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?