Jennifer Block, a former editor at Ms. Magazine as well as an editor of the revised Our Bodies, Ourselves, has clearly devoted herself to uncovering the obstacles to ensuring women's health and health care access in this country. Block's first book, "Pushed: The Painful Truth About Childbirth and Modern Maternity Care," takes you on a sincere truth-seeking expedition to discover why childbirth has become "medicalized" around the United States. As you wind your way through hospital halls and birth centers, listening in on interviews with midwives, OB/GYNs and childbirth advocates, Block uses meticulous research to paint a picture of a world where women are encouraged to disconnect themselves from their own bodies, rely on "modern" medical intervention for labor and delivery, and where hospital personnel are pushed to advocate for speed and profit over maternal and baby health.
AN: Why did you write this book?
JB: I get that question a lot—you've never given birth, why a book about childbirth? I've always been interested in women's health, in how we experience our bodies, the healthcare system, and in how politics so often affects our health and our healthcare. Childbirth never struck me as a political issue, but it turns out that it very much is. And I think it's important to know just how it affects the kind of care women receive, and what birth options they have or don't have. So I wrote the book to shed light on the reality of the U.S. maternity care system, which is not serving women and babies as best it could.
AN: What do you see are some of the root causes for, according to you, "overusing medical technology at the expense of maternal and infant health"? Have we (women) become less comfortable with and confident about our own bodies and our ability to birth naturally?
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JB: I would agree that there has been a collective loss of confidence in the female body's ability to give birth, and a quiet acceptance of surgical birth as the solution. Having said that, however, I think we still have to ask how much of this system women are choosing, and how much is beyond their control. The women I've talked to overwhelmingly just want what's best for themselves and their babies.
When women agree to, say, induce labor because they're "overdue," or to schedule a cesarean because they're told the baby has grown too big (both are common reasons) those might be considered "patient choice" procedures, but we need to ask what kind of information they were given about the risks and benefits. The fear of a lawsuit and the financial pressures exerted by malpractice premiums drive physicians to intervene more. Many doctors told me that they are moving to cesareans more quickly because "you don't get sued for doing a cesarean."
At the same time, women are just bombarded by messages that our bodies don't work, that physiological childbirth isn't important. And the cesarean trend feeds this doubt, because women begin to think that if one-third of their sisters can't do it, then maybe they can't either. The fact is, we know from studies of healthy women who labor and give birth in supportive environments, with care providers who are trained to support the physiological process, 95% can birth vaginally. And that's optimal, for both mother and baby. The cesarean trend does not represent necessary cesareans.
AN: You address the issue of women seeking a vaginal birth after a cesarean (VBAC) in your book. Can you tell us a little bit about why VBACs are controversial? And why you believe this to be a reproductive "choice" issue?
JB: VBACs are controversial because they put doctors at risk of a lawsuit they can't defend, and because the American College of Obstetricians and Gynecologists has set a standard of care that is nearly impossible for physicians to meet. I explain more in the book, but the result has been that hundreds of hospitals have banned VBACs, and many doctors are refusing to attend them altogether.
The best data we have say that 1 in 2000 VBACs will result in the death or severe brain damage of the baby. That's an outcome that nobody wants, of course. But the reality is that the chance of a baby not making it through a first-time vaginal birth is about the same. One prominent OB/ethicist calls the VBAC hype a "distortion of risk."
So the decision of whether to plan a vaginal birth or a repeat cesarean is one that women need to make with full, unbiased information. But for many women, there is no choice. A recent survey found that more than half of women seeking a VBAC were denied it by their provider or hospital. Many, many women are being told they must have surgery – a clear violation of their constitutional rights.
AN: You tell the story of a man in Seattle who handcuffed himself to his wife's maternity bed so that he could be with her during the birth of their child. Washington State has been on the forefront of licensed midwifery. However, in Seattle, where I live, our second longest-running independent midwifery practice is only seven years old. Many have been forced to close—or have chosen to close—because of rising malpractice rates or are being "pushed" out by the mainstream medical movement. Can you elaborate on the "midwifery strain" and the discrepancy you uncovered in the ways in which midwifery is treated in this country from state to state?
JB: Midwives are a vital part of maternity care around the world. The World Health Organization has called them the most appropriate care providers for women experiencing normal pregnancies and births. They provide the bulk of care throughout Europe, and yet here in the U.S., Certified Nurse-Midwives are constantly fighting for coverage from Medicaid and private insurance while battling sky-high malpractice rates. At the same time, Certified Professional Midwives, who attend births out of the hospital—in birthing centers or in women's homes—find that in about ten states their job is illegal. For consumers it is a terribly confusing system. In New Mexico, for instance, you can choose a home birth with a midwife and Medicaid will cover it; in Illinois, you have to go "underground" and find an illegal provider. Midwifery care both in and out of hospital has been studied extensively and shown not only to be safe, but more likely to result in a healthy, vaginal birth. And yet in the U.S., we are driving midwives out of practice and underground.
AN: Did you research or uncover distinctions between upper-and middle-class women and their childbirth experiences and lower-income women's childbirth choices and experiences?
JB: The media often present obstetric trends as consumer trends, but the research (not mine, but large studies by CDC epidemiologists and public health researchers) actually shows that the rising cesarean and induction rates have little to do with women's bodies or choices, and more to do with changes in the way OBs practice. For a while there was a perception that high cesarean rates were specific to a white/wealthy demographic (one theory was that women with private insurance were more likely to be sectioned) but this isn't true today. Black women are generally more likely to give birth via cesarean. A recent survey actually found that almost half of first-time black mothers had given birth surgically.
One major difference between low-income women and high-income women, however, is that low-income women generally have fewer options to raise their standard of care. Doulas, who provide birth support and patient advocacy, cost between $500 and $2000 out of pocket. A home birth with a certified midwife can be anywhere from $1500 to $5000 [Editor's Note: in some states, as referenced above, midwifery care is covered by Medicaid for those who qualify]. So women who would otherwise choose a midwife often go with the care covered by their insurance because they can't afford otherwise.
AN: I know you spent a lot of time doing field research, watched many babies being born, and spent time with many laboring mothers. Was there one story or situation that particularly moved you?
JB: I did see a number of births, and I found them all moving in various ways. I like to tell the story of the very first birth I saw, because it was such a surprise. I was expecting to see what most of us think of as "normal" birth—woman lying flat on her back, people yelling "Push!", woman screaming, then baby screaming. I got quite a re-education. First of all, the woman gave birth standing up—I barely saw the baby coming out! The whole event was so much more peaceful than I'd imagined. The baby hardly cried, the mother was certainly experiencing pain, but the contractions looked more like hard work than anything else. There was hardly any medical intervention. Afterward, her family brought in a roast chicken and they had a party. Six hours later she went home. This is about as optimal as it gets, but this was in an independent birth center run by certified professional midwives. It's unfortunately not the norm.
AN: You say that this issue needs to be addressed as a significant women's rights issue. How can the women's movement/feminism address this issue more thoroughly? What do we need to do?
JB: Childbirth was an issue that feminists took up in the 70s and 80s, and some change happened. Even in the mid 1990s, a coalition of groups published a position paper calling for an overhaul of the maternity care system. But the issue has largely been dropped, and the focus is on preserving a woman's right to prevent pregnancy or terminate pregnancy, rather than on what happens when women choose to carry a pregnancy to term. In January, the National Advocates for Pregnant Women held a tremendous conference and challenged the pro-choice movement to advocate for pregnant women's rights, not just abortion rights. I strongly agree. I think the VBAC ban is the most salient issue, and women's health groups need to stand up and hold physicians, insurers, and hospitals accountable for effectively forcing women into unwanted surgery. But there's a much larger issue of women's access to optimal maternity care that feminists need to address. Some women are going to great lengths to access support for physiological birth, meanwhile most women are getting care that is not evidence-based and more likely to cause themselves or their babies harm. This should be of major concern to feminists. Women deserve better.