The following selection is excerpted from my 8,000-word master’s project “Home Truths” about the home birth debate. The article examined research on the safety of home birth, the contentious relationship between midwifery and obstetrics, and the movement to integrate midwifery into mainstream medicine in hopes of lifting the United States’ poor infant mortality rates and lowering health care costs.

Control is a word that comes up often in the discussion of maternal healthcare. More and more mothers arm themselves for delivery by writing birth plans, documents that state a woman’s tolerance for specific interventions, such as a desire to move around during labor or hold their infants immediately after birth. But whether hospital personnel take these plans seriously is open for debate. Indeed, many women are unprepared for the amount of control that hospital policies require them to surrender.

Aubrey Russell’s story is an example of how the best of birth plans go askew. Russell, a 30-year-old jewelry designer, gave birth to her first son Hendrix in January, an event she had been carefully planning for years, ever since a close friend of hers delivered in a birth center in San Francisco. She had seen “The Business of Being Born” and read the companion book, and she was determined to avoid the “cascade of interventions” that many experts say lead to unnecessary cesareans. Still, Russell wanted to be near a hospital in case anything went wrong, so she opted to deliver at the birth center at St. Luke’s-Roosevelt in Midtown Manhattan, a hospital that features prominently in both the film and book. There, she would labor in a homey bedroom with hardwood floors and a Jacuzzi.

“It’s like going through the eye of a needle to get in,” said Russell. “You have to take a course and then they show you a list of all these criteria that you have to meet.” In the end, Russell “risked-out” of eligibility for the birth center because her pregnancy continued past St. Luke’s deadline of 41 weeks. Placing a time limit on childbirth is common practice, but for some women, the clock starts ticking before labor even begins. Around 25 percent of inductions and a small number of cesareans are performed because the baby was overdue. Some home-birth midwives will also refer a patient to hospital delivery when the baby reaches a certain gestational age.

Russell would have to deliver in the hospital’s labor and delivery suite but she was told that she could still use one of St. Luke’s midwives and could opt for a special “approximation of the birthing center experience”, in the words of the hospital’s website.

“I was promised that they would make the L and D floor as much like the birth center as possible—no stupid rules about eating and drinking anything but ice chips,” said Russell. “I was told I wouldn’t have an anesthesiologist breathing down my neck. They don’t know what to do with a woman who doesn’t want an epidural.”

Russell had consulted a doula, a birth attendant who helps women manage pain and provides emotional support in labor. The doula had been a labor and delivery nurse at St. Luke’s and on her advice, Russell decided that the best way to approximate the birthing center was to stay home for as long as possible. When she and her husband finally left their Brooklyn apartment for the hospital at 4:30 in the morning, Russell was fully dilated and, though her water had not broken, her body had already begun to push the baby out. She had hoped to check in and deliver fairly quickly, but hospital protocols would soon intervene.

The receptionist couldn’t find Russell’s paperwork, so her husband had to fill it out again before she could be admitted. Meanwhile Russell was so consumed by her contractions that she was down on all fours at her doula’s feet. “Now, I’m on the floor and the woman at the desk was like, and why are you here? They all acted like they’ve never seen a woman in labor before. Everyone was frenzied and looking worried at you and there was this beeping.”

Because her midwife had not yet arrived, the hospital put her through triage where they realized how just far along her labor had progressed. Russell’s instinct told her to stay on her feet and push, but the hospital staff lifted her onto a gurney and she had to remain on her back for the duration, even after her midwife appeared. Russell thinks it was the stress of the situation which caused her labor to stall and her blood pressure to rise. She developed a nosebleed—a normal occurrence for Russell though she had no history of blood pressure problems—and her midwife threatened her with an episiotomy, an incision to widen the vaginal opening.

“The urge to push had gone away and I needed some kind of visualization to center myself and understand what I was going to do. Instead I got, ‘If you don’t push this baby out I will cut you.’ And I did get cut.”

The experience is not one that Russell plans to repeat. “There are lots of women who say, yeah, I want to have a natural labor but I’ll just be open to what they say at the hospital. But it doesn’t work that way. If you want what you want, you have to be militant. If I do this again, I will have a home birth.”

Is it possible that even the very atmosphere of American hospitals is adverse to healthy childbirth? We are mammals after all and mammals need privacy. Another mother who recently delivered at home said it this way: “You’re really never more vulnerable than the minute after you’ve had a baby. If you talk to any veterinarian, their advice when your dog or cat is giving birth is just to put them in a warm box and leave them alone.”

Why then do humans give birth in an unfamiliar environment, under bright lights, surrounded by gleaming steel and masked strangers?

When hospitals first sprang up in response to new public health concerns during the Industrial Revolution, poor and unmarried women in overcrowded cities often had nowhere else to deliver. They flocked to hospitals despite shockingly unhygienic conditions. There was often no hot water for bathing and women sometimes labored next to patients with infectious diseases. Before the germ theory of disease caught on in the medical community, doctors passed an infection known as childbed fever—or puerperal sepsis—from patient to patient. The disease was a special hazard of teaching hospitals, where physicians sometimes went directly from the dissection of a cadaver to the bedside of a patient. Home births, by midwife or doctor, remained the only sensible choice for “respectable” middle- and upper-class women.

Ultimately, well-to-do women came to hospitals in search of pain medication. Throughout the ages women have sought relief from their contractions, using wine, poppy juice, coca leaves and willow bark, from which aspirin is derived, but Christian societies, saw the pain of childbirth as the burden of womanhood, meted out after Eve’s original sin. To alleviate pain offended God. For decades Catholic hospitals in the United States refused to provide pain medication for laboring women. When ether and chloroform emerged as labor anesthetics in the late 1800s, both Catholic and Protestant churches objected, and freedom from pain became a women’s rights issue. The fact that women today have to negotiate for the right to bear a child without medication is one of the greatest ironies of this complicated history.

Then in 1914—while American women were engaging in civil disobedience to win the right to vote—German medical science came up with a way to escape labor entirely through a combination of scopolamine—an alkaloid of belladonna—and morphine. The cocktail resulted in a semiconscious state known as “Twilight Sleep.” The treatment caught on quickly with upper-class women who traveled to Europe late in their pregnancies hoping for a pain-free birth. Except birth under Twilight Sleep wasn’t so much pain-free, as it was memory-free. The injection brought on amnesia as well as loss of inhibitions, causing women to thrash violently in their agony and remember nothing of the experience later. Hospital staff tied women to their beds where they could be left unattended for hours.

A New York Times article from 1915 quotes one Mrs. Sargent of Nebraska on her experience with Twilight Sleep: “The next thing I knew I was awake, and I heard the sympathetic voice of Dr. Krönig saying saying ‘All ees well,’ and then I thought to myself ‘I wonder how long before I shall begin to have the baby,’ and while I was still wondering a nurse came in with a pillow, and on the pillow was a baby, and they said I had had it—perhaps I had—but I certainly can never prove it in a court room.” By the 1930s, infants across America were being born to unconscious mothers, a trend that continued into the 1970s, erasing the birth process from the consciousness of at least one entire generation of women.

By the middle of the 20th century, American maternity wards had undergone a complete change from their toxic beginnings, becoming so rigorous in “preserving the sterile field” that they began to resemble scenes from alien abduction movies. A woman giving birth in a hospital in the 1950s could expect to have her pubic hair shaved off, be given an enema and left to labor for hours with their arms and legs strapped to a gurney. Afterward, supposedly for the health of the baby, mother and child were kept apart and only reunited for feeding every four hours.

Many medical technologies invented for use in life-threatening situations—the very reasons women deliver in hospitals in the first place—are now used preventatively to appease insurance companies and improve efficiency on the labor floor, according to maternity care reformers.

The synthetic hormone Pitocin, for example, revolutionized obstetrics because it offered an induction method that was safer and more reliable than anything that had come before. It eliminated the frustration and dangers of a stalled labor; it also allowed childbirth to be scheduled during business hours, or while a doctor is on call at the hospital. While there are many legitimate medical indications for induction of labor, Pitocin has frequently been used for convenience, according to Tina Cassidy in her book, Birth. Officially, 22.5 percent of births in the US in 2006 were induced, but the “Listening to Mothers Survey” conducted that same year showed medical inductions at a rate of 36 percent. And recent research suggests that Pitocin’s convenience comes with serious risks.

Because the drug causes intense contractions, induced labor is more painful than natural labor and has a tendency to rupture scars from a previous cesarean section. Women given Pitocin are more likely to need an epidural, which can slow labor down, creating the need for more Pitocin. These fluctuations can lead to labor dystocia, also known as failure to progress, or an “unreassuring” fetal heart rate tracing—the two most common indications for a Cesarean. A 1999 study published in the journal Obstetrics and Gynecology found that elective induction of labor increased the Cesarean rate among first-time mothers by almost ten percent.

Electrical Fetal Monitoring, or EFM, is another technology that may have done more for hospitals than for patients. As Jennifer Block wrote in her 2007 book Pushed, EFM was first marketed to hospitals in 1969 using clinical trials conducted by some of the company’s biggest stockholders. Subsequent studies have shown that EFM is no more effective in high-risk deliveries than frequent listening with a fetoscope, but its use increases the cesarean rate dramatically. Since the 1980s fetal heart tracings have been admissible in court and hospitals are loath to lose the “paper trail” that could clear them in a malpractice lawsuit. EFM also comes with central monitoring capabilities so that a nurse can observe the heart rates of multiple fetuses at one time, a development that allowed hospitals to reduce the number staff on the labor floor.

And while the cesarean section may be one of the oldest interventions in childbirth history, it is also of great convenience to doctors. According to Andrew Garber, an obstetrician who delivers at several New York hospitals, on average, labor for first-time mothers lasts around 13 hours; a C-section takes only one hour. The difference has an impact on doctors’ decision-making. One third of American women undergo major abdominal surgery instead of vaginal birth, putting us well outside the World Health Organization’s recommendation that no country have a cesarean section rate greater than 15 percent.

“Everybody agrees that you need at least a ten percent rate,” said Eugene Declercq, professor of community health services at Boston University’s School of Public Health, “because there will be that many cases where a cesarean justified. The OB community says there’s nothing wrong with the cesarean rate for babies, if not for mothers. I think a larger portion would say legally it’s the safe thing to do.”

Birth moved into hospitals in part because more Americans had moved into cities, which were less conducive to home birth. By 1938, around half of all births in the US took place in hospitals. During World War II, the federal government began paying for the healthcare of veterans and their families and by 1945 hospital births reached 80 percent. Today, obstetricians outnumber midwives by a factor of seven, and more than one-third of all children born in America are delivered surgically.

September 2010