Born in the USA (44 page)

The MCA has used the results of its survey to advocate for change. For example, in July 2004, the MCA released a report titled
What Every Pregnant Woman Needs to Know about Cesarean Section
.
³³
This excellent report gives the data from the survey, gives the scientific evidence, and then makes recommendations. (In January 2006, MCA changed its name to Childbirth Connection, but its goals and activities are unchanged.)

In
chapter 3
, we saw how in Brazil the C-section rate soared in the 1980s and 1990s and many Brazilian obstetricians insisted that this was what Brazilian women wanted. Then in 2001, a paper was published of a large, prospective survey of Brazilian women proving that they did not want cesareans.
³⁴
Now in the early 2000s in the United States, many obstetricians have been claiming that the steady rise in cesarean rates is largely due to women's requests for C-sections. Then in March 2006, Childbirth Connection (formerly MCA) released the results of another
Listening to Mothers
survey of birthing women in which women were asked whether they would choose cesarean birth without medical necessity.
³⁵
The survey found that one of the 1,300 respondents (.08 percent) who might have chosen an initial or “primary” cesarean without medical indication did so. And 10 percent of the respondents had felt pressure from a health care provider to have a C-section. American doctors, like their Brazilian brethren, have been blaming women for what in reality the doctors want.

A much more recent grassroots organization in the maternity care field is the White Ribbon Alliance for Safe Motherhood.
³⁶
The group has taken as its symbol a white ribbon dedicated to the memory of women who have died during pregnancy or childbirth. The group focus is maternal mortality and it is active in more than seventy countries around the world.

In the United States, the White Ribbon Alliance for Safe Motherhood has a national working group that brings together community organizations, such as midwifery and public health organizations, that share a concern about the fact that the U.S. maternal mortality rate has not been reduced in more than two decades. The group also brings attention to racial disparities in maternal outcomes and in women's access to maternity care in the United States. A major event for the White Ribbon Alliance in the United States is its yearly campaign for Mother's Day, when people are urged to wear white ribbons to raise awareness of the threat to safe motherhood in the United States, as evidenced by the increasing number of maternal deaths.

In countries around the world, coalitions have played a key role in bringing about change in maternity care. CIMS has become an important force for change and is recognized by the United Nations. CIMS has developed the Mother Friendly Hospital Initiative, consisting of ten steps to a mother-friendly hospital. These ten steps, available on the Internet,
³⁷
are worth reading by every woman in the United States who is pregnant or may some day be pregnant or may some day be the mother or friend of a pregnant woman. They paint a clear picture of what is needed to stop the abuse of women and babies in maternity care in the United States. The ten steps, when accomplished, transform an obstetrician-controlled hospital environment into a place where women and families control childbirth.

Hospitals can apply to the group for designation as “Mother Friendly.” CIMS will then send a team to do an on-site review to see if the hospital qualifies. Any hospital employee or anyone who is a patient in a hospital can bring the program to the attention of hospital management and suggest that the hospital apply. Applying for “Mother Friendly” designation and committing to meeting the qualifications are also one way hospital administrators can join the movement to improve maternity care.

The Mother Friendly Hospital Initiative is modeled after the World Health Organization—UNICEF Baby Friendly Hospital Initiative, which outlines ten steps to promote breast-feeding. Indeed, step ten in the Mother Friendly Hospital Initiative links the two initiatives, stating that a hospital designated as Mother Friendly “strives to achieve the WHO—UNICEF Ten Steps of the Baby Friendly Hospital Initiative.” More than eighteen thousand hospitals around the world have been designated as Baby Friendly by UNICEF. So far, forty-eight U.S. hospitals have been designated as Baby Friendly, and more are added each year.
³⁸
There is now an effort to combine these two initiatives, so that in the future a U.S. hospital can be designated as Mother/Baby Friendly.

In the United States, grassroots consumer groups for maternity care are growing every year although they may not yet be as powerful as ACOG and the medical establishment. But throughout history we have seen that, in democratic societies, these groups play a pivotal role in eventually bringing about change at all levels. As discussed earlier, they have played an important role in bringing about improvements in maternity care in Germany, New Zealand, and Brazil. Small community groups and Internet groups can consider joining larger coalitions such as CIMS. Individuals can also join coalitions such as CIMS—I am an individual member—and it is not necessary to be a health care worker.

7. THE EMPEROR HAS NO CLOTHES: MAKE PUBLIC HEALTH PART OF THE SOLUTION

For years, the citizens of Virginia have been trying to get legislation passed to license certified professional midwives (CPMs or direct-entry midwives) to attend planned out-of-hospital births in their state. In 1999, draft legislation was being considered and a hearing was held by the Joint Commission on Health Care of the state legislature. In July 1999, a doctor from the Virginia Department of Health testified before this Commission. His testimony shows one way public health agencies can fail in their primary mission—to protect the people. Instead they can be quite eager to protect doctors by not telling the people that the emperor (doctor) has no clothes, that is, that doctors are behaving in a way that is detrimental to people's health.
³⁹

In 1999, the Department of Health in Virginia had no data on the outcome of planned home births in the state. All it had was information on all out-of-hospital births, and these couldn't be separated into planned versus unplanned. As I discussed in
chapter 6
, without data on
planned
home births specifically, it is scientifically impossible to draw conclusions about the risks of planned home births and the risks of having home birth midwives attend births. A “high-profile” doctor from the Virginia Department of Health presented the department's data, saying nothing about the serious problems with the data he presented. He also never mentioned the fact that the lack of data on planned home birth was due in part to the lack of legislation to license direct-entry midwives in Virginia. The lack of legislation has driven home birth midwives underground and, since they are not licensed, they are not allowed to report a birth, making it impossible to separate out-of-hospital births into planned and unplanned.

This doctor from the Department of Health did, however, take the time to present a number of graphs and tables, all of which looked terribly scientific but were essentially meaningless, given the faulty data. For example, in these tables, CPMs are included in a category called “other attendants of out-of-hospital birth,” which also includes taxi drivers, policemen, and so on, so that midwives attending planned home births are not separated from people who assist a birth simply because the woman didn't make it to the hospital in time.

Another part of the presentation by the doctor from the Department of Health was designed to show how very dangerous birth can be, and included a list of medical emergencies. The list included meconium (fecal waste on the baby) and breech, neither of which is an emergency, and no
attempt was made to document whether or not midwives in out-of-hospital settings can deal with these situations. The review of the literature on home birth was also totally inadequate and severely biased.

The representative of the Department of Public Health in Virginia drew four conclusions at the end of his presentation. The first one was that “present regulations do not safeguard the health and safety of pregnant women and their infants.” It's ironic that the speaker apparently did not realize that this is a strong argument in favor of legislation to license CPMs. The second conclusion, “Consumers may not be well informed about midwives,” is nothing but speculation as the Department of Public Health has no data on what Virginia consumers know or don't know about midwives. The third conclusion, “Home birth may present a significant risk due to emergencies,” is a typical attempt to scare politicians, and, as explained earlier, was not based on hard data that separated planned from unplanned home births. In fact, as discussed in
chapter 6
, scientific literature shows that planned home birth is a safe option, but, as I've said, this doctor had no data on planned home birth in Virginia.

The fourth and final conclusion, “Midwives may not be equipped to handle emergencies,” is laughable. There was no evidence that this public health doctor had conducted research on planned home birth or on the capabilities of home birth midwives, or evidence that he had read all the relevant studies and understood them. And it is most unlikely that he had ever personally attended a planned home birth. So it was quite clear that he didn't have the foggiest notion what home birth midwives are equipped to handle.

As I mentioned earlier, I was a director of maternal and child health in the California State Department of Public Health. In this capacity and subsequently, I have, sadly, seen many examples of public health officials who are more focused on job security than on ensuring the health of the public. Other examples in this book include the director of public health in Connecticut who went after what he called “lay midwives” and compared home birth with home brain surgery. In
chapter 6
, I mentioned that the Illinois State Health Department has joined with obstetricians in insisting that all ABCs must meet all the public health regulations of a hospital—a strategy that is clearly not meant to protect people but rather to keep ABCs out of Illinois.

Want another example? A family in the U.S. military service wanted a home birth and applied to their commanding officer for permission to use a certified professional midwife, licensed in the state where they were stationed, and for this midwife to be reimbursed by the military. A Mickey Mouse passing of the buck ensued until their request reached a top-ranking
military health official in Washington, D.C., who in turned asked the chief of obstetrics at Walter Reed Army Hospital for an opinion. And, no surprise, this obstetrician was opposed to home birth, so the family's request was denied. This story illustrates another common public health bureaucratic ploy: never take responsibility, but instead protect yourself by passing responsibility to someone else who will do what you want to do.

For those trying to improve our dangerous American way of birth, public health agencies are often part of the problem, not part of the solution. But this can and will change. The American Public Health Association has passed resolutions in favor of midwifery, has presented important papers on planned home birth at its annual meetings, and has published important papers on midwifery and on home birth in its
Journal
. Of course, this is all at a national level, where it's less likely that jobs are on the line, but it is still encouraging.

Most public health officials at the state and local level have the right training, have their brains in gear, and have their hearts in the right place. But perhaps they need a bit of strengthening of their backbones. I've found that as long as taking a particular action won't make medical practitioners mad, public health officials may say or do the right thing, but when there is a conflict between the needs of the people and the needs of doctors, they will usually choose to protect their careers by supporting doctors. Still, when the movement for humanized birth gains sufficient momentum in the United States, I believe public health professionals will be more than glad to join the movement. As the public and maternity care advocates become more aware of the potential role public health officials can play in improving maternity care, I hope they will push harder at all levels to keep them honest—and expose them to the media when necessary.

8. FOLLOW THE MONEY

There are precious few situations in life where the cheaper alternative is also the better alternative—and maternity care is one. If we eradicate the unjustified obstetric monopoly in the United States, with its extreme medicalization of birth, and replace it with humanized maternity care, we can vastly improve the care of women and babies, lower death rates for both women and babies, and
save vast sums of money
at the same time.

A few facts:
⁴⁰

•   Percentage of gross national product spent on health care

1966: 6 percent

1992: 12 percent
⁴¹

•   Percentage by which U.S. health care expenditures exceed those of

Canada: 40 percent

Germany: 90 percent

Japan: 100 percent

•   The twenty-two countries with lower infant mortality rates than the United States: Japan, Sweden, Finland, Switzerland, Canada, Singapore, Hong Kong, Netherlands, France, Ireland, Germany, Denmark, Norway, Scotland, Australia, Northern Ireland, Spain, England and Wales, Belgium, Austria, Italy
⁴²

•   Percentage of countries with lower infant mortality rates than the United States that provide universal prenatal care: 100 percent

•   Percentage of U.S. women who receive little or no prenatal care: 25 percent

•   Chances that a woman with little or no prenatal care will give birth to a low-birth-weight baby (less than 5.5 pounds) or premature baby (less than thirty-seven weeks of gestation): 1 in 2