Tuesday, November 27, 2007

A family doctor's perspective on BOBB

Among members of the audience for The Business of Being Born was a family physician who attends births and her youngest daughter. She emailed me some of her thoughts about the documentary and gave me permission to repost them here. I highly admire her dedication; she works hard to give women hands-off, physiological births in a hospital setting.
Overall, I was impressed with the movie. I tried to look at it with two viewpoints in mind. One, my own sort of "birth junkie" self. Two, I tried to see it as my mostly mainstream clients and acquaintances would.

I was pleased overall with the births they showed, and I loved many of the commentators. I loved that the births were shown to unfold in their own time and that the mamas looked free to move on their own and birthed upright. I love that upright birth center birth where the mama is so joyous right after. I thought Michel Odent was absolutely great. I liked the juxtaposition of the "woman on the street" type comments in between, too--sadly, all those women ready to sign up for their epidural are what I deal with a lot of the time and are very realistic.

It was funny, because looking at the births, I actually thought some were a bit hands-on for my taste. (Why does the midwife have her hands around that woman in the water? What was she trying to do?) On the other hand, I think a mainstream viewer might think they were too "non-medical" especially since Cara can't seem to get gloves on in time ever.

I cried at every one of those births. Don't know what was up with that! My little dd even kept asking me if I was okay. (I cry a fair amount of the time at actual births, though, too--you'd think I'd get over it.) I think if people watched this movie and the only thing they took away was visions of women pushing their babies out standing, squatting, in the water, whatever, that would at least be a start. I find that I have to talk quite a bit during prenatal care about how women should try out different positions ahead of time and see what feels comfortable to them, and how we will be encouraging them to move any way they feel comfortable during labor and pushing. Sometimes family members especially are just shocked when the birthing woman ends up standing or squatting or kneeling. Sometimes I think they then think I'm a little nutty or not very professional, because I "let" this go on. Fortunately, usually the birthing woman herself can verbalize how being free to choose her position made her feel better, or that it was more effective for pushing, or whatever.

I was disappointed in the ending. I don't think they explained enough what was happening, and I was disappointed that the final interview blew off any benefits of homebirth and implied that it's all nice if you can have it, but thank God we had this cesarean and saved my baby. I actually think in her particular case transferring for a breech, growth-restricted baby was probably a good idea--but there had to have been a better way to wrap up that movie than Abby saying "Oh well, at least I got a healthy baby" you know?

I wish they'd wrapped up with some kind of activism information--like talking about CIMS, or ICAN. Here's where you can start to change the world kind of info.

The discussion after was really something. It was interesting to hear people's stories and encouraging to hear so many women who think this stuff matters. It was also discouraging, though, to hear how people struggle to get the birth they want. I am pretty disappointed in this whole VBAC thing, and disappointed especially that so many "low-risk" providers are just giving up VBACs and verbalizing that it's just too bad, so sad for the women involved, but nothing we can do. The midwife who talked expressed similar feelings to what I've been hearing from other family docs: "Oh well, we just can't because of these rules." I feel like so many birthing women basically can only have midwifery, or at least woman-centered physician care, if they are low risk, don't have any problems or inconvenient history, and do what the low-risk provider wants. Otherwise, you are stuck in the OB system and have to take the full court press. It's just not fair and I can't figure out how to fight it. Especially in this stupid state. I wish women like that woman who had an episiotomy against her will would make complaints--take it to the hospital administration, the chief of medical staff, and the medical board for failure to get informed consent. I know one complaint is not likely to do anything, but if there were more and more, I think hospitals and regulatory boards would have to listen. It is not okay that thousands of women are treated as if their wishes don't matter one bit routinely in the name of "standard of care."
I actually think all of medicine needs to be reworked. Something I was trying to say, and may not have got it out coherently at the panel discusson, is that having doctors in charge of medical care and responsible for the outcomes doesn't benefit anybody. If birthing women were in charge, in power, and responsible for decision making (not really so much the outcome, because there is so much that is up to chance), I think they would be more satisfied--AND doctors maybe could relax some. Because I think if we stopped this patriarchal, authoritarian way of practicing medicine there would be far fewer lawsuits. If every woman got actual informed consent AND had the opportunity to make her own decisions and then got supportive care when they needed/wanted it, they would be far less likely to sue. (I just went through a long involved discussion with a new client about VBAC and feel I gave her a good understanding of the risks either way, but she is really stuck in that no one in driving distance who takes her insurance does VBACs anymore--doesn't matter how informed you are if your options are so limited.) As a profession, though, we docs don't want to give up the power. We want to be in charge, want to be seen as demi-gods often, and don't want to present our selves as fallible humans doing the best we can with the knowledge we have and freely sharing that knowledge with our clients.
I'm not sure how to make a change in modern obstetrics, but I think one factor is that women have to refuse to accept paternalistic, condescending care. I don't care what kind of choices women make, but they need to insist on accurate information and fully informed decision making.

OBs need to get out of the business of normal maternity care. We have put normal care into the hands of folks trained in the abnormal. You know the saying, “if the only tool you have is a hammer, everything looks like a nail?” If you are looking for trouble, you generally find it one way or the other. Somehow, we have to get in through our heads that women's bodies have not changed that much in the last 30 years, so if the cesarean rate has sextuptled (and it has!), something must have changed in doctors. I'd like to see more consumer-driven organizations getting more and more active and making more of a mainstream presence. I mean, how many women even know there is something like ICAN or CIMS?
The problem, too, is that it seems that as a whole group, women may not care that much about birth. I wish this was more of a feminist issue--I don't understand why women are willing to be condescended to in this area and have choices taken from them. Have you ever read Barbara Katz Rothman? She is a feminist writer who has done a lot of work on birth politics and talks about how she talked an OB into attending her first home birth by basically appealing to the female OB on a feminist basis. (The book is In Labor: Women and Power in the Birthplace.) I just don't see that happening any more. I went into medicine out of a desire to provide woman-centered care from a background of feminist ethics. I feel more and more out of place in modern medicine every year--my colleagues think I'm sort of nuts, my family suffers from me not being there, and even many of my clients don't seem to care much about having the chance to direct their own care.
I wish I could have come to the rest of the discussion. Did you all come up with any way to change the world?


  1. Oh, wow, she put it so, so well--it was a pleasure and an honor to meet her and we got to talk about this stuff after the film a bit, too-- but she really nailed so many things on the head; this being absolutley a feminist issue, an issue of taking back power, of reclaiming what is ours, of standing up for ourselves and our rights as consumers and as people--such futile frustration we all feel, but for her, especially. ARGGG

    I agree so much with the flaky ending of the movie, and have concluded personally that it was only made that way because the producer so happened to get pregnant during filming and wanted her story to be included. It didnt fit with the film at all, it wasnt a balance or anything, it felt random and awkward and not too much was said about it by the filmmakers or anything. It didnt fit in there, especially to be at the end.

    I just agree so much with all of this, and she did a very eloquent job of expressing what so many of us are noticing and trying to rally against. What can we really do? I am officially apprenticing to be a homebirth midwife. Thats what I am doing. More midwives. More visibility for alternatives in birth care choices. Speaking and writing and touring and spreading the word, ESPECIALLY outside of our own little crunchy circles. Using the internet, interpersonal networking, I dont know--- looking to the past when "media" was so limited and seeing how our foremothers fought for stuff--marching in the streets is always a good one.

    this stuff is making the news, it really is. Look how much (rediculous) coverage the breastfeeding-in-public stuff got a few months back. Its hard, though, no postpartum mamas should be worrying about participating in marches, so there are logistics problems, but we must get loud and louder. For our sisters and ESPECIALLY our daughters.

    Great job, Dr J. You rock. We are all behind you!

  2. Wow, Joy! Midwife Joy! What an incredibly curageous decision.

    It was very nice to meet you, Dr. Jen. You reminded me of a couple of nice family practice docs/moms I knew from the web! ;-)

    I tried to watch the movie with mainstream mom's eyes too, and also liked what I saw, except for the ending. I agree with Joy that the director (understandably, for personal emotional reasons) could not bear to finish the film with a conclusion that the material logically demands. But by sharing us with those fragments of her experience, she leaves us with so many unanswered and disturbing questions. Why was her baby IUGR, how did that go undetected, how early was he/why did they labor at home at all, etc. Dr Jen makes an important point that 'I got my healthy baby' (as well as 'breastfeeding didn't work'!) do not lend the insights the viewer had come to expect by this point in the film! Why not at the very least edit in a quote from one of the experts about screening of low-risk mothers and transfer of care to appropriate providers when necessary, about the importance of cooperation between the different models of maternity care, etc.? I wish she had had the strength to take the effort to make her birth experience into a learning opportunity for the viewers that rings with the same clarity and conviction that the rest of her film does...

    Okay, as far as the dilemmas raised by the discussion afterwards. I do not envy the choices any dedicated birth practitioner has to make. Those licensed care providers who (most of the time) play by the rules are frustrated by not being able to offer care to everyone in need. Those direct entry midwives who work underground so they can provide true informed choice and then follow the mothers' lead, they risk losing their livelihoods and being criminalized. I honestly can't decide which is a thougher place to be. My instincts tell me to advocate for more caregivers to leave the system inviting their clients to follow. This is just armchair ethics though, so please don't take me seriously. I very much respect staying at the hospital as well, where most mothers will remain and where compassionate and empowering care is more important than ever.

  3. Thank you so much for posting the Dr.'s perspective on the movie. It's pretty much exactly what I thought too...such a big missed opportunity by ending all about Abby. I really appreciate having an "insider" commenting about the current state of medicine. I hope we'll be hearing more from this great doc...:)

  4. That's awesome, Joy! Too bad you live so far away. Otherwise I'd sign you up as my midwife. :)

    I agree with the prevailing feeling about this movie. I didn't realize how prevalent the ideas that Dr. Jen talked about are until I tried to tell my own sister about the movie. She got so upset that we had to end the conversation. She tried to tell me that women DON'T want something different from what they already have. Women AREN'T angry about c-sections, and that I am completely crazy for thinking otherwise! Her idea of a perfect birth is to go in, be induced, get hooked up to the epidural, and watch movies until the baby comes out. ARRRGGGHHHHH! It makes me want to scream. Why are women who are otherwise very vocal and strong and determined to be in charge of their own lives allowing their choice to be taken away in such a powerful arena?

    I wish, like Judit, that I could find some magic way to fix this. I guess the best thing I can do is to talk to my friends, talk to the young girls I know, talk to my own kids, and let them know that the slice-and-dice way of having babies is not the only, or even the best, choice out there.

  5. Wow, what a well spoken community of women are commenting here! I find I don't have much to add. Just wanted to say that I appreciated reading the doctor's amazingly worded thoughts on the movie. I admire her so much for trying to give women better births within the hospital system. Talk about swimming upstream...
    By the way, I am the woman who had the episiotomy against her will. And, now, I do wish I had filed a formal complaint. I'm not sure why I didn't... I was young, and the birth was long and utterly exhausting. I even had to return to the hospital for a few days (without my baby) because my blood pressure was still high. Ugh. Those days are a blur. And, while I was angry about the episiotomy, soon I was consumed with simply trying to care for a baby... trying (and failing) to breastfeed, trying to deal with all the emotions after a highly complicated delivery that was the opposite of what I had wanted. Anyway, perhaps I should have filed a complaint. But my hospital experience did convince me to have a homebirth with my second. And now one of my best friends is preparing to have a homebirth (which she thought was crazy until she heard about my experience). So, despite not filing a complaint against my snip-happy doctor, I feel like my actions have wrought positive change. Another baby born at home is a beautiful thing to me!

  6. The difficulty is that some women are fine with the system--and they cannot accept why others have the same experiences and come out feeling upset, sad, traumatized, or depressed. It's not that we're trying to take away choices from women. I mean, if you really want to be induced and have an epidural, no one is stopping you or outlawing your choices state-wide or throwing your doctors in jail for it. We do want you (a hypothetical "you" of course) to know the full range of risks and consequences that such a decision might entail, and what other alternatives exist, and why you might or might not want them.

    It's kind of like a person who adores fast food dismissing those who want to buy locally grown, organic produce and to make their own meals from scratch. "It's good enough for me; I don't see why you don't just stop complaining."

    Well enough of my bad analogies. Ciao.

  7. maiasaura - I hope my comments weren't interpreted as a criticism of your response. Believe, I'm well aware of how consuming just getting through every day is when you have a new baby, and how sometimes you don't even have time to process until months later, and then all seems too late.
    After my own 2nd birth (an accidental UC and hospital transport) I was treated absolutely terribly by the hospital and a resident physician who was cruel, arrogant and unnecessarily rough. Not only did I not complain at the time, but I also didn't follow through later, after time to heal and process. I wish now that I had. In my case, I wouldn't have even commented about how things didn't go the way I wanted, but just basic patient rights principles like I had a right to have the resident physician tell me her name and what department she was from without having to get in an argument to just get that basic info, and how I should have had the right to know where my newborn was and what her condition was.
    I know from experience inside hospitals that patients complaints aren't always taken seriously, but multiple complaints at least follow the doctor around as they try to get privileges, go to work at different places, or apply for insurances. Somehow, we (collective we, that is) have to make our voices heard and insist on different treatment.
    It always makes me so sad to hear stories of outright abuse - docs doing things against the express wishes of clients, some even with sadistic intent. You know, the type of care providers who say things like they are getting the OR ready because the mama dared to have a birth plan, or the OB who says they will cut an episiotomy no matter what you want if THEY feel like you need one, and they will NOT be consulting you either. Hard to envision working with those kind of folks on changes in care.
    Joy - how very, very exciting! I hope you will blog all about your experiences and we'll get to live them through you!

  8. Sorry, serial commenting here.
    On women who want to buy the hospital ticket and go for the hospital ride - there is a range there as well. Some are merely uneducated. They come in my door and the more I talk about risks/benefits, and options, and responsibility, the more they step up and take control from me. I'm always thrilled when I have a client who starts ordering me around (which I know makes me quite the oddity.)
    There are women in the middle who don't start ordering me around, but do at least have the ability to verbalize how they are making their decisions, can at least tell me the risks/benefits of their choices, and at least understand what's going on around them.
    Some women, though, are deeply rooted in modern birth culture and are looking for the kind of care that is standard there. They feel threatened if I try to put decision making on them. They sometimes fire me because I'm not doctor-y enough. They fuel the rumor mill in my town that I don't like epidurals, that I won't let people have pain meds, that I won't do a nice episiotomy but "she just lets you tear from end to end" They are traumatized if they have intense sensations of any kind during their births. (even if it's just pressure during descent of the baby which is really hard to medicate away, no matter what kind of epidural you run.) And, they feel threatened by women who do it differently, who don't feel there is no reason to forego an epidural ("because you wouldn't have your appendix out without anesthesia, would you?")
    These are the clients that I can't decide how to approach. Do I just let it go because it's not about me and there are plenty of other docs who will do what they want?
    What I'm trying hard to work on in this area is continuing to speak truth "here are the risks of inductions" kind of thing and say "but ultimately, this is your body and your decision to make" as long as it's not completely ridiculous (I'm not inducing anyone at 36 weeks, no matter how sick of being pregnant they are or who is in town visiting and wants to see the baby before they go home) I'm trying to let go of the need to be right myself and figure that at least I can encourage people to expect to be told how medical decisions are being made, and maybe it will prepare the way for them to do things differently one day, or at least be supportive of someone who does things differently.

  9. maiasaura's comment is right on--new moms often don't complain much because all mothers, especially new ones, are exhausted, overworked, and under-supported in this country. By the time you get past the worst of the exhaustion, you feel silly for complaining about something that happened a year or two years ago (it can take that long to process it all!)

    We also don't complain because we are pressured not to; when I would speak of my trauma at my son's birth, people would ask if I had "sought help"--in other words, take your antidepressant and shut up. It was infuriating. Women are still being made to feel that *they* are the defective ones, not the system that abuses them.

  10. I SO agree about the ending. And birth being a feminist issue. Why don't ALL women band together on this issue?
    If interested, you can read my review of the film here http://enjoybirth.wordpress.com/2007/10/26/business-of-being-born-movie-review/

  11. I think the reason that all, or even more, women DON't band together about this is because so many of them have been brainwashed by the media and society that birth is painful, and must be medicated against. Then they go to the hospitals, often wanting to "try" a natural birth, and they quickly realize that the peaceful, painless birth they hoped for is not possible with all the interventions being thrown at them. Unfortunately, instead of looking at the establishment as the basis of the problem, they decide that their bodies are not cut out for birthing "naturally", that those who do it without drugs must be super-women, and so they go for the drugs and interventions even faster next time thinking that they are doing the best thing for themselves and their babies.

    I think if women could truly, truly understand before they start having kids that when they step through those hospital doors they are agreeing to the Standard Operating Procedure (hmm, interesting how that word "operating" is what happens so often), but that there are other options, more women would speak out to get what makes the most sense - birth being allowed to proceed in the mother's body's own way in the peaceful, quiet surroundings of her home. Sounds like a great recipe to me.

  12. Dr. Jen,
    If I ever need hospital care I will be more than happy to order you around!

  13. When I saw BoBB many months ago in Los Angeles, I made the same comments about the ending - and then, when I sponsored multiple screenings of the movie here in San Diego, I watched the movie about 15 times, growing used to Abby's story being the end. When the movie was screened by birth pros, the ending was an oddity and we/they wished the ending had been very different.

    However, the lay folks that saw the movie LOVED the ending and I stopped saying anything about how odd the ending was lest they have their experience tainted. It was a "doula" move/choice.

    Remember the story on my blog about the woman who was sewn up without pain meds? She was also neglected beyond what any human being should be expected to endure. And then the hospital called the police on me and CPS on the family? Not only did we complain to the hospital, but the family tried to find a lawyer to sue them. I also reported the hospital and doctor to JCAHO (the folks that accredit hospitals) and the family lodged a formal complaint against the physician to the Medical Board.


    No laywer would touch the case - and they tried about 20 of them.

    JCAHO wouldn't allow us to speak at their meetings with the doctor, nurses or hospital staff. A mole inside told us *we* were made out to be the monsters during the stay in the hospital. The doc, nurses and staff were exonerated and the hospital got it's "excellent" rating for the next 2 years.

    The Medical Board dismissed the charges against the doctor - uh, actually, they thought the charge was against ME and I *did* get charged - until the parents straightened that crap out. When it came to the doctor, though, nothing happened at all.

    The police left after I showed them my license.

    Child Protective Services eventually dismissed the case the hospital brought against the family. And me.

    So, the moral of this tirade is that even WHEN a family/midwife complains, WHO CARES?!?!? It seems no one does.

    It is so frustrating/sad/horrible to witness the pain and attempt at healing after so many people "in charge" don't give one whit about what she went through.

    How do we work with this system!?

    I just try to keep my head down and not look up too much at the horror around me. I just try to be there for whomever comes my way.

    It isn't easy, is it, Dr. Jen? It's so painful sometimes.

    The beauty of women and birth is what keeps me going.

  14. NGM, I wish I could say that I'm astounded by that woman's treatment by the powers that be, but I can't. The more I learn about how so many people in labor and delivery really DON'T care about mothers and babies, the more sickened I become.

  15. I think it depends on how you look at the Abby situation. On one hand, I wished they had given a little more detail about why in that situation, it might have made sense to transfer. However, in keeping with the accessibility of the film to a general audience, I thought it nicely showed that when a transfer is warranted, it can be done on time, safely, successfully, etc. which seems to be a big worry people have.

  16. Kelley said:
    "Her idea of a perfect birth is to go in, be induced, get hooked up to the epidural, and watch movies until the baby comes out. ARRRGGGHHHHH! It makes me want to scream. Why are women who are otherwise very vocal and strong and determined to be in charge of their own lives allowing their choice to be taken away in such a powerful arena?"

    Birth is not about empowerment to many women- I don't understand it, but it seems to be that way. They want things easy and pain-free, and if that's their opinion who can stop them... UNLESS that manner of birthing is not advantageous for the baby, which it is slowly being proven that it is not.


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