the media as the birth wars.

The birth wars have often been simplified as doctors verses midwives. In this simplification, obstetricians are painted as scientifically brilliant and competent, but also cold, selfish, and arrogant, and midwives are viewed as experts in transforming one of the most horrible experiences for pregnant women into one of the most wonderful, but also hit-and-miss as far as medical competency goes. Of course the truth is far more complex.

First, many of the criticisms of obstetricians coming from the "other side" of the birth wars are unfounded and incredibly insulting. The contentions include that obstetricians use pitocin to induce labor for the sake of their own convenience, that they discourage or refuse to offer VBAC (vaginal birth after c-section) out of personal fears of being sued and total disregard for what is best for the patient, and generally push for unnecessary c-sections because they like doing surgery and make more money that way. These accusations and more are frequently and casually expressed by advocates on the side of natural childbirth. They were expressed in Ricki Lake's film The Business of Being Born, and they come up over and over again in literature and websites advocating natural childbirth.

Midwives come in a several stripes, and can hardly be aligned as a whole group to one side in the birth wars. Many fall somewhere in the middle of a spectrum between the two sides. There are two basic types of midwife in America. Certified Nurse Midwives (CNMs) are trained and certified as both nurses and midwives. They most typically work in hospitals. They are part of and have a good reputation within the medical establishment. The other type is direct-entry midwives, who gain their experience through self study, apprenticeships, or midwifery programs. They most frequently work in homebirth settings. Some direct-entry are Certified Professional Midwives (CPMs), certified by the North American Registry of Midwives. Others are merely licensed in a particular state, and still others are lay midwives. As one can imagine, direct-entry midwives level of training, experience, and competency can vary widely. Whenever horror stories of homebirths gone wrong appear in the news, the midwife involved is a Direct-entry midwife.

While most midwives tend to advocate natural childbirth to some degree, CNMs tend to be more knowledgeable and concerned with risk factors that might disqualify a woman from attempting totally natural childbirth.

For example, the Birth Center I went through will not accept clients who are VBAC, over a certain age or weight, pregnant with multiples, and many other risk factors. Women in labor had transfer to the hospital across the street if any complications ensued. Roughly 20% of the Birth Center's clients end up giving birth at the hospital, and 10% end up having a c-section. I was in that 10%.

I never had any doubts about the care I received at the Birth Center. All the midwives were experienced CNMs. I was required to have blood tests for various risks such as parvovirus B19. 24 hours after my water broke we promptly packed up and went to the hospital. After many hours of excruciatingly painful contractions, a midwife was the one to strongly recommend an epidural so that I could relax, rest, and have enough strength to push. And when it finally became apparent that a c-section was necessary, a midwife stood side by side with the doctor, explaining the process and paperwork I was required to sign. Clearly this was a competent operation where the health of mother and child are paramount. Right?

In the case of my first pregnancy, yes, the Birth Center's approach was competent, totally appropriate, and ultimately successful. Any pregnancy that ends with a healthy baby and mother is a success. So here's the problem. This time around I'm no longer a totally low-risk candidate. When I found out I was pregnant again, I immediately called the Birth Center. I found out I couldn't have my second baby there, so I asked for recommended options. I was given a short list of CNMs who work at or with hospitals, which was great.

But then the person on the phone said, "I can also give you the names of midwives who do homebirths." What!? If it isn't considered safe enough for me to attempt VBAC at a top notch Birth Center across the street from a hospital, why the hell would it be safe for me to try it in my home that is a 20 minute car ride (not accounting for traffic) from the nearest hospital? If the Birth Center is responsible enough to not take on clients with higher risks, why would they be so irresponsible as to recommend alternatives which are even less safe? This is the influence of natural childbirth, a movement that is more motivated by crackpot theories and warm-and-fuzzy feelings than science and evidence.

Dr. Amy, the Skeptical OB, is a one-woman army at war with natural childbirth pseudoscience. In her article Is Natural Childbirth a Form of Quakery? she explains one characteristic of natural childbirth that might partially explain why it has managed to fly under the larger skeptical movement's radar:

"Unlike traditional pseudosciences (homeopathy, creationism) which have always denigrated scientific research, in the last decade, natural childbirth advocates have based the validity of their philosophy on the claim that it is supported by science while modern obstetrics is not."

Dr. Amy points out that the founder of natural childbirth, Grantly Dick-Read, was a white man whose ideas about childbirth are not rooted in any science, and whose writings and work were motivated by his concern that upper class white women were not having enough children to keep up with poor, black women.

Dr. Amy also writes frequently (and harshly) about "the mother of authentic midwifery", Ina May Gaskin. An article in Salon about Gaskin mentions her total lack of formal medical training, and more startling, the story of how one of her own children died during a natural childbirth that could have been prevented had it happened in a traditional medical setting.

Quotes from both Dick-Read and Gaskin, as well as quotes from other major proponents of natural childbirth are frought with bullshit, identifiable as such to any seasoned skeptic. Consider these:

"It is important to keep in mind that our bodies must work pretty well, or their wouldn't be so many humans on the planet." - Ina May Gaskin (Yeah, let's just ignore the fact that childbirth has always been a leading cause of death for women and babies. There's billions of people on earth, therefore childbirth must be inherently safe!)

"Women's bodies have near-perfect knowledge of childbirth; it's when their brains get involved that things can go wrong." -Peggy Vincent (Silly brains, always getting in the way.)

"I have personally come to believe that childbirth is a blessing to women sent straight from God. I mean, in its purest form, birth is the most fantastic orgasm married with a miracle! What more heavenly gift could there be?" -Laurie Annis Morgan (Yes, those pesky doctors are trying to take away the best orgasm of your life. And a miracle. Those bastards.)

But, hell, if pregnant women at low-risk for complications want to think of childbirth without painkillers as some kind of earth-shattering, mega-spiritual experience, let 'em. So long as the end result is a healthy mom and baby, it's all good. The problem arises when even women with greater risk factors and their midwives are so moved by the power and importance of having a natural childbirth experience that they don't take proper precautions and take necessary actions when complications ensue, putting both the woman and child in harm's way.

Let's get to the real meat of the debate. To put it most bluntly, will more babies die during homebirths than would have had they been delivered in hospitals? Many advocates of natural childbirth mention the United States's high c-section rate and connect it with the USA's realtively high infant mortality rate. Dr. Amy argues that infant mortality is the wrong statistic:

"It is a measure of pediatric care. That's because infant mortality is deaths from birth to one year of age. It includes accidents, sudden infant death syndrome, and childhood diseases.

The correct statistic for measuring obstetric care (according to the World Health Organization) is perinatal mortality. Perinatal mortality is death from 28 weeks of pregnancy to 28 days of life. Therefore it includes late stillbirths and deaths during labor.

The US has one of the lowest rates of perinatal mortality in the world."

She further points out that the Netherlands, which has the highest percentage of homebirths in the world, also has a higher perinatal morality rate than any other European country.

If she's correct, then the rising rate of homebirths in the United States should be as alarming as the anti-vaccine crowd. After all, both put the most vulnerable in our population at risk.

Why is this not an issue regularly raised by skeptics-at-large? Could this be the result of what PZ Myers calls The Woman Problem? Or is it that the natural childbirth movement has managed to convincingly appear "evidence-based"? Whatever the reason, it seems clear to this skeptic that there needs to be more skeptical critics of the pseudoscientific and dangerous aspects of natural childbirth.