Wednesday, August 29, 2007

Pushed

You have got to read this book! (Pushed: The Painful Truth About Childbirth and Modern Maternity Care, by Jennifer Block)

I just finished it, and it is one of the most powerful books I've come across in a very long time. That's saying a lot, because little of the information in the book was new to me, and yet it still blew me away. I wanted to stay up all night to finish it, like Sage Femme, but frankly I cannot pull that off with a round-the-clock nursing baby! So I forced myself to put it down at 11 pm yesterday and finished it today.

Block's central thesis is this:
What's best for women is best for babies. And what's best for women and babies is minimally invasive births that are physically, emotionally, and socially supported. This is not the experience that most women have. In the age of evidence-based medicine, women need to know that standard American maternity care is not primarily driven by their health and well-being or by the health and well-being of their babies. Care is constrained and determined by liability and financial concerns, by a provider's licensing regulations and malpractice insurer. The evidence often has nothing to do with it.
Block paints a depressingly grim picture of modern maternity care in which only a handful of women experience physiological childbirth. The rest give birth plugged into machines. Drugs and hormones course through their veins; scalpels and scissors cut them open, often after coercion and frequently despite the woman's expressed refusal. Almost everyone she interviews admits there's a problem, but no one seems to be able to change the system. Those who buck the system altogether--home birth midwives and unassisted birthers, for example--face legal harassment, imprisonment, fines, or loss of custody of their children. Block's book points out several captivating ironies that, if they weren't so depressing, would be laughable:

1) ACOG recently decided to support elective "maternal request" cesareans--surgery for no medical reason--as ethically justifiable (even though the medical evidence shows that cesarean sections for no medical indication lead to higher morbidity and mortality for mothers and babies, rising sharply with each successive surgery) yet refuses to allow women to choose out-of-hospital birth, direct-entry midwives, or, in many hospitals, VBACs (even though the medical evidence clearly shows that these choices are safe & reasonable).

2) Although physicians and midwives tout the importance of evidence-based medicine, less than 2% of American women received "optimal maternity care" that consists of these six basic aspects, all of which are well supported by the best evidence-based medicine:
1. Labor begins spontaneously
2. Women have freedom of movement during labor.
3. Interventions are medically justified rather than routine.
4. Women have continuous emotional and physical support.
5. Pushing occurs in any position but flat-on-back.
6. Mother and baby are not separated.
In other words, 98% of women received sub-optimal care.

Surprisingly, this book gave me a greater sympathy towards obstetricians (well, some of them at least). Many of the physicians she interviewed held great respect for the natural, physiological birth process; bemoaned the current state of malpractice litigation, VBAC bans, and the dogma of automatic surgery for breeches; and secretly supported home birth midwives--often facing censure from their peers for their views.

Pushed shows a maternity care system that has gone malignant. Instead of being a tool to aid women when pathology arises, it is now our master. Obstetricians, nurses, midwives, birthing women and unborn babies are all slaves to the machines and the technologies that they have created. Birth, for most women, is managed by drugs, hormones, and clocks, rather than being a chaotic but gloriously intricate and rewarding physiological process. In this system, no one wins. Instead of being bathed in a complex "cocktail of love hormones," as Dr. Michel Odent put it, women are on morphine drips in post-operative wards. Their babies are intubated, suctioned, and injected. Mothers are separated from babies, vaginas are separated from birth, and birth is separated from labor.

I want to share a final excerpt from the book, which illustrates so exquisitely why a "natural birth" is so difficult to attain in a typical hospital setting. The vast majority of American births involve myriad kinds of medical devices, all of which tether the woman to an obstetric bed and deprive her of the ability to move freely during labor: IV, automatic blood pressure cuff, pulse oximeter, electronic fetal monitor, epidural catheter, urinary catheter, intrauterine pressure catheter, and circulation stockings. The latest device, just approved by the FDA, consists of two electrodes inserted inside the vagina that automatically measure cervical dilation. Judith Lothian (PhD, board member of Lamaze International, and professor of nursing at Seton Hall University) explains: "If we put women in hospitals with restrictive policies--they're hooked up to everything, they're expected to be in bed--of course they're going to go for the epidural, because they're unable to work through their pain." British midwife Tricia Anderson writes:
Let us bring them into harsh rooms with bright lights. Let us make them lie on their backs on hard narrow beds. Let us tether them to machines so they cannot move. Let us make them stay silent and make no noise with their pain. Let us expose their most private parts and threaten them with cold steel. Let us make them push their babies upwards, against the pull of the earth...In these conditions, labour swiftly becomes unbearable and pain relief becomes a woman's only hope....This is not the natural cry of a woman in labour bringing a child to birth, although if you have only ever witnessed childbirth in a medicalized setting you might be forgiven for thinking so. This is the screaming plea of a tethered animal in pain.

13 comments:

  1. Wow, that last line gave me chills. I will definitely have to get my hands on a copy of that book.

    -Jill

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  2. Me too, can't wait to read it. Thanks so much for the review. Have you considered writing one on amazon, too?
    I also wonder if it swould be a good read for a brilliant, but not at all the wholistic-health-type first time mom to be? You know, not too scary, and more useful than What to expect...

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  3. I posted this review with a few changes on Amazon under my "nom de plume." Good idea.

    This is not a birth preparation book. That said, I think it's imperative that pregnant women read this book because it's a realistic (and frankly, scary at times) look at modern childbirth practices. I'd suggest it along with a few others that are more geared towards making decisions for an upcoming birth, such as "The Thinking Woman's Guide to a Better Birth" and Sarah Buckley's "Gentle Birth Gentle Mothering" (or even selected articles available on her website, especially about the physiology and hormonal processes of birth).

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  4. Rixa --

    I totally agree. This book was amazing. My biggest revelation is that the *majority* of care received in hospitals is not evidence-based. Moreover - this type of non-evidenced based care if used in other fields would be heinous. Why is okay to routinely surgically remove a woman's child where in another field, say orthopedics, this type of non-evidenced based care would be outrageous?

    My biggest question is why haven't we (in general) advocated for what's in the best interest of our health and that of our child as well?

    Your review is wonderful. This book just shows how much work there needs to be done. I'm glad I'm starting on the path to make a difference :)

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  5. Why haven't we made more of a fuss? Because our culture does not question doctors, especially when they say that our babies will die, that we will suffer grievous injury, if we don't do things their way. Combine unquestioned authority--especially in obstetrics--with good 'ole fashioned paternalism (just trust me, Sweetie) and our culture of fear, and there is almost no way that most people will speak up. Plus, the realities of mothering a newborn put things on hold. And, as the recent article from the Ottawa Citizen said, women generally have healthy, beautiful babies at the end of the process, no matter how arduous.

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  6. "Instead of being a tool to aid women when pathology arises, it is now our master."

    So true. Unfortunately, this is becoming true in many areas of our society. Birth, parenting, education, health and nutrition. So many areas would be applicable with this quote.

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  7. Where do you (or Block) get that 2% figure? I don't doubt it at all - just putting together my own personal arsenal.

    Just came across your blog via Technorati. I'll check in again!

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  8. The 2% is based on a recent "Listening to Mothers II" survey. Here's a quote from the nationwide study, which asked women birthing in hospitals about their childbirth experiences: “Despite the primarily healthy population and the fact that birth is not intrinsically pathologic, technology-intensive childbirth care was the norm....A very tiny minority (2%) experienced all of the care practices that promote normal birth and are endorsed by Lamaze International.” Those 6 practices are listed in my post and all evidence-based. Block discusses them more in her book.

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  9. If you click on the link "Childbirth Connection" (under Birth Links) you will be able to find the Listening to Mothers I and II studies.

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  10. kettunainen9/4/07, 10:49 PM

    1. Labor begins spontaneously
    2. Women have freedom of movement during labor.
    3. Interventions are medically justified rather than routine.
    4. Women have continuous emotional and physical support.
    5. Pushing occurs in any position but flat-on-back.
    6. Mother and baby are not separated.


    So good to know that the birth I ended up with was technically considered optimal by these standards. It certainly wasn't the UC I'd worked so hard for, but I didn't end up too traumatised despite having to transfer. :\

    1. Labour began spontaneously, unless you consider it an inadvertent induction due to having sex just prior to labour commencing.

    2. I got freedom of movement for the first 23 hours (the first 20 of which were at home).

    3. The interventions were unfortunate, partially-necessary evils: I chose the epidural and the amniotomy. I didn't choose the pitocin or the forced pushing. (I got the epi before the pit. 20 hours of being in transition took its toll.)

    4. I had everyone I wanted with me throughout the entire birthing process.

    5. I ended up pushing in an inclined McRoberts. Not optimal by my own standards, but I wasn't flat on my back, either -- as in, a 0% incline.

    6. Baby was placed on my chest after the bastards clamped and cut his cord (I'd desperately wanted a lotus birth). Our only separation was when they weighed and measured him a few feet away from me about a half hour after his birth.

    For any readers in Toronto, I went to St. Michael's Hospital. While they didn't take too kindly to the woman roaring in the peak of labour who saw neither obstetrician nor midwife during her pregnancy, who planned an unassisted birth, they treated me much better than I had anticipated. The attendants and OB who made unsavoury remarks were mostly elsewhere during the remainder of my labour.

    Having been through a mostly typical hospital birth (though with atypical beginnings), I'm even more infuriated at the whole process -- the whole birth industry. It's a veritable monster.

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  11. I am sorry that your birth did not turn out as planned...hugs...

    I would disagree with Jennifer Block that "anything but flat on back" is "optimal"--actually semi-sitting is a terrible position physiologically, because it closes the pelvis, especially the sacrum. Granted with an epidural, options are fairly limited: flat on back, semi-reclined, or side-lying are about all you can do.

    I hope you and baby are doing well.

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  12. kettunainen9/10/07, 3:59 PM

    thanks, Rixa. baby is awesome; we're ECing with a good amount of success. I'm doing ok, all things considered.

    McRoberts is semi-reclined, but with hiking your knees up towards your ears, so it doesn't compress the tailbone. Not great at all for the pelvic opening, though, and absolute hell on the perineum.

    I think I'll have an amniohook at my next birth and, having made that preparation, hopefully I won't need it and everything will go smoothly and at home with only family around.

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  13. I like such kind of books for women!

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