“Birth is a miracle, a rite of passage, a natural part of life. But birth is also big business,” starts the Website synopsis of former talk show host Ricki Lake’s new documentary, The Business of Being Born, now available on DVD.
Left unsatisfied by the experience of her first child’s birth in a hospital, Lake began a personal quest to uncover traditional, non-medical choices in maternity care, such as midwives and birthing centers. As she and her friend, documentary director Abby Epstein, delved into research and interviews, a complicated historical, political and economic picture of the country’s health care system emerged. The first two minutes of the film establish the battleground of ideologies:
“Maternity care in the United States is in crisis,” says a former director in the World Health Organization in the film. “It is in many ways, a disaster.”
“I call it ‘feminist macho-ism.’ You know, when they’re pushing a baby in a stroller three months later, they’ll say ‘I did it naturally,’” says the head of OB/GYN at Cedars-Sinai. “Personally, I don’t think it’s that important.”
“There is so little understanding of how incredibly important [birth] is to a woman,” says a midwife advocate, “The medical community has … convinced the large majority of women that they don’t know how to birth.”
And a New York OB/GYN insists, “Technology is technology, this is what life is all about, so if you’ve got it, why not use it to get the best outcome?”
But as the film and a deluge of other research (including a 2006 Save the Children report) confirm, technology in itself can’t promise “the best outcome.” Since 1996, cesarean section rates in the U.S. have nearly doubled — now hovering at close to 30 percent of all births, despite recommendations by the World Health Organization that no more than 15 percent of babies be delivered by c-section. But that doesn’t mean it is safer to be born in the U.S.: In fact, the U.S. has the second-worst newborn death rate in the developed world, in a tie with countries like Slovakia and Poland.
Adding further to the contention that birth is a business, the reported cost of a vaginal birth with no complications is less than $7,000 nationally, while the cost of a cesarean ranges from $11,000 to $15,000.
The film asserts that concern over malpractice suits and a lack of connection with the needs of laboring women are guiding the way hospitals provide care. Instead of being viewed “as a natural life process,” says the film’s narration, “every delivery is treated as a potentially catastrophic medical emergency.”
“The whole film pivots on [activist and researcher] Michel Odent’s assertion that we know what women need in labor, and we’re not providing it,” says Spokane certified nurse midwife Margaret Lipton. “Whatever lies behind the decision to not provide that in hospitals needs to be addressed.
“Women want perfect outcomes,” she adds. “We have a powerful drive to go someplace safe.” Women have come to trust in the technology at hospitals, she explains, “But hospitals are no longer driven by the realities of childbirth; it’s all risk management, or ‘What are we likely to be sued for?’”
Spokane OB/GYN Kurt Fine disagrees with the notion that financial considerations drive his specialty, allowing, “I do think that most OBs and hospitals are pushed to do interventions,” he says. “But I can almost guarantee that not many of us went into this field to make money.”
Fine is a proponent of midwives practicing in hospitals, and of in-hospital birthing centers. But as beautifully as The Business of Being Born portrays a home birth, and despite dozens of studies concluding a single baby, head-down at term, can be delivered safely at home, he can’t agree.
“Labor is never low-risk,” he says. “I’ve seen perfectly normal, low-risk labors go bad quickly.” He says he’s been called on when a midwife birth at a hospital needed intervention. “If I wasn’t there, the baby would have died. That scares me. Why would you put your child at risk?”
Fine insists there are other low-intervention options. “You could still get the natural birth experience in a hospital. If you’re wise enough to research home birth then spend some extra time to find a doctor who would let you do it in a hospital.”
Lipton says she isn’t in the business of providing home births just for the “experience” Dr. Fine alludes to. “I don’t care about the ‘experience.’ What’s the point of seeing the most beautiful view in the world if the result is you have to drive off a cliff?” she quips. “My commitment is that the baby be safely born. It is not empty of content. I am convinced by the evidence that the safest for mother and baby is a normal birth with minimal intervention and stress.”
Lipton hopes The Business of Being Born will create a movement of women who begin to believe in the power of their bodies again. She predicts more women will demand clearer answers from health care providers.
“I’ve told the nurses, ‘Brace yourselves,’” Lipton says, “You’re going to get hit with questions you haven’t heard in 30 years.”
Does one C-section have to lead to another?
Many women who give birth via cesarean section find their birth options limited for future deliveries because of the health risks. Current research shows that the risk of a uterine scar (from a c-section) rupturing in a vaginal birth is 1 in 500. Even though the risk of the scar tearing open is low, a rupture can threaten the life of both the mother and baby. The American College of Obstetricians and Gynecologists (ACOG) for years recommended that “anesthesia and personnel be readily available” within 30 minutes for women attempting a VBAC (vaginal birth after cesarean). Then in 1999, ACOG changed its position to “immediately available,” meaning an OB and staff had to be present throughout the labor process. That means fewer doctors and hospitals are making VBACs an option. Hospitals unwilling or unable to hire needed staff or pay higher liability insurance premiums may choose not to allow VBAC births. The International Cesarean Awareness Network (ICAN) says at least 300 hospitals across the U.S. deny patients access to a VBAC.
In the Inland Northwest, only one hospital, Holy Family, offers regular VBACs because doctors who deliver there, including Dr. Kurt Fine, rotate 24-hour shifts at the hospital.
“Holy Family has been doing this for 20 years,” says Fine. “We were one of the first hospitals in the country” to set up on-site, on-call doctors.
“Of course I would rather sleep with my wife in my own bed,” Fine says, “but our patients get great care when the doctor is in the hospital. The liability thing is a factor,” Fine admits, “but I’m willing to do VBACs because patients deserve it.”
Fine says he has a patient driving from Wenatchee because no hospitals there would allow a VBAC, although she was “a great candidate.”
If patients committed to a VBAC can’t drive two hours to find a willing doctor and facility, they may be forced to consider home births, but Fine says this is flawed rationale.
“If you want to do a home birth because it’s a natural process, that c-section scar has now made it a non-natural birth. I’m a big supporter of VBACs but it’s a high-risk pregnancy.”