Part One: Assessing the Business of Being Born 8 Years Later

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Image courtesy of Sandor Welsz of Flickr.com.

This is part one of a series entitled Intervention on Interventions which seeks to address the place of medical science, interventions, and public policy in the lives of women.  Using research done on interventions, pilot studies, and public policy interventions, this series will highlight whether or not interventions are to be feared and how public policy – not the distrust of doctors and medical professionals – can help women have safer, more empowering birth experiences.

8 years ago, The Business of Being Born was released.  For any millennial or Gen X woman who has given birth in the past 5 or so years, it has probably been considered required viewing.  I saw it when my first group of friends to give birth was having their babies in 2010.  The film criticizes the over-medicalization of birth as the film’s directors and producers see it, and highlights how “choices” for women are significantly reduced by the current status quo for childbirth.  The film highlights a number of “sins” from episiotomies to inductions to c-sections and suggests that for most women, midwives and homebirths should be utilized.  Overall, it raises some important questions and it’s no doubt that women have taken to heart over the past 8 years.  And considering that the history of medicine has historically ridden roughshod over the actual experiences and needs of women, it is no surprise that many medical interventions could be used without question and without concern for the risks and benefits for the women they are practiced on.  Overall, I think the documentary is still worth a watch on Netflix but this series suggests you watch it with some counterpoints in mind.

TBoBB’s strongest criticism seems to be of medicalization and of hospital births.  While it is true that in other countries, midwives and homebirths are more common, this doc does not get into the nuances of the difference between homebirth or midwifery in the American perspective and that in other countries.  This will be flushed out in much greater detail in a later segment but suffice to say, midwives in most countries are highly trained medical professionals while most homebirth midwives in the United States are not medically trained in a comparable manner.  Likewise, there are serious issues with the assertion that birth in a hospital is without a place in today’s world.  Maternal and fetal mortality have declined significantly over time – from almost 700 deaths per 100,000 live births to now about 60 deaths (HRSA 2007).  This is largely due to medical interventions which have saved lives.  There is a reason that women see health professionals in this country as they go through the processes of gestation and birth.  Birth is an incredibly risky event no matter how “low risk” both for mother and child.

No better illustration of this is seen than in Epstein’s homebirth experience.  Her midwife notices that baby is coming out in breech position and they head to the hospital.  In the end, Epstein and her child were saved by the wonder of modern medicine and were luckily able to get successful treatment in a timely fashion.  Her baby was also premature and required NICU treatment that wasn’t really addressed much by the dialogue in this film.  The documentary does a poor job of addressing these complications – leading to a shaky conclusion that lower intervention is better because most birth is not that complicated.  Epstein’s experience is unfortunately not atypical.  The American Pregnancy association states that 1 in 25 births is breech (APA).  These births typically require a c-section as breech presentation makes a vaginal delivery complicated.  Thus, Epstein’s baby and labor weren’t serious outliers.  They are the reason that hospital births and births in birthing centers which are attended by serious medical staff who work closely with OB’s are the standard of care most women choose and most physicians require.

However, these problems are still not the most problematic part of the film.  The problem identifies an issue- the medicalization of birth – due to hospital and physician greed.  The very title affirms that doctors and medical professionals view birth as a business and the reason they diagnose and treat the women in their care the way they do is their bottom line.  For these providers, childbirth is a business and women and babies are simply obligatory customers.  Basically, birth is like dealing with your cable provider – you know you have to but you really wish it didn’t suck.   This is a really salacious and entertaining thought but it’s neither particularly accurate nor particularly useful.  While economic means do play into childbirth and while maybe the anecdotal evidence suggested in the documentary affirms that some doctors are out to get women so they can make their 10 AM tee time, these aren’t problem that can be easily solved by the documentary’s proposed solution – homebirth and midwives.  If homebirth and midwifery are to work, then why didn’t these solutions even work for Epstein?  The answer is that these solutions aren’t really feasible for a large number of cases – not just outliers – but that the solutions that are don’t entertain or allow the documentarians to tie this up with

The reason is that physicians’ greed is not the issue.  The business of being born is actually driven by other factors which I will get into later in this series.  Most actually arise from a serious of intentionally or unintentionally bad public policy decisions that have been made over the same period where birth has gotten much safer.  The plateau shown by HRSA’s 2007 report in maternal mortality may be changed and birth experiences may be changed by empirically-sound and women-focused public policy not by demonizing the role of the physician and hospital in childbirth.  Of course, public policy is a much less sexy story but public policy seems to be best able to address a number of concerns.

As a feminist, I love anything that focuses on empowering women in a safe way.  But as a scientist, I have to wonder if the evidence supports the conclusions of this doc.  And, in all honesty, while I think TBoBB offers up some great talking points, it falls short of actually offering legitimate improvements to the way providers, women, and hospitals approach birth. The purpose of this series on interventions is to assess the world after The Business of Being Born using empirical evidence, important medical research, and knowledge surrounding how good public policy can help move childbirth forward.  I’m a political scientist and a researcher by trade but my goal with this series was to educate myself in preparation for birth.  I’m not an MD but as someone who does research for a living.  Still, what I found did surprise me.  And I think my findings about public policy are really important.  I share them here to try to balance the dialogue that has been going on for years.  The next segments in this Intervention on Intervention are meant to serve as talking points in a debate on how to improve health care.

Please note that I come here with my own biases.  After tons of time spent researching interventions, I found what I was comfortable with and have planned my own birth around that.  Having had a high-risk pregnancy thus far with a number of complications, I do feel it is important to trust my provider.  I am lucky to have found one who listens to new studies and who works at a hospital that tries to use science to improve the lives of women.  I had 4 hospitals to choose from and was really lucky in that regard.  Many women only have one option.  But, that said, because my pregnancy is now considered to be “high risk”, I am limited in the options I have.  Even if there was a birth center nearby, it would no longer be an option.  I have attempted to look at this puzzle not only to help myself but also help others but I acknowledge my own reading of this is filtered through the above perspective.  I think TBoBB is an entertaining documentary that raises excellent questions about women’s agency, maternal health, and interventions but my commentary explores these topics 8 years later to see how far we have or haven’t come and where we go from here.

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