Do Women Matter in Childbirth?
The news recently has been full of stories about home birth -- they're on the rise in the United States (up 29 percent since 2004), even though rates remain comparatively tiny. A home birth advocate in Australia died from unknown causes after giving birth at home, and more recently, a woman was arrested in Indiana for practicing midwifery.
I wrote a piece for Slate about it, hoping to clarify that not all home births are created equal and one with an experienced, well-trained certified nurse midwife (CNM) with a hospital-based, backup OB and hospital access is the gold standard if home birth is your choice.
I also argued that many women in the U.S. don't have this choice or the choice of a hospital that offers an environment conducive to health and bonding between mother and child, which is, in fact, the case. A blogger over at Babble summed up this core argument better than I did in her post about my piece:
Even if home birth was a real option for a segment of the population in the US, we still need to work on improving hospital care and outcomes! Fewer women would be opting out of hospital births if they didn’t feel their births would be overly medically managed to the point of introducing new risks from medications and surgery. Hospitals have much to offer in terms of emergency care, and a lot less to offer a low-risk mom who would prefer a birth with few interventions.
My Slate piece opened with a paragraph about my own experiences with the births of our first two children. In my original draft, I'd had that information at about paragraph three and written differently, but for reasons of narrative and word count limitations, it was moved to the top. It opens with a mention of fluorescent lights -- not the way I'd originally described it, which was simply, "fluorescent lit" -- and continues with a very brief description of that birth and the sequelae. The birth was no picnic -- what birth is? -- and my husband and I both were not thrilled with aspects like hospital visitors peering in through the open door as I laid there, spread eagled in stirrups, pushing and covered with the effluvia related to birth. But the aftermath was what left us so upset that to this day, we just don't talk about it with each other.
Photo by dchasteen. (Flickr)
I described this aftermath briefly in the article -- it consisted of the hospital's forcing our son to have 12 blood draws for glucose testing for no medically indicated reason (he was full-term, perfect Apgars, feeding well, all readings were normal, our pediatrician was appalled) against our will and without our informed consent.
They also aggressively threatened us with separation from our healthy son and with dismissal from the hospital while they retained our son, unless we took him against medical advice. I was probably a hormonal mess -- I had just given birth after three days of sleepless prodrome, we were first-time parents -- but hearing the click as they ripped into his heel 12 times and listening to him shriek with pain every three hours (during which we anticipated each draw with growing dread) made me feel like I was feeling what he did, and that empathy between us has persisted to this day. When we finally did leave the hospital, within a day or two, I was fighting a raging hospital-acquired infection that required some powerful drugs to treat and interfered with my ability to breastfeed our boy.
It was these effects on my son -- not me -- that led us to pursue home birth for our second child, born in 2002. I was terrified of the prospect of a home birth, not because of safety issues -- the literature I could find at that time indicated good safety profiles for CNM-attended births with an OB backup and hospital access nearby, which is what we had -- I was terrified about the pain, about whether I could do it. But I forced myself to do it because I did not want our second son to go through what had happened to our first without medical indication.
It wasn't because I had some nutty idea about a beautiful or lovely or fluffy birth experience. Birth isn't fluffy. It's hard as hell, and yes, emergencies can be sudden and fatal. We were fully aware of that. A hospital was blocks away. Had it not been, we'd've elected simply to be in a hospital because safety would have tipped the scale that way.
When my water broke and I went into labor, I stood in my kitchen and ate some lasagna, then -- dilated to about a 5 -- I went into my bathroom, looked at myself in the mirror, and said out loud to myself: "You can do this. You're scared shitless, but you can do this because it is best for your son." That was our conclusion at the time, and that's what we did.
Now, when someone asks me about the 1 to 10 pain scale, I know what my 10 is. Was I comfortable? No, not at all. Was he comfortable, peaceful, safe, and with me without separation from the moment he was born? Yes, he was. And only one heel prick, for the metabolic screen.
Our third child was born in 2006, in a different hospital, five years after our first hospital experience. This hospital was new, and they did labor, delivery, and recovery all in the same family-sized room, with family welcome at any time of day or night. They never once separated our son from us, they helped us with breastfeeding -- it turned out that because of a motor deficit, he couldn't -- and they did do two blood sugar draws, each carefully and clearly explained to us and done with our informed consent.
I sent flowers to the staff after we left because they had done everything that was the right thing for our third and final son and they'd had a hard couple of days that had included a neonatal death on the L&D floor. This last birth of ours was the kind I'd choose again were I going to have any more children, which I am not.
The thing is, that last experience is not one that is widely available to women, women of any ethnicity or socioeconomic status. Many women I know have two widely different options where they live: birth in a hospital with a poor reputation for birthing women and childbirth, or childbirth with a direct-entry midwife who does not have the level of training of a certified nurse midwife (an RN) or the OB or hospital backup.
To have a better option, you have to be living in just the right place and have just the right kind of insurance. Talk about white privilege. Speaking of which, does anyone really think that the hospital would have kept us there with our first son, against our will, had we not, at that time, had white-glove health insurance?
In the Slate piece I wrote, I argued that women need a spectrum of choices that are best suited to their situations. Stress and anxiety and separation from the mother at birth are not optimal childbirth outcomes and rarely are necessary for a birth that proceeds normally. CNM-attended births are associated with specific benefits in this regard.
In the piece, I argued that a national infrastructure of CNMs who are associated with OBs and have hospital access would be a boon to women everywhere, giving them the choices we didn't have in 2001 and that many still don't have today. Whether a woman chooses to birth at home -- and increasing numbers of them are -- or in a hospital, or, possibly best of all for low-risk pregnancies, a birthing center -- there are safer and stress-reduced options that should be available.
I also noted that a recent U.K. study found that home births with the gold standard I describe above are safe for low-risk women who have already had a child, but not for women giving birth for the first time. Birth in a birthing center, however, was safe for any woman who was low-risk. I also cited studies about childbirth factors associated with post-traumatic stress disorder in mothers (here and here). This is not simply a theoretical exercise.
In this society, no one has a right to a personal and informed decision, yet everyone has a right to tell someone how to do things. After that piece appeared, some people read the central message -- a need for choice so that mother and baby can be healthy, safe, with limited stress and with each other whenever possible -- and some others read the first 157 words about our experiences among the 1302 words of the piece and began to attack me.
They misread some of what I wrote and accused me of linking my first son's autism with the unnecessary and invasive interventions inflicted on him in his first 36 hours. I did exactly the opposite. They accused me of being a narcissistic princess who did a home birth only to make myself more comfortable and without consideration for my son, writing only for my own benefit (which is odd, as I'm all done with childbirth). Again, the opposite is the case.
They accused me of being an entitled white woman with no idea of how poor people live and access medical care... and that one also is untrue. Maybe I am entitled now, although I feel that I've never lost touch with my roots. I've been poor. Very, very poor, very sick, with no access to medical care at all. I'll never forget the clinic doctor who did my lung X-rays for free -- I had severe pneumonia -- when I didn't have a quarter to my name. I'm not poor now, and I'm glad, but I have experienced it close up and personal. The midwives I've had have always had a sliding scale for their already relatively minimal charges and in some cases provided prenatal care to mothers for no money at all.
And some commenters can't let go of the fluorescent lights that open the piece. I'll admit -- I am photophobic and I do avoid fluorescent lights. But our problems with the hospital -- which, by the way, were not unique in our community -- were not about the goddamned lights or even about our experience. It was about what happened to our son. Period.
Those events were so powerfully embedded in my psyche that when I returned to that hospital five years later to have my thyroid removed, pulling into the parking garage and walking through the doors brought on, unexpectedly, a huge anxiety attack that I had to force my way through just to keep on walking.
People can diminish what happened to us as not really traumatic in the grand scheme of things, but we are simply people with our own histories and own triggers and own experiences, and these -- not other people's experiences -- dictate our reaction to things and the decisions we make. That's so clear to me, that perspective taking -- yet it seems to escape a whole lot of people.
The commentary on the Slate piece has been highly informative to me. I have a deep interest in how the Internet allows open discussion and how people take advantage of that discussion, for better and for worse. In this case, rather than address the core arguments of the article itself, many of these comments have been personal -- deeply personal -- attacks on me, my white privilege, my (presumed) socioeconomic status and history, my "narcissism," my whining about fluorescent lights, my alleged linking of my son's autism to those earliest hours of his life.
So very few of the comments talk about the core discussion at hand, which is that in this country, women -- from every ethnicity and every socioeconomic background -- deserve respect and dignity and consideration while they're giving birth and access to safe care that provides it.
And many do not have it. That is the problem.