Born in the USA (43 page)

Increased monitoring and regulation by federal and state agencies of maternity care practices, including drug use, is an important long-term solution to vigilante obstetrics. Until we have maternity care sheriffs and judges in our local communities who are not afraid of hospitals and doctors and are willing to name names, we will not truly have accountability in medicine and protection for women and families.

6. FORM COALITIONS

Imagine for one minute what would happen if the thirty thousand labor and delivery (L&D) nurses in the United States decided that they would no longer take care of birthing women, take grief from omnipotent doctors and hospital administrators, and get none of the credit. If L&D nurses called a work stoppage for even one day, and there was no one to monitor the ten thousand women who give birth each day in the United States, the
entire hospital maternity care system would collapse, along with the obstetrics profession.

Such labor action (double entendre intended) will not happen, of course, because L&D nurses are committed to serving birthing women, but the idea illustrates the power L&D nurses have to force change if they really want to and have the courage. Groups have a lot more power than individuals, generally speaking. Groups of health professionals can work in their own community to promote improvements in pregnancy and birth care. They can go beyond pushing for a pretty new “birth suite” in the local hospital to lobbying hospital administrators to spend less money on high-tech equipment of dubious value and more money on increasing the number of midwives on staff.

In many cities and states and on a national scale, diverse midwifery groups, women's groups, and consumer groups that share a concern for improving maternity care have found one another and formed coalitions. These coalitions are often successful because the issues in maternity care transcend the usual group boundaries. Groups that hold right-wing family values join with groups that hold feminist values, groups working for religious freedom join with groups working for individual freedoms, and so on. Compromise is essential. I remember attending a conference where a maternity care coalition was forming (the Coalition for Improving Maternity Services) and listening to an anti-circumcision advocate who was being opposed by a Jewish physician. Eventually agreement was reached in the form of a recommendation against
nonreligious
circumcision.

If groups generally have more power than individuals, then groups of groups (coalitions) have even more power. In my experience, coalitions form when women feel that their basic rights are being threatened. Women's rights groups in the United States have been relatively quiet on maternity issues until recently, when the media reported on a case of attempting to force a C-section in Pennsylvania and a case in Utah in which a woman who refused a C-section was accused of murder.
²²

Midwifery groups in the United States, while performing vital functions during recent years, have also spent too much energy fighting one another. An effective strategy is for midwives' groups to form coalitions, not only among different midwifery groups but also with women's groups and consumer groups. In
chapter 1
, I described some coalitions that include midwifery groups as well as other grassroots organizations that are working with midwifery groups to improve maternity care through strengthening midwifery.
With the renaissance of midwifery in America and the energy they get by collaborating in coalitions, midwives are becoming more assertive and coming to realize that they must fight for what they do in the service of women.

Consumer action is an important part of the American way of life. It's the primary reason we now have informative labels on soup cans. Consumer groups in maternity care are working for better labeling of hospitals and obstetricians. These groups usually start at a grassroots level, when a woman or a small group of women has a negative birth experience. Then slowly the group grows. For example, a woman whose uterus ruptured after Cytotec induction organized a group using the Internet that now includes more than three hundred women who have suffered ruptured uteruses during birth.
²³
The Internet is a powerful tool for grassroots efforts.

ICAN is the acronym for the International Cesarean Awareness Network, a consumer group working to reduce unnecessary C-sections in the United States.
²⁴
ICAN activities include protesting at a meeting of ACOG where the glories of choosing C-section were being promoted and organizing petitions against the ACOG recommendation that VBAC be done only in hospitals where a surgeon and anesthesiologist are present round the clock.

The following story illustrates what a consumer group such as ICAN can do, as well as how unbalanced and biased medical journalism can be. On June 4, 2002, the
Wall Street Journal
published an article with the headline “Growing Number of Physicians Warn of Serious Risks from Vaginal Deliveries.”
²⁵
The article states that a number of “high-profile doctors”
(high-profile
doesn't necessarily indicate competence or credibility, of course) are challenging the conventional wisdom that vaginal childbirth is the best way to have a baby. (It's hard to be more anti-nature than that.) The article goes on to say, “At the very least, [these “high-profile” doctors] say obstetricians need to give their patients more information about the risks of vaginal delivery just as they would a C-section or any other medical procedure.”

The
Wall Street Journal
article claims that one-third of women have suffered injuries while giving birth—urinary or fecal incontinence, pelvic pain, sagging pelvic organs, sexual dysfunction—and quotes a professor of obstetrics, gynecology, and urology who calls vaginal birth “the silent epidemic of motherhood.” It goes on to blame the increase in injuries to women giving birth on the public health effort to reduce the nation's C-section rate. The article implies that public health scientists are to blame for the increasing incidence of birth-related injuries to women, not doctors.

Jill MacCorkle of ICAN wrote a letter to the editor criticizing this article, and thank God the
Wall Street Journal
printed it:

I couldn't have said it any better. Though it is great news that this brilliant, scientifically sound summary of the situation got published, it is a shame that far fewer readers saw it than saw the original article. The obstetric myths about surgical birth continue and the vigilantes ride on, sometimes in cahoots with unbalanced or biased journalism.

Another consumer organization working to improve care for women giving birth is Citizens for Midwifery. They have an excellent Web site featuring thoughtful explanations of what midwives do, the evidence for midwifery practice, and how women can support expanding midwifery in America.
²⁷

There are also several large organizations of childbirth educators (people who teach prenatal classes) in the United States representing more than one hundred thousand members.
²⁸
Although I believe that it is safe to assume that all of the thousands of childbirth educators want the best for birthing women, I still feel that it's useful to apply the “trust test” to this group and
separate those who tell women to “trust the doctor” from those who tell women to trust themselves and their own bodies and to carefully evaluate what the doctor says.

Childbirth educators in the second category are often in a dilemma similar to what L&D nurses experience. Their allegiance is split between the women they teach, on the one hand, and doctors and hospital administrators, on the other. Those who offer classes in a hospital and were hired by hospital staff have to be careful what they say or they risk being fired. If they're fired, they lose their chance to help pregnant women. So if a childbirth educator is teaching a hospital prenatal course, and in one of the sessions an anesthesiologist talks about the glories of epidural for normal labor pain without once mentioning the serious risks of the procedure because he doesn't want to “scare the ladies,” the educator must make a serious choice on whether to confront him or otherwise present alternative views so the women in the class can learn the whole truth.

I lectured once in Medford, Oregon, and a local childbirth educator described this very dilemma. She was hired by a big hospital and was experiencing a lot of frustration that she could not tell the pregnant women in her classes all she knows. We corresponded, and she hung in there as long as she could, but finally she had to leave the hospital and give prenatal classes “out-of-hospital.” In the end, it is a personal decision. Some educators find a way to compromise sufficiently to keep their hospital jobs and help the women who are there. Other educators find they do better if they offer “out-of-hospital” childbirth education, where they feel free to tell the whole truth. In general, I have found childbirth educators to be committed women who do their work for pennies because they care.

Even the childbirth educators whose classes are not controlled by doctors and hospitals struggle to find a middle ground, because they know that their students will probably give birth in hospitals, where there is little possibility for them to have a real say in what happens. However, I've found that most childbirth educators are well aware of the obstetric monopoly and its negative effects. It is good news for women that there are thousands of childbirth educators out there who will teach them to trust themselves and their own bodies and insist on the kind of birth they and their families want, not what their doctors want.

Childbirth education organizations have also set standards for their classes and for pregnancy and birth services and have been active in organizing communities and lobbying for improvements in maternity care. For example, these groups were instrumental in forming the Coalition for
Improvement in Maternity Services (CIMS), which has become a leading force in the movement to humanize birth.
²⁹
Maternity care in the United States would be a lot further down the birth evolution circle if it weren't for all the women who give so much of themselves out of a deep commitment to their sisters: midwives, L&D nurses, doulas, childbirth educators, and community activists.

In 1918, a small group of middle-class women in New York City who were concerned with the inadequate care available for pregnant and birthing immigrant women started the Maternity Center Association (MCA).
³⁰
They developed programs for prenatal care and prenatal education classes. In 1920, they produced a handbook for maternity services that described standards of care, many of which would be wonderful to have today—for example, one-on-one nursing care during labor and birth. In 1931, the MCA started the first formal training program for nurse-midwives in the United States, and in 1975, the association opened the first out-of-hospital ABC in the United States. The MCA has historically had a threefold mission: to provide services, to demonstrate the value of innovations, and to advocate for the spread of key innovations.

In 1999, the MCA changed direction, moving from a focus on the edges of maternity care—home birth and birth in out-of-hospital ABCs—to making mainstream birth (that is, hospital birth) more accountable. It adopted a new plan, called “Maternity Wise,” built on evidence-based maternity care practices.
³¹
The MCA's new modus operandi is to do research leading to education and advocacy. The group does research to measure present practices, and then locates relevant evidence and identifies gaps between evidence and present practices. It takes action based on its findings. One MCA program, for example, focused on the nature and management of labor and labor pain, which led to a series of systematic reviews published in a leading American obstetric journal.
³²

Between 2000 and 2002, the MCA conducted a national survey of maternity practices. Instead of gathering data from doctors and hospitals, the surveyors interviewed women who had recently given birth about what had happened during their childbirths. This was an important breakthrough in research into obstetric practices. Women certainly remember what happened to them during one of the most important events in their lives, and they are not afraid to tell the truth. They have no need to put the best spin on the practice. This
Listening to Mothers
survey then used these women's voices to measure gaps between the practices used on them and the scientific evidence. The survey also took a step toward correcting the serious
lack of transparency and accountability of maternity care in the United States.