Review of Your Best Birth

After the release of their documentary The Business of Being Born in 2007, Ricki Lake and Abby Epstein wrote a book called Your Best Birth: Know All Your Options, Discover the Natural Choices, and Take Back the Birth Experience. I have written a lengthy summary, followed by my own brief commentary, of Your Best Birth.

Summary
Foreword by Jacques Moritz, OB-GYN

Dr. Moritz, the obstetrician shown with Abby during her prenatal visit in The Business of Being Born, wrote an introduction to Your Best Birth. Instead of paraphrasing his comments, I will include some excerpts from his foreword:

On a recent, beautiful fall day in New York City, my family and I went for a walk around Gramercy Park. It was a walk we had taken a hundred times before, but this time, as we passed by a brownstone, we all noticed a National Parks Foundation sign that read “The Birth Place of Theodore Roosevelt.” My fourteen-year-old son asked if Theodore Roosevelt was actually born in this house or if it was just the place where he grew up. I thought it was a great question. Of course the year, 1858, meant that he was actually born in this house. My daughter’s response was “cool!” At that time, Mrs. Roosevelt didn’t have a choice. Giving birth at home was her only option.

A lot has changed in the 150 years since Mrs. Roosevelt delivered. If you were to walk into the coincidentally named Roosevelt Hospital’s labor and delivery floor, where I’m the director of the gynecology division, the first thing you would see is two sixty-inch plasma monitors displaying an array of data such as fetal heart rate, intrauterine pressure readings, blood pressure, pulse oximetry readings, and the list goes on. In front of these monitors would be a group of well-minded physicians and nurses that are all “managing” the laboring women. It reminds me of air traffic controllers at JFK trying to get a 747 on the ground in one piece. And patients love it. They say, “The care must be good—look at all that high-tech equipment they are using.” But is all this high tech a good thing? Have we now entered the day of “high-tech, low touch” deliveries? And if we have, what are the risks and benefits? These are all questions that expecting mothers should ask themselves. These questions and more are answered in Your Best Birth....

The state of obstetrics in America is in a crisis mode….Women must understand this crisis and how it will affect their birth options. Physicians and midwives are being squeezed between the dual constraints of rising malpractice premiums and increasing lawsuits. The record numbers of OB-GYNs who are voluntarily stopping obstetric practice and of midwives who are unable to find backup physicians or get malpractice insurance are signs of a major crisis. Even more importantly, there are increasing limitations imposed by insurance companies that introduce restrictions on how OBs can practice. In Oklahoma, for example, OBs are not covered by their malpractice provider for VBAC….Obstetrics training itself is questionable, in my opinion. In my four years of residency at Columbia University, the only natural childbirth I ever
saw was done by midwives.

The days of pregnant women interviewing their doctor (as seen in the film Knocked Up) may be a thing of the past. I know doctors who now interview patients to see if they will accept them in their practice, or “fire” patients if they have too many questions. The days of your health care provider’s being the person who attends your birth are also over….And this new trend goes one step further with the “laborist,” a physician who is now commonly hired by a hospital or large obstetrical group exclusively to deliver babies. Laborists often have twelve-hour shifts. You will never meet the laborist before you start labor and you won’t see the laborist again after delivery, and if your labor is a long one, you may have more than one laborist
taking care of you. Welcome to the new world of obstetrics.

Preface: Ricki and Abby: Our Best Births

In the preface, Ricki Lake and Abby Epstein tell the stories of their sons’ births: Ricki’s first birth began as an unmedicated birth in a hospital birth center and ended in the L&D unit with Pitocin and epidural. Her second birth took place at home with a CNM. Abby saw Dr. Moritz until 30 weeks into her pregnancy, when she changed to a home birth CNM. However, she went into premature labor at 35 weeks with a breech baby, which meant a transfer to the hospital and an unplanned cesarean section.

Ricki discusses how when she was pregnant, everything seemed beautiful:

The birth center took up part of a floor of St. Lukes--Roosevelt Hospital in New York City. When Abby saw it later she thought the big birthing tub and the blocky, impersonal furniture made it feel like a cheesy hot tub suite in a slightly run-down Las Vegas hotel. The sheets on my bed at home had a much higher thread count. At the time, I thought it was beautiful. Right then, though, I thought everything was beautiful. Even my 210-pound ass was beautiful to me.

Abby comments on learning how to surrender to what birth brings:

Although the dash to the hospital and the emergency C-section were traumatic, I never felt Matteo [her son] and I were in any real danger or that my little birth team of Cara, Ricki, and Paulo couldn't handle the situation. In truth, I really did feel empowered. I had information and wasn't going to do anything unknowingly or be railroaded into a certain kind of birth. I surrendered to the birth Matteo needed, and I don’t feel disappointed. I think it’s almost impossible, in that moment when you have a new baby, to feel disappointed about anything. In some ways, it was a perfect entry into parenthood—these little people arrive and make their own path beyond your control. They start teaching you lessons before they are even born.

Introduction: Your Birth Is Your Business

Ricki and Abby emphasize that this book does not tell other women how they should birth their babies. Instead, their goal is to help women learn what the range of choices are and how to “decide what kind of birth is best for you….Your best birth is one where you feel empowered because you know all your options and are confident in the decisions you have made about the birth.” They believe that the goal of a healthy mother and baby isn’t incompatible with an optimal, empowering experience. The write, “we believe that you can place the health and well-being of your newborn as your highest priority and still have an optimal, empowering experience that is right for you both—whether that is in your bed, in your bathtub, in a hospital room, or on an operating table. All the choices are yours and we want to give you some information and encouragement to resist and question the current trend toward more medicalized births that are not appropriate for everybody.”

The main goal of Your Best Birth is to “demystify the natural options that [many] doctors didn’t present as viable and that would offer these options in a straightforward and comprehensive format that could educated and empower women….In this book we will be looking to a wide array of experts to educate you about the possibilities that generally don’t come up in discussions with doctors and in hospitals.”

Section I: Know Your Options

In the introduction to this section, Ricki and Abby describe a “typical hospital birth” to educate women about procedures and practices that commonly occur in hospitals. After stressing that hospital practices can vary widely, they overview common hospital practices that many laboring women will encounter: when you’re advised to come to the hospital, what happens in triage before you’re admitted, consent forms, meeting with the anesthesiologist, epidurals, Pitocin, artificial rupture of the membranes, episiotomy, and standard newborn procedures.

Chapter 1: Not Your Mama’s Birth Plan
The chapter begins with the story of Jennifer Jilani’s pregnancy and birth. An American living in the Netherlands, she was initially skeptical about using a midwife—something that all healthy Dutch women do—but came to enjoy the personalized, laid-back care. She had planned a hospital birth but, late in labor, decided to stay home (something that the Dutch system allows for; women don’t have to decide until the day of labor where they want to give birth). Ricki and Abby remind women that even in the US, a similar positive, empowered experience is possible if you do your homework and assemble the right people to be with you. It’s up to you to advocate for your best birth. One major step in that process is overcoming your fears, both external (ones from Hollywood depictions of birth or “horror” stories that women often tell each other) and internal (fears that you create in your own mind). They encourage you to approach fear as your friend; use it as a starting place for education and growth. Another major step is looking carefully about your attitude towards pain. They encourage their readers to think about it in a new way: not as something awful and terrifying, but as something that is healthy and that can help your body move and shift around just the right way. They include several useful excerpts, such as the top 10 non-narcotic pain relievers (from laboring in warm water to movement to vocalizing) and Penny Simkin’s Pain Medication Preference Scale.

Chapter 2: Your Best Birth Place
In this chapter, Ricki and Abby discuss the pros and cons of the four main choices of birth place: hospitals, hospital birth centers, freestanding birth centers, and home. This section contains great advice for how to ask the right questions when you’re taking the hospital tour. It’s not enough to ask things like “do you have showers or tubs for laboring in?” or “can I use different positions for laboring and birthing?” The answers to those types of questions will almost invariably be yes. However, whether or not those things actually happen once a laboring woman arrives is another story. (For example, during her first birth my sister-in-law was not even allowed to go into the shower because her water had broken and her doctors told her that it was too dangerous because of the risk of infection!) So you need to ask follow-up questions and sleuth around, so to speak, to see how often women actually are allowed to be in the shower or in the tub, or whether the nurse or physician will actually be okay with you squatting on the bed to push. They write, “As you walk around the hospital on the tour of the maternity ward or attend an orientation session at a birth center, you need to remember that this is a sales pitch. The people conducting the tour are going to show you all the pleasant features of their establishment….The style of rooms means far less than the attitudes and behaviors or providers. The hospital’s cesarean rate is a better indicator of these than its room décor. Hospitals can use style to co-opt substance.” They include a list of questions to ask on the hospital tour, ones that should reveal attitudes, routines, procedures, and practices common at that hospital.

The rest of the chapter overviews the pros and cons of the other three birth locations (hospital birth center, freestanding birth center, and home). It includes questions to ask for each location and information about water birth and helpful positions for labor & birth.

Section II: Putting Your Dream Team Together
Your birth team is key to having the kind of birth you want, even more than the location of birth. Choose your care provider carefully; when you decide on a particular physician or midwife, you’re essentially agreeing to his or her philosophy of intervention and pain management. The next two chapters overview the general differences in philosophy and management between obstetricians and midwives.

Chapter 3: Obstetricians: Finding Dr. Right
This chapter begins by discussion the pressures obstetricians face that limit the kind of care they are able to give. OBs have to keep a high volume of patients in order to pay for their (increasingly expensive) malpractice premiums. Many practice defensive medicine by actively managing labor and intervening sooner rather than later, in the hopes of avoiding a lawsuit. They comment:

The financial and legal pressures on obstetricians are enormous. Every minute they spend answering your question s is a minute they aren’t spending with money-making patients in the other rooms. This is probably why many doctors trained in obstetrics and gynecology only practice obstetrics for a few years and move in mid-career to the better hours and more manageable risks of plain gynecology. For many it’s a terrible disappointment. They started in this specialty because they loved helping women have their babies. The way obstetricians are trained and the legal environment they practice in gets them further and further away from their original expectation of being a doctor.

LA Obstetrician Stuart Fischbein bemoans what he calls the “coercive” business of medicine: “Hospital risk managers and insurance companies are making the decisions that affect the lives of patients who they never have to look in the eye. We are training doctors to be sheep, not shepherds. One successful lawsuit can devastate the hospital’s bottom line for years, so there is pressure to protect the hospital from liability, despite what the hospital’s television commercials tell you.”

Although this chapter mainly discusses obstetricians’ training and style of practice, it does include a brief section about family physicians, who usually practice with a more integrative style and tend to have lower intervention rates than their OB colleagues. Family physicians attend about 8% of all births in the US, similar to the percent of births attended by midwives.

Ricki and Abby advise women to use pregnancy as a time to stop being people pleasers. Don’t hesitate to “fire” your caregivers, even if it’s late in pregnancy, if they are not the right fit for you. One way to find out if your physician is “Dr. Right” is by asking the right questions—a list is included in the book.

Chapter 4: Midwives: Not Just for Hippies Anymore
Ricki and Abby begin by outlining the midwifery model of care (keeping in mind that midwives, like physicians, can vary dramatically in their practice style depending on where they were trained and their personal philosophy of care). In general, midwives view birth as a normal, healthy process that usually needs little or no intervention. They spend much more time with women than OBs do during both prenatal visits and during labor. They outline the various types of midwives available in the US, including primarily hospital-based CNMs and home-based CPMs. They also discuss the historical turf wars between physicians and midwives that still exist today in battles over midwifery licensure and autonomy. They also include lists of questions to ask when you’re interviewing midwives.

Chapter 5: Doulas: Labor’s Love
This chapter discusses what a doula is and how she can help the birth process through education, advocacy, and encouragement. You will learn what doulas do at a birth and how to pick the right one for you.

Chapter 6: The Guest List: Birth as a Private Party
Pregnancy and birth are opportunities to develop trust in yourself and deepen your knowledge of what you want and what is best for you—not a time to be “nice” or to do what other people tell you to. With that in mind, whom should you invite to be at your birth? Ricki and Abby feel that it should be “only people whom you trust completely, who approve of your birth plan, and who you don’t mind seeing you naked.” They comment: “that certainly shortens the list. Particularly the naked part….Birth is not a party, like a wedding, where you have to worry about offending those who were not invited.” Don’t worry about hurting people’s feelings when you’re in labor; you need to focus on clearly stating your needs and on feeling completely uninhibited with the people around you.

Chapter 7: For Sexual Abuse Survivors, a Healing
This chapter discusses the ramifications that labor & birth can have on sexual abuse survivors. For some survivors, labor can bring up old traumas. But it can also be a profound healing experience, as Ricki found. She was abused as a child and, after giving birth the second time, finally learned how to fully accept her body. She writes: “Then I totally looked at my body in amazement, like look what I’m capable of. It is amazing that we can carry children and give birth. After Owen was born, I started to lose weight easily. Well, it definitely didn’t fall off. I made a decision, but it was the easiest time I’d ever tried….I don’t know how to explain it other than it just felt like this purging of that pain and trauma from the past.” The chapter discusses how to help abuse survivors plan for their birth and how care providers can avoid bringing up past traumas.

Section III: Interventions: The Slippery Slope

To summarize the third section of Your Best Birth, I will quote from the introduction to Section III. “Things happen pretty quickly in the hospital and informed consent isn’t always the staff’s highest priority, even if getting you to sign the release form is. If you don’t know the risks, how are you supposed to weigh them against the benefits? In this section, we’re going to speak candidly about different kinds of interventions so that now, as you sit calmly reading a book and are not in labor, you can think these things through and talk them over with your partner and your caregiver. That way, if you find yourself in a situation where things are moving quickly and there is pressure for you to decide, you can say, ‘Wait! There is a reason I decided against this. Everybody, let’s just slow down and give me a minute to think this over.’”

Chapters 8-12 cover several main interventions and procedures that might be proposed during the course of a woman’s labor: epidurals, inductions and Pitocin, electronic fetal monitoring, episiotomies, vacuum extraction, forceps, cesarean section & VBAC. These sections focus more on the potential risks and drawbacks, since the authors assume you’re already informed about the possible benefits. Their main approach to interventions is that they can be useful and even life-saving in certain circumstances. However, every intervention or medication has potential risks and drawbacks, which are important to be aware of. They write: “every attempt to interfere or interrupt the natural process of birth has to be considered very carefully. Even though your baby is strong and resilient, a little super hero making the journey down the birth canal, every intervention, every drug, carries with it some risks. You need to know those risks.”

Section IV: Take Back Your Birth

This section emphasizes the care practices that will help you have “your best birth.” Ricki and Abby include the World Health Organization’s recommendations that support and protect normal birth. These are similar to the Mother-Friendly childbirth Initiative and Lamaze’s 6 Care Practices That Support Normal Birth. They reiterate that it is up to you to seek out the birth that you want and that you feel is best for you and your baby:

We’ve been describing a kind of childbirth throughout this book that, we hope, is centered on you and your baby and exactly the situation in which both of you would feel the most supported and the most comfortable. This idea of labor and birth insists that you think things through for yourself and decide what you believe to be best. In addition to that, we want you to go out and get exactly what you want, like a good consumer. Once you’ve examined all your choices, talked them over with your partner, and surrounded yourself with an environment and a team that you believe can handle whatever comes up, you have the right and, in fact, the responsibility to completely relax and simply birth your baby.

Chapter 13: Loving Your Labor
This is a rambling, somewhat disorganized chapter about the birth process, different types of childbirth education classes (such as Bradley, Birthing From Within, Lamaze, and Hypnobirthing), and tips to help labor go more smoothly.

Chapter 14: Bonding with Baby
This chapter discusses the routine newborn procedures typical in hospital births and stresses that they can be delayed, leaving the first hour or two for breastfeeding and snuggling. Ricki and Abby discuss the astounding hormonal adjustments your body goes through as you give birth and begin breastfeeding and remark upon the newborn’s ability to crawl to the breast and self-attach (if the mother had an unmedicated labor). They mention the role of postpartum doulas and emphasize the importance of rooming-in and uninterrupted contact with your baby.

Epilogue

Ricki and Abby have noticed that our birth culture is beginning to shift. In order to have a VBAC, women are driving over one or more state line to find a provider, or they are laboring in the parking lot until birth is imminent. “Midwives all over the country have reported that demand for their services is growing….Medical students and nursing students are demanding rotations in midwifery and more training in the physiological process of birth. The system has swung so far out of control that attitudes are shifting back toward respect for the natural process.”

They encourage women to speak with their pocketbooks—one of the only ways to get our for-profit health system to take notice. “After reading this book,” they write,” we hope that you will begin to demand more choices in childbirth in your community….If you used a fantastic OB-GYN or midwifery practice, tell other women to seek them out….If your local hospital doesn’t have a birth center or offer midwifery services, make a big fuss about it.”

They conclude by reiterating their core message of education, empowerment, responsibility, and action: “Many parents are starting to understand that the birth of their child is something that can be ‘taken away’ from them. It takes a lot of research and guidance to make sure you are with providers who will respect your family’s birth plan….At the end of the day, we feel that the true mark of a ‘best birth’ is when the mother is respected, informed, and treated as a participant in every decision about her pregnancy, labor, and delivery.”

Appendix

The appendix provides information about the following topics:

• Making Your Birth Plan
• Making Your Wishes Known
• A sample birth plan
• Resources (including midwives, doulas, consumer advocacy & birth resources, childbirth education, Baby-Friendly hospitals, cesareans, books, magazines, videos, breastfeeding, low-income and teen parent resources, intimate partner violence, lesbian and gay parenting, research, waterbirth, alternative medicine, and postpartum depression)

My thoughts on Your Best Birth

Your Best Birth was written for women who have little or no knowledge about their birth options, rather than for those who have already begun that journey. I think this is why I liked the book more the second time I read it. This last time, I tried reading through the lens of a woman whose only knowledge about birth came from the media or from casual conversations with friends or co-workers—you know, “just get the epidural!” or “I had to have an episiotomy because the doctor said I was going to tear.” This book opens your eyes to the many possibilities and options surrounding childbirth, from conventional OB-GYN care and medicated hospital births, to midwives and doulas, to waterbirth and thinking positively about the sensations of labor. I would guess that many women do not even know there are other ways of giving birth. This book is most valuable for presenting the many options for pregnancy & birth, urging women to carefully research their options, and encouraging them to take action and work hard to create the best possible birth experience.

Your Best Birth is written in a chatty, conversational, informal tone—the kind of things that a good friend might tell you. Ricki and Abby speak favorably of natural birth and midwifery and other alternatives to conventional obstetrical care, but they do not present these choices as The Only Right Way To Give Birth. At times I found the writing style somewhat rambling and disorganized; the book could benefit from another round of editing and polishing.

I was glad to see an entire chapter devoted to birth after sexual abuse. It's something that isn't written about very often, but should be. With a large minority of women experiencing sexual abuse in this country, it's important to know how labor and birth might affect abuse survivors.

The weakest part of the book was the section on interventions—not because the information was incorrect, but because Ricki and Abby did not provide references to back up their claims. This book was not written as a reference text or guide to the medical literature, of course, but providing some information about their sources and giving suggestions for further research—the Cochrane Reviews or Lamaze’s Research Summaries, for example—would have greatly strengthened Section III.

I’ve been thinking about the core message of consumer empowerment in Your Best Birth: the idea that, as consumers, you have a right to demand options for your birth and to “vote with your pocketbook.” It’s a very individualistic message—it’s up to you to create the kind of birth you want. Sometimes I wonder whether it sets women up for failure, because it isn’t always so simple as asking for and then receiving the things you want. There are things like hospital culture, malpractice insurance regulations, and physicians’ fear of litigation that strongly limit the options available to women. Simply asking for change on an individual level might not be enough to overturn these deeply entrenched forces. On the other hand, individual advocacy on a massive enough scale translates into a powerful force for change. I’m thinking back to the days when husbands weren’t allowed in birth rooms. It was individual women and men demanding change, persistently, over and over, that gradually led to a dramatic reversal of policy. Nowadays, it’s expected that the woman’s husband or partner will be present at the birth—something that was fairly unthinkable just a few decades ago. In sum, I find Ricki and Abby’s message of consumer empowerment a pragmatic one. If you know you want a certain kind of birth—whether it’s at home or in a hospital, under water or on an operating table—you need to speak up and work hard to get what is right for you. It won’t happen by itself.