In 2001, Ricki Lake gave birth to her second child with the assistance of a midwife in her home bathtub. She made the choice for a home birth after she experienced unwanted medical interventions while delivering her first child at a hospital birthing center. Ricki succeeded in giving birth on her own terms and the experience was so unexpectedly empowering and life-changing that she felt every woman should know what they could be missing out on. Ricki approached filmmaker Abby Epstein (Director of Emmy-Award winning UNTIL THE VIOLENCE STOPS) to collaborate on a film that would examine birth culture in America.
To most people, the idea of giving birth outside of a hospital seems foolish and even dangerous: why would any parent limit their newborn’s access to technology in the event of an emergency? Why would any couple put their child’s life in the hands of a midwife instead of an obstetrician?
“Most obstetricians,” we learn from obstetrician Dr. Michel Odent, “have no idea what a birth can be like.”
Adds Susan Hodges, president of the organization called Citizens for Midwifery: “Very few doctors have ever observed a normal birth, either in medical school or in the hospital. It [normal birth] is almost an oxymoron.”
Epstein’s camera verifies this when she asks three female OB/GYN residents at NYU’s Bellevue Hospital Center how often they get to see “a fully natural birth.” “Rarely,” one says. “Almost never,” says another.
Indeed, Epstein’s own obstetrician, Dr. Jacques Mortiz of New York City’s St. Luke’s Roosevelt Hospital, tells her, “I always think that midwives do a better job at the normal deliveries than we do. For a normal, low-risk woman, it’s overkill going to a doctor, it’s almost too much. The doctor is not really excited about things when they’re normal.”
“An obstetrician is a trained surgeon,” explains Carolyn Havens Neimann, a certified nurse-midwife.
“They should be doing childbirth surgery all day, every day, when needed,” adds Elan Vital McAllister, president of New York’s Choices In Childbirth. “They should not be doing normal births because they’re not trained in it. They have no idea how to do it.”
In America, midwives attend less than 8% of all births and less than 1% of those that occur outside a hospital. At the same time, the US has the second worst newborn death rate in the developed world.
So how did we get here?
In 1900, 95% of all births took place in the home. In 1938, half the births took place at home, and the trend continued to spiral downward.
According to Robbie Davis-Floyd, a PhD in medical anthropology, “In the early 1900s, physicians in the east but also in the deep south to some extent went on a very effective smear campaign against midwives.” Davis-Floyd cites one poster that invoked racist imagery, depicting “a black granny midwife in a very poor home.”
“It was sort of a cultural shift where midwives were portrayed as a vestige of the old country,” adds Tina Cassidy, author of the book Birth: The Surprising History of How We Are Born. “They were [portrayed as] dirty, they were ignorant, they were illiterate.” At the same time, “Hospitals were offered as this gleaming, wonderful place where you could go and have a baby that would be cleaner and safer. The reality of course was that giving birth with an obstetrician at that time was much more dangerous than giving birth with a midwife because as doctors were graduating from medical school, many had not witnessed a live birth before they went out to practice.”
As public heath expert Nadine Goodman puts it, “All of sudden, the concept of ‘normal’ changed,” as hospitals specializing in obstetrics started springing up around the country, creating a demand for their services as well as some stigmatizing alternatives.
But as new drugs, technologies and techniques developed, did hospital childbirth get safer? Not really. Indeed, when it comes to obstetrics, mainstream medicine seems to feel its way – dangerously – in the dark.
THE BUSINESS OF BEING BORN touches on a number of past medical interventions that have gone terribly wrong. The film explores the use of the drug scopolamine in the 40s, 50s and 60s that put mothers into a kind of “twilight sleep” that didn’t stop pain, but merely eliminated the memory of pain by attacking the brain functions responsible for self-awareness and self-control, resulting in a kind of psychosis, followed by post-traumatic stress-like memories in thousands of new mothers. In the 30s doctors routinely took x-rays of the pelvis, resulting in babies with cancer. In the 70s, use of the drug thalidomide, used for morning sickness, caused birth defects, while in the 90s, the drug Cytotec was used to stimulate contractions in mothers who had undergone previous Cesarean section. This was later found to cause ruptured uteruses and high infant mortality.
“The point here,” observes Dr. Marsden Wagner, former director of Women’s and Children’s Health, World Health Organization, “is there’s not a good history in obstetric practice of careful study of the long term effects of all these interventions. This is why, if you really want a humanized birth, the best thing to do is get the hell out of the hospital.”
The film points out that some of the most traditional practices of contemporary obstetrics have everything to do with the convenience of the physician, but can actually make delivery more difficult for the mother.
Every woman depicted giving birth on TV or at the movies is shown in the “lithotomy position,” on her back on a gurney, legs suspended in stirrups, the doctor standing between her legs and encouraging her to “push.”
“The lithotomy position is the most physiologically dysfunctional position ever invented,” says medical anthropologist Robbie Davis-Floyd, author of Birth as an American Rite of Passage. “Putting the mother flat on her back literally makes the pelvis smaller, makes it much more difficult for the woman to use her stomach muscles to push, and therefore makes it much more likely for an episiotomy to be cut, or for forceps to be used, or for the vacuum extractor to be used.”
Obstetrician Dr. Ronaldo Cortes prefers the mother to squat during labor, explaining that while this position is easier for the mother and her baby, squatting is much more stressful on the doctor, whose job is to “catch” the baby.
It also seems like every conversation about an impending birth includes a mention of the coveted “epidural,” a lumbar injection that kills pain below the waist. But, as Ricki Lake observes, the introduction of one drug during her first delivery caused “a big snowball effect.” The epidural kills pain but it also retards natural contractions. To keep contractions active, a drug call pitocin is often administered. The pitocin makes contractions longer, stronger and closer together, causing more pain, and then consequently another epidural. This then requires more pitocin, which again causes longer and stronger contractions, and stress to the baby. Ultimately, this often triggers an emergency Cesarean section. The sum total of such interventions is ostensibly a shorter labor, benefiting the hospital, but certainly a more stressful one for the mother and baby.
Finally, statistics indicate that the use of Cesarean section, a major surgery, is being widely employed, more as a measure of convenience for both doctor and patient instead of a last resort in the event of an emergency.
Dr. Michael Brodman, Chief OB/GYN at New York’s Mount Sinai Hospital, cites a study that reveals the peak hours for Cesarean section procedures are 4:00pm and 10:00pm. Brodman interprets the data from the perspective of the hospital-based physician: “It’s obvious,” he says, “that four in the afternoon is ‘It’s late in the day, I don’t know what’s going on here, I want to get out of here and the ten o’clock at night is, ‘I don’t want to be up all night.’”
“Somebody clearly is going to have to step in and stop the trend” of high C-section rates, Brodman warns, “or else we’re going to get to 100%.”
After completing THE BUSINESS OF BEING BORN, Epstein and Lake have drawn the conclusion that many women unknowingly give up a potentially life-altering and empowering experience. A hospital environment is not conducive to the true needs of a laboring woman, making a birth without intervention almost impossible. As a result, the physician, instead of the mother, delivers the baby,
During a visit with Lake at her home in California, Epstein, who was pregnant at the time, asked about Lake’s contrasting birth experiences. It’s clear that Epstein was there as both a journalist and someone who was making some very personal decisions about the delivery of her own child.
“I wanted a home birth experience almost as much as I wanted a second child,” Lake offers. “I love pain medication, I love numbing myself. I don’t want to feel even a headache. I’m that person, too. But when it came to giving birth, it wasn’t an illness, it wasn’t something that needed to be numbed. It was something to be experienced.”
In a subsequent interview, Lake tries to explain the significance of the event:
“That is just everything to me,” she says. “I could start sobbing right now. It was so empowering. This was what I was after. This is what I wanted for my child.”
Like most American women, Epstein always imagined herself giving birth in a hospital, and, due to the premature arrival of her child, this was indeed her path. But she remains convinced that THE BUSINESS OF BEING BORN makes a compelling argument for more humanistic approaches to birth, challenging the ideals of our technocratic society which places absolute faith in machines and technology.
“In a culture where all of our rituals have become standardized and commercialized, birth is the one rite of passage that can remain individualized and sacred if parents are exposed to the truth behind the medical myths,” Epstein said recently.
Epstein and Lake also hope audiences and policy makers will recognize the economic truth about birth outside of a hospital: it’s cheaper, something insurance companies should theoretically embrace.
Carol Leonard, a nurse-midwife and director of the New Hampshire Birth Center, cites that hospitals in her state charge $13,000 for a normal vaginal birth, while she charges $4,000 “for everything, including post-natal care.” Births that take place with multiple interventions and Cesarean section can cost as much as $35,000.
However, as medical anthropologist Robbie Davis-Floyd points out, the medical-industrial complex – the relationship between hospitals, the powerful lobby group the American Medical Association, and the insurance companies – has a history of discouraging home births, and discouraging midwives who practice in a hospital setting. Indeed, Epstein’s camera captures one birth center associate struggling to get an insurance company to re-process a claim from a new mother who gave birth at their facility. While Mayra, one of the film’s expectant mothers who chose home birth, reports that her insurance company had a hard time understanding that there even was an alternative to hospital birth.
“The whole insurance thing has been kind of crazy,” Mayra tells Epstein. “Everyone was acting like I had a third eye. It’s cheaper to have a birth with a midwife; you’d think they would be all over it. So it kind of makes you wonder what the agenda is.”
“Why has the medical model of birth gone unchallenged for so long?” Epstein and Lake ask. “And why do less than 8% of Americans take advantage of the benefits of midwifery, which is statistically safer and cheaper than physician-attended birth?”
As the nation’s heath care crisis continues to grow, the filmmakers hope THE BUSINESS OF BEING BORN will ultimately play a role in heath-care reform and raise awareness of the options for parents of the future. They also hope to enlighten and inspire parents to advocate for themselves and to “own” their birth experience wherever it takes place.
-- Used with permission, courtesy of Jeremy Walker and Associates, Inc., from the film's Press Notes, 2007.