We had been instructed to form a group separate from our partners to discuss our fears about the labor experience and our expectations of what we would get out of this Childbirth Education Class, now in its first session. But for some of us it was like therapy in a bomb shelter. The issue looming overhead was not the risk our own bodies might present to us, but the risks we knew were standard protocol in the hospitals we were suddenly being farmed out to.
Most of the women in that group were roughly six months into their pregnancies and prenatal care at the Birth and Women's Health Center when we learned in mid-May that no more births could take place there as of June 1. Known simply as "the Birth Center" to the many families who have delivered there for the past 20 years, the Birth and Women's Health Center had been part of the for-profit Associates in Women's Health Care for the past four years. But midwifery, the care provided at the Birth Center, is not terribly profitable when placed alongside the cash cow of modern obstetrics. So the hundreds of families expecting to deliver at the Birth Center this summer and fall have found themselves the collateral victims of a budget cut.
The Birth of Obstetrics
"One cannot help an involuntary process. The point is not to disturb it." So renowned French physician Michel Odent articulated the philosophy that has been the cornerstone of birth assistance worldwide since human birth began.
Under this philosophy of childbirth, the modern medical model borders on absurdity. Monty Python's The Meaning of Life shows obstetricians preparing to deliver a baby shouting, "More apparatus! Get the machine that goes ping!" Assistants scurry to bring in the equipment, and the most expensive machine soon serves its sole purpose when the hospital administrator stops in to visit and is clearly impressed. "Ah, I see you have the machine that goes ping! Carry on!" Meanwhile they have literally lost the laboring mother behind all the large equipment. They fetch her, deliver her and leave her behind, dazed, as they run out with the baby ... and the machine.
Real-life hospital birth today is not so different from this comic scenario, but birth was not always this way in the United States. According to The Encyclopedia of Childbearing by Barbara Katz Rothman, in the early 1800s the average woman in this country gave birth at home attended by a woman midwife, and low-income women in particular depended upon the services of midwives for many years following. However, in the 1900s birth moved to the hospital, due in part to industrialized America's starry-eyed wonder at technology and the male-dominated medical profession, and in part because physicians who'd formerly shunned poor women began to offer their services at free clinics for the purposes of experimentation and instruction. Meanwhile, the midwives who had become competition were being discredited by doctors based on gender and lack of formal training.
The medical model of childbirth continued developing new, complex technologies. In the words of medical writer Henci Goer, "Over the past 30 years, obstetric management has converted what should, in most cases, be a healthy, normal process into a high-tech event." And while some would argue that we're better safe than sorry in our caregivers' preparedness for crisis, statistics show that the vast majority of hospital births in this country find mother and baby at greater risk for complications due to unnecessary medical intervention. A 1997 Public Health Report found that the U.S. ranking in infant mortality rates worsened from 12th in 1962 to 21st in 1994, due in large part to a rate of cesarean sections that was and still is twice what experts consider safe and necessary, all patients' risk levels included.
Delivering the Cash Cow
"The best way to avoid a c-section is to be informed," our childbirth educator told us. Despite informed consent laws and assurances from administrators that all procedures are the mother's decision, few women go into labor confident that they know better than their doctors which procedures are useful and when. Instead they trust their obstetricians. Midwives do attend some births at hospitals; in fact, the midwives from the Birth and Women's Health Center will now be attending births at TMC. But the hierarchical protocols in hospitals sharply reduce the authority of midwives in favor of the medical model, making the obstetrician the authority.
Why not trust the obstetrician? Won't she or he want what is best for the patients? The answer is complex and alarming: Not always, particularly when "what is best for the patients" permits the entry of common beliefs in obstetrics management. For example, a woman's likelihood of having a cesarean depends very little on her or her baby's physical condition. The factors that sway the statistics much more include where she is giving birth (a hospital, freestanding birth center, or at home), who is assisting (an obstetrician, family practitioner, or midwife), hospital culture and policies, and--the strongest determinant--her caregiver's cesarean rate. These factors influence not only who has cesareans, but who receives most of the medical procedures and drugs currently in fashion. These include fetal heart monitoring (the machine that goes ping!), episiotomies, IV, labor induction, epidural anesthesia, forceps and vacuum delivery and a host of other technologies that studies show compromise the health of the patients with little or no benefit.
One more factor significantly increases the likelihood of unnecessary procedures: profit. Obstetricians often receive hundreds of dollars more for ceseareans than vaginal births, and hospitals can receive thousands of dollars more. An epidural jacks the bill up another grand. Fetal heart monitoring saves hospitals money by allowing one nurse to monitor several babies, as does the heartless practice of whisking the baby away to the nursery once born.
The philosophy of obstetrics management posits that childbirth is a pathological condition requiring the intervention of surgeons. Hospitals are our culture's centers of crisis and disaster, and that is why the majority of births do not belong there.
In the 1970s, women's dissatisfaction with the medical model of childbirth gave rise to the concept of the freestanding birth center. Birth centers, usually located close to but separate from a hospital, provide more supportive, less technologically oriented maternity care for low-risk women by certified nurse-midwives. By 1989 there were 132 freestanding birth centers operating in the US, delivering about 20,000 babies each year. A study published in the New England Journal of Medicine, and in which Tucson's Birth and Women's Health Center participated, found freestanding birth centers offered medical care comparable to hospitals for low-risk women, often at half the price. More importantly to many of us, the birth center of Tucson was covered by most AHCCCS (government-sponsored) insurance plans.
I asked the eight women in Childbirth Education class if any were planning a home birth, and only one raised her hand. Several others said they would like to, but they just don't have the money. Home birth in Tucson, together with prenatal and postnatal visits by a midwife, costs around $2,000--a pittance compared to the astronomical costs of hospital birth, which can be over $10,000. Ironically, though most of us had been "lucky" enough to have insurance that covered the birth center, none of our plans cover home birth however inexpensive, so hospital birth has become our only affordable choice.
With the closing of the birth center, the choice covered by my particular AHCCCS plan is UMC, whose web site looks wonderful to the average 5-year-old with its "soft pastels" and "time for cuddling." But unfortunately I've had medical care there. I've had questionable procedures performed by interns when I was expecting doctors and gone dizzy at the flurry of faces that popped in to ask if they could observe. I even had the doctor--hallelujah! The only occasion I ever got to meet him was when he suggested a hysterectomy because "we don't know how your condition will behave," regarding a condition that disappeared on its own four months after I refused all surgery.
Now the 49 women who were due to deliver at the birth center next month, and those like myself who were due not long after, are hauling our backaches around Tucson to check out our alternatives. Meanwhile we're all praying that storks with more money than we have will drop big checks on the Birth and Women's Health Center. Barring that, I'm hoping someone drops a home-birth sized check on me.