Born in the USA (41 page)

Occasionally, thanks to a journalist's commitment to balanced reporting on other issues in addition to induction of labor with Cytotec, another view of childbirth sneaks in. Because a journalist for
U.S. News and World Report
had met me and we had discussed birth issues, she decided to do an article on C-section that was excellent and balanced.
¹⁴
After a birth activist contacted
a journalist at the
San Francisco Chronicle
and told her that the FDA had just moved to warn patients of Cytotec's serious risks when used for labor induction, an excellent article appeared in that paper the next day.
¹⁵

Local television and print media are often more likely to be open to another point of view on childbirth. When a family in Las Vegas was being hassled because they chose a home birth, when a woman died at the time of birth following Cytotec induction in a small town in upstate New York, and when obstetricians in Des Moines tried to shut down an ABC, local journalists and their editors got riled up and jumped in with excellent editorials and good investigative reporting on issues such as freedom of choice in childbirth, respecting family sanctity in childbirth, and the safety of births at birth centers and at home.

Another source for education of the public in the American way of birth are those newspapers, magazines, and Internet magazines focusing on controversial issues. The first real “break” in news regarding the dangers of Cytotec induction came from an article in the activist magazine
Mother Jones
.
¹⁶

Mothering
is an excellent magazine containing many carefully researched articles on childbirth, for example, one titled “Induced and Seduced: The Dangers of Cytotec.”
¹⁷
Midwifery Today
, a monthly journal for midwives, has many excellent articles on the state of affairs in American midwifery, which are well written and easy to understand.
Salon
(salon.com) also has good articles on obstetric issues, sometimes written by midwives. But watch out for some of the magazines found in doctors' offices, many of which are full of sycophantic drivel about how wonderful doctors will save the woman and her baby. It is sad to see these articles, because once in a while doctors are really necessary during pregnancy and birth and do save lives. It is a disservice to obstetricians to have their role glorified and romanticized in slick magazines.

It is also fair to hope that books written for popular consumption would be an excellent source of education on childbirth, but there is a real problem here as well. I once went to a large bookstore in Washington, D.C., and surveyed all the books on the pregnancy and childbirth shelf. There were twenty-eight titles, and twenty-three of them I would put solidly in the category of obstetric party-line dogma, the kind that insults the intelligence of women and urges, “Do what the doctor says, dearie.”

There is a simple test women can use to determine whether or not a book or magazine article is worth reading. I call it the trust test. If the book or article says, “ask your doctor,” “trust your doctor,” or “listen to your doctor,”
it has failed the trust test and should probably go back on the shelf. If it says, “trust yourself,” “trust your body,” or “trust the scientific evidence,” then it is probably worth reading. The quotation at the beginning of
chapter 3
, in which the author of a popular book titled
The Girlfriends' Guide to Pregnancy
urges the reader to choose C-section for convenience and cheat her insurance company, is typical of this surfeit of insulting and misleading books.

Fortunately, books for women who want the correct facts about pregnancy and childbirth do exist. I can recommend anything by Ina May Gaskin, Henci Goer, Sheila Kitzinger, Robbie Davis-Floyd, Elizabeth Davis, and Barbara Katz Rothman.

Multidisciplinary conferences are another important means of educating the public about the need for change in maternity care. A conference can reach a wide variety of groups from health care providers to politicians to the media, like the conference in the year 2000 in Brazil described earlier. Women's groups and consumer groups can get together in a coalition, either locally or on a larger scale, and invite key people in the field of maternity care to help them choose topics and speakers for a conference. If necessary, they can bring in people who have organized conferences in the past to help. One thing those with experience in maternity care conferences will always stress is that it is important to include the media from the beginning.

As discussed in
chapter 8
, I also believe it is important to begin teaching children about birth at a young age to kick-start a change in attitudes toward pregnancy and childbirth. Interested parents and teachers can recruit school nurses to be expert consultants and help in the preparation of teaching plans, as well as working with midwives and others in the community.

2. REVISE EDUCATION FOR MATERNITY CARE PROVIDERS

As I discussed in
chapter 8
, we currently have far more obstetricians than we need in the United States, and far too few midwives. Because public funds are used for training maternity care professionals in the United States—nearly every training program for obstetric residents is heavily subsidized by the federal government, although there is far less subsidizing of midwifery training—that means that, in theory, the public can work through their government representatives to influence such funding decisions.

But how are these who-will-be-trained decisions made? I decided to find out and, after several hours of telephone calls, I finally managed to get
through the federal bureaucracy to determine that somewhere in the federal Department of Health and Human Services there are people who approve the funding of training of health professionals, including heavily subsidizing hospitals that train obstetric residents. It was clear that I would not be able to get further without spending many, many more hours on the telephone. Ultimately, those I spoke with were unwilling to tell me who makes the decisions about such funding, except to say that ACOG advises them. I was told that although such information is in theory available to the public, no one ever asks for it. I can say that they were certainly not eager to provide the little information I received, despite the fact that I used the magic words, “This is
Doctor
Wagner calling.”

In addition to federal funding, whenever obstetricians train in state or local government facilities, including state university hospitals and county hospitals, state or local government is subsidizing obstetric training.

The public needs to be made aware of this government subsidizing of obstetric training with far more transparency and accountability than now exists. Individuals and organizations committed to the humanization of birth need to be persistent in pursuing this information and then getting it out to the public. The public has a right to participate in deciding whose education will be publicly funded.

Obstetricians want the public to believe that they are leaving obstetrics in droves because of the litigation crisis. Well, thank God! Bring in the midwives and start public funding of midwifery training instead.

The training of midwives, both nurse-midwives and direct-entry midwives, is slowly growing in the United States. That we now have regulations in the federal Department of Education for the training of direct-entry midwives was the result of a big effort sustained over many years by a coalition of midwives groups. Now midwifery organizations and advocacy groups need to study how many midwives will be needed when all low-risk pregnancies and births are attended by midwives, and set targets for training them. Here the Canadian experience is relevant again. Midwifery organizations need to collaborate on recommendations for expanding and subsidizing midwifery training and become advisors to the same government departments that ACOG works with.

3. REGULATION BY LITIGATION: PRESERVE THE RIGHT TO LITIGATE

Litigation may not be the most elegant way to bring about change in American maternity care, but right now it serves three important functions. First, it helps put the brakes on excessive obstetric practices. In a way, trial
lawyers actually have functioned like the sharks they are so often compared to. If an obstetrician sticks his hand outside the limits of good evidence-based practice, thereby increasing the risks of serious outcomes for the woman and baby he's supposed to care for, a legal shark will swim by and bite it off, as it were, by suing for lots of money—a strong incentive for evidence-based practice. But politicians have been killing off the sharks. Wave after wave of “tort reforms” are making obstetricians increasingly sue-proof by putting caps on how much the patients can sue for, and are creating obstacles to litigation, for example, requiring that a local judge determine whether or not a proposed case of malpractice litigation is “legitimate.”

The second function litigation serves is to guarantee individuals and families an arena where they can seek justice if they feel that they have been abused by powerful forces in the medical world. The right to seek justice is fundamental to the American democratic ethic and is enshrined in the U.S. Constitution. Doctors are not gods operating outside the law; they must be accountable to their patients. If doctors become sue-proof, patients will lose their rights and any chance at justice.

The third function litigation serves is to drive obstetricians out of the business of attending women having normal, low-risk births. In a high-risk childbirth situation, the woman and her family understand that there may be adverse outcomes, they are more likely to be given information because interventions are more likely to be necessary, and family members are less likely to feel disillusioned by what has taken place. In a low-risk hospital birth, there is a greater chance that unnecessary interventions will be used, leading to unnecessary adverse outcomes, and the obstetrician is less likely to have established a close relationship with the woman and family and less likely to provide information.
¹⁸

If the United States trains midwives as fast as possible and stops training so many obstetricians, existing obstetricians can safely stop providing care for low-risk births and focus their practice on gynecology and serious medical complications of pregnancy and birth. The net result will be a much-improved maternity care system. The more lawsuits obstetricians must face, the faster this day will come.

If litigation is evil, as obstetricians would have us believe, I believe that it is a very necessary evil, as it is a source of protection for women and babies. We must do what we can to fight any attempt to take this protection away. When legislation is proposed for tort reform to make doctors sue-proof, concerned citizens interested in optimal maternity care must work against it by contacting their legislators and the media. Lawyers and
their organizations can help by making clear to the public that litigation has a legitimate role in maternity care.

4. TAKE POLITICAL ACTION FOR HUMANIZED BIRTH

Birth also has political dimensions (especially regarding who has decision-making power), and political action plays a role in each of the steps covered in this chapter for getting to where we need to be. Too often, politics is seen as “dirty.” But in today's world of maternity services, it is the reality. It is inevitable that obstetricians will resist change, as they presently have power, money, and, for the most part, no one to answer to. So it is essential that supporters of the movement to humanize birth be politically active. Politicians and government agencies that make crucial decisions about maternity care and the training of providers of maternity care must be thoroughly educated on the issues. ACOG is very active politically, as we have seen from the organization's letters to politicians, journal articles, and news releases, and advocates of humanized birth can make sure that policy makers and politicians are aware that the point of view put forth by organized obstetrics is not the only point of view. They can demand that policy decisions be based on scientific evidence—and even bring specific studies to policy makers' attention when necessary. Advocates can make politicians and policy makers aware of the scare tactics used by the more reactionary elements in the medical establishment. Finally, advocates of humanized birth can prepare themselves to address erroneous statements made to the media and others—such as those often made about the safety of midwives and out-of-hospital birth—and the standard “What if something goes wrong?” argument. (For responses, see
chapter 6
.) And on occasion, advocates need to organize political events or outings. It can make a big difference for an organized group to attend a hearing on pending legislation on tort reform or licensing midwives, or to hold public rallies that bring the issue and the legislation to the attention of the public and the media.

Legislators can be most helpful as well. Often if a single legislator takes on an issue close to her or his heart, amazing legislative action follows. One important strategy is to locate such legislators and work closely with them. At the request of local advocates of humanized birth, I have met with such legislators in Vermont, South Dakota, California, and elsewhere, and I admire what they have accomplished. On the other hand, one legislator in Ohio, a nurse by trade, has successfully blocked progressive legislation on midwifery year after year. A reliable source told me that the night before legislation on midwifery was voted on in the state legislature in Wyoming, a
group of doctors called those legislators who were their patients and told them all manner of nonsense about the dangers of midwives and out-of-hospital birth. Sadly, the midwifery bill was voted down. This is called “playing hardball.”

One strategy often used by obstetricians whose goal is to influence legislators is to attempt to overwhelm them with technical language. Organizations and physicians who do this are implying that only doctors can understand the intricacies of maternity care. I've found that these groups and individuals are often the same ones who take the approach, “Trust me, I'm a doctor.” As I mentioned in
chapter 2
, the best way for politicians and policy makers to respond to this approach is with a simple request for scientific data. It can also be illuminating for legislators to ask someone who is making scary statements about out-of-hospital birth how many out-of-hospital births he or she has attended.