The Business of Being Born: You Cannot Have Bliss Without Pain
Cara Muhlhahn, Certified Nurse Midwife (left) with Mayra and David Radzinski. Photo Credit: Paulo Netto
Social Medicine Rounds on 9/23/08 was devoted to a showing of the film The Business of Being Born, produced by Ricki Lane and directed by Abby Epstein.
The film, which traces several pregnancies and births, offers an extended contrast between the highly medicalized world of US obstetrics and the world of homebirths and midwifery. It argues that American medicine has so lost touch with the basic needs of women in labor that most obstetricians have never seen a home birth and only rarely witness a ‘normal’ birth.
In 1900, 95% of birth in the US occurred in homes. Fifty-five years later less than 1% did. During this time, physicians asserted control over pregnancy and birth, progressively marginalizing midwifery. With the introduction of fetal monitors in 1970, Cesarean Section rates in the US climbed from 4% of births to 23% in the space of a decade. This dramatic change in medical practice occurred without evidence to support the benefit of fetal monitoring. The film argues that hospitals and physicians, anxious to keep the assembly line of the obstetrics floor moving smoothly, simply don’t have time for normal labor. Women are started on epidurals for pain, their labors slow, they are given pitocin to augment contractions, they get more pain, more pain medicine, more pitocin, and so on in a cycle of ever increasing medical intervention. “Her labor is taking longer than it should,” is the comment of the obstetrician. Finally when the monitor shows fetal distress, the doctor intervenes “for the sake of the baby.” The woman ends up with a Cesarean, the safest solution, we are told, for the doctor concerned about malpractice.
Woven into this story is the counter tale of how home birth was revived by the hippies during the 1960’s. Ina Mae Gaskin, the “mother of authentic midwifery” is interviewed and we see scenes of her working at the Farm Birthing Center. She proudly recounts that they did not do their first Cesarean until after over 180 births. The film also follows a contemporary certified nurse midwife (seen in the photo above) as she rounds in New York City. We witness several home births - including that of Ricki Lane. These are clearly the most striking moments of the movie. The women labor in a variety of positions - squatting down, lying in a tub, squatting in a tub, lying propped on a couch. In an amusing moment a Brazilian doctor describes how the lithotomy position (lying flat on your back with your feet up) is the worst possible one for a woman delivering a baby. Finally, after the intense pain of labor, there is a moment of silent release and the baby is born. “Reach down and take your baby,” the midwife says to the new mother. As a physician who has experienced only hospital births these scenes were revelatory.
Running throughout the film is a concern over the safety of homebirth and the competence of midwives. And not all of the home births shown are successful. But if one can question homebirths and midwifery, is it not also legitimate to question hospital births and the competence of physicians? Clearly, 1/3 of all births don’t have to be done by Cesarean Section. The question really is how to design a health care system that can find the right place for each type of practice. But academic medicine seems largely unable to even pose that question.
Our thanks to the filmmakers for posing it so movingly. And for allowing us to share in the births of their children.
The film’s website has links to a variety of resources on midwifery and a short trailer.
Posted by Matt Anderson, MD
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