Hanging on the wall beside my desk is a photograph from my first morning on earth, and as I’ve endeavored to organize my thoughts on natural childbirth—and on the wisdom of trusting nature in general—my eyes have strayed to this image so often that it has taken on iconic significance. The family is captured in black and white, lounging on homemade corduroy pillows, which lean against the dark grain of a redwood wall. A mobile hangs half out of frame—balls of yarn dangle from a coat hanger. The two preteens in the picture are unfamiliar to me: They are my half brother and half sister, but I remember them only as adults because their father, from my mother’s first marriage, took them into his custody a few years after this picture was made. I’m the baby in the center, contorted into a posture of spastic newborn disorientation. My brother smiles down at me; my sister looks into the camera from under a Cal Bears visor; Dad, thickly bearded, long-haired and leonine, lies with an arm around me; Mom lounges in back, radiant and beautiful, which is a bit staggering since she’d recently delivered me to that bedroom. What sets it apart from most newborn photos, however, is not what’s in the picture, but what’s missing: There are no IV towers, no ID bracelets, no hospital-issue blankets, or bassinets of industrial plastic to interrupt the natural-fiber aesthetic. In this family—the picture says—we don’t fear nature, instead we embrace it, moving in harmony with its cycles. It was taken on October 9, 1978.
I only got around to asking my parents about the photo a few months before my wedding. That’s probably because I’d never thought much about birth or babies until Beth, my fiancée, made having children a precondition to her acceptance of my marriage proposal. Fatherhood, which had been a theoretical possibility, assumed an onrushing inevitability and, suddenly, it seemed important that I develop a position on progeny politics, starting with birth. Beth had no bias against hospital births. We came from opposite sides of the cultural divide: While my father had made his living as a psychotherapist—exercising extrapolations from Jung on dreams and ephemera—her father had worked as an orthopedic surgeon, exercising concrete mechanics on bone and muscle. A few months after I was born at home, she was born via scheduled Caesarean section. If I was going to insist on homebirth and breastfeeding and all the other natural practices my parents had embraced, it seemed only fair that I discuss this with Beth while she still had the option of finding a less doctrinaire partner in parenting. And, if I was going to articulate my position on these issues, it no longer seemed acceptable to base it on the hazy warmth I got from a picture. I started my remedial education by calling my parents and asking them to share their recollections.
My mother, Gail, had given birth to my brother and sister in a Berkeley hospital. Brent was her first, born in 1966, and it had taken nine hours and forceps to convince him to exit. She’d been left alone during most of her labor and perhaps it was the resulting memory of neglect, or perhaps the way the forceps had cut and welted Brent’s head, or perhaps the general feeling of helplessness associated with being a patient in any hospital—whatever the reason, the experience felt unnecessarily traumatic. My sister, Erin, was born at the same hospital in 1970, and though that birth was uncomplicated, it had left Mom with that same vague sense of wrongness.
By the time I came along, things had changed. The agent of that change was a six-foot-two poet with blue eyes, a swimmer’s body, a declamatory basso voice that rumbled up from his belly, and wavy brown hair that cascaded down between his shoulder-blades. He had a name like some fictional frontiersman: Belden Johnson. Dad swept into Mom’s life like a flood, overflowing her banks and casually demolishing the contours that had contained her. She exchanged her tightly restrained role as immaculate hostess and lawyer’s wife for the liberty and chaos of the counterculture. The photographs from this time show a luminous woman, smiling, with straight hair to her waist over simple tunic dresses.
After my parents began living together, they would periodically rent a cabin in the California wine country where they’d hole up for days on end with a grocery bag of food and occasionally a few tabs of LSD. My conception was very likely buoyed on that psychedelic tide. They both remember feeling, that night, in that cabin in Sonoma County, the utter certainty that they had just made a baby. Though it’s unlikely that the chemicals would have altered the dance of the gametes in any biological sense, this event does seem metaphorically significant: My parents, who would become so committed to safeguarding their children from the corrupting influence of modern technology, had unwittingly undermined themselves, baptizing my first moments of mitosis in Timothy Leary’s bioluminescent broth. They thought they were raising an earth child, but my ecosystem was already polluted with synthetics.
My parents, like all parents I suppose, later tried to put from their minds the possibility that they might have ruined their child. When I pressed Dad on this point he managed to recall only vague trepidation.
“But, Dad,” I said, “if you were, you know, um, tripping, weren’t you worried that you were going to get a really messed-up baby?”
“That certainly did cross my mind,” he said, hesitantly, before settling on a flip response: “and obviously it was true.”
Somehow, the knowledge of this contamination was less disturbing than the shadowy dangers of environmental pollution and industrial toxicology of California in the 1980s, over which my parents had little control. Teasing aside, from the moment of conception Dad did everything he could to shelter my newly formed embryo from all insults—chemical, psychological, or physical. I would be his first child, and he threw himself headlong into parenthood.
Realistically, however, there wasn’t much he could do before birth and absent any practical outlet for his creative paternal instinct, he became ferociously and dubiously helpful. He read poetry and sections of the Iliad to Mom’s abdomen. He built a deck off the bedroom so that when I emerged, I could lie in the sun. He played music for me and made up snatches of a lullaby in French (Mon petit bébé, tu es très joli), which he’d sing over and over. The pinnacle of Dad’s efforts, however, was the “beasty-yeasty”: a concoction of brewer’s yeast, yogurt, and granola, blended until smooth. The idea was to prevent morning sickness—brewer’s yeast contains vitamin B, which seems to ease some women’s symptoms—but the beasty-yeasty was where Mom drew the line.
“You couldn’t exactly drink it,” she said. “You kind of had to gag it down.” No matter how unpleasant the retching, Mom would explain to Dad, the expulsion of vomit was preferable to drinking it in this ersatz form.
Behind all this action were hours of study. Many people were becoming alarmed enough by the state of childbirth around that time to write books about it, and Dad read everything he could get his hands on. Birth Without Violence, by Frederick Leboyer, had just come out, suggesting that, rather than enduring the bright lights and cold metal of a delivery room, babies should be placed into warm water to mimic the environment of the womb. And Suzanne Arms’s Immaculate Deception made the convincing case that many of the technical birthing interventions were not employed out of necessity, but because a historically male medical culture presumed that women’s bodies were inherently dysfunctional.
None of this was foreign to my father, who’d been born without medical assistance. His parents—a Washington bureaucrat (father) and professor of English (mother)—were in many respects conventional citizens of the buttoned-down 1950s, but they had occasionally indulged their own attraction to nature’s way: in birthing babies, in growing their own food, and in milking their own goats. There was another even more powerful factor working to convince Dad of the superiority of home-birth. He explained matter-of-factly to Beth and me over breakfast one morning that while in therapy he’d relived his own birth—he’d actually felt sensations and emotions that he interpreted as neonatal memory. “I know,” he said, looking at me with a little rumble of bass merriment. “I can tell, that’s got your skeptical mind going.”
Some of the details he’d recalled from his birth were specific enough for him to check. Most convincingly, he remembered experiencing the panicked feeling that his shoulders had become stuck in the birth canal, a detail that his mother supposedly later confirmed. “She was shocked,” he said. “She asked me how I could possibly know that had happened.” Dad lifted his hands heavenward at this revelation, as if to say, “How else can you explain it?” For him, the experience of reliving his birth had been so profound that he became a therapist, leading others on the same journey into memory. The tenets of this practice, called primal therapy, hold that the psychic scars of birth and babyhood often form the foundation of self-destructive habits in adults, and that healing this residual infant pain is the way to dissolve the emotional stumbling blocks people end up tripping over throughout their lives. The experience of leaving the womb, Dad was convinced, was formative. Babies born via Caesarean section, he said, often become adults who drift along without taking initiative, letting others determine their direction in life.
I’d always avoided thinking too deeply about Dad’s belief in the power of neonatal psychology because the whole business made me a little queasy. It just didn’t square with my experience of the way the world worked. My friends who were born via Caesarean were not detectably different than those who had passed through the birth canal. And the idea that a person’s emotional architecture is defined by his experiences on day one was, for me, uncomfortably similar to the notion that personalities are determined by the stars under which they are born. Most of all, it bothered me that I had only my father’s non-verifiable experience as evidence.
In the decade before I was born, however, my father’s theory must not have seemed as far-fetched as it does today. Back then—when young men were being drafted to firebomb villages in Vietnam; and all the writers seemed to be drinking themselves to death in the suffocating normalcy of the suburbs, or dropping out and joining communes; and every inspirational leader was being assassinated; and the police were firing tear gas at the rioters a few blocks away in Berkeley—the idea that the psychic trauma of medicalized birth had created a generation of damaged people seemed plausible to a lot of well-respected psychologists and sociologists. Mom was also immersed in the literature of counter-cultural birth. She read the stories of doctors performing Caesareans in order to make their tee time. She saw a film, shot to prepare Navy wives for birth, full of searing images: women strapped into stirrups, drugged, and casually cut open fore and aft to hasten birth. She was convinced that she (and I) would be safer at home. “It seemed like a hospital birth was insane and inhumane,” she said. “There was no question in our minds.”
My parents would not be dissuaded. They had found a doctor who was just as radical as they were: Lewis Mehl, who had published one of the first peer-reviewed studies on modern-day homebirth in the United States. When my due date came and went, Mehl explained that the risk of stillbirth increased for babies who stewed for too long, but my parents, confident in their choice, simply smiled and said that I would emerge when I was ready.
I was ready three weeks later. It was early October, when the heat spills over the coastal mountains into the San Francisco Bay. In autumn it’s as if someone has opened the oven door to California’s Central Valley, and plumes of summer-forged air flood down the delta to cut back the fog. Flowers burst into bloom again in this weather, and Mom must have noticed them as she walked down Benvenue Avenue. It was a quiet neighborhood, where trees shaded tall houses. She had recognized the pattern of contractions, and had asked a friend to come over and look after Erin and Brent. When she returned, she found that they had baked a heart-shaped birthday cake. Mom called the midwife, then went upstairs. There were a few hours of intense labor, and some pain: Years earlier she’d hurt her back horsing around with the kids, and the contractions triggered spinal spasms. The night fell and brought slips of cool ocean air through the windows. Someone lit candles. When progress seemed to slow, Dad went looking for upbeat music. He put a Chieftains record on the turntable, and I emerged to an Irish hornpipe. My brother cut the umbilical cord. My sister wiped the sweat from Mom’s forehead. As a neo-Nate, I was massive: They weighed me on a fish scale, and it was clear that I exceeded 11 pounds, though it was hard to judge by exactly how much because the load was close to the instrument’s limit. (Nine pounds is a lot of baby, 11 pounds is an orca.) Mom held me and I began to nurse.
What came next spoiled, or at least complicated, the moral of the story. The scene had become quietly celebratory as the newly enlarged family crowded into the room. The sun rose. A family friend took the photograph that now hangs on my wall. But the midwife was nervous. It’s normal for some blood to come with the afterbirth, but the flow was not tapering off. Dr. Mehl, who arrived shortly after the birth, said that it looked a lot like a postpartum hemorrhage. My parents didn’t know it, but postpartum hemorrhage was the leading cause of maternal death (and it still is, due to the lack of skilled birth attendants in the developing world).
Mehl saw that he quickly had to decide whether to take Mom to the hospital or act on his own. He took a coin from his pocket and flicked it into the air. Heads. He cleaned one arm, then reached up into my mother’s uterus to scrape away the bit of placenta that had not delivered and was preventing the blood vessels from closing. The pain was severe, worse than any part of the birth. Mom closed her eyes and relaxed, willing herself out of her body to a place where she could observe the sensations from a detached remove. She was so successful, so serenely still, that everyone watching panicked.
“Oh my God, she passed out,” someone shouted. “Stay with us, Gail,” the midwife urged.
Mom was thinking, Shut up, I’m fine! When she told me the story, she laughed ruefully and said, “It’s just pain.”
Some 30 years later it was a bit destabilizing to learn that there had been an element of danger in my otherwise idyllic birth—especially since it was around this same time that my wife and I learned that our first tentative foray toward parenthood had been successful. My birth research, which had been a pleasantly abstract exercise, gained the consequential heft of reality.
All things being equal, a candlelit homebirth sounded far more tranquil (not to mention affordable) than a gadget-packed delivery room. But, after hearing the full story of my own birth, I began to wonder if my aversion to the sterile ambience of fluorescent tubes and whooshing heart monitors was based less on questions of medical safety than on a dislike of hospital decor. And, however strong my opinions were, they would not count for much if Beth disagreed. It was her body after all—and she had been raised with a very different set of assumptions about hospitals. While I’d rebelled by questioning the tenets of my parent’s natural ideals, she’d rebelled by moving to liberal San Francisco and voting a straight Democratic ticket. The equal and opposite force of our de-nesting ejector systems had propelled Beth and me to stake our claim on the same turf.
It looked as if the political terrain we were homesteading would not shelter a homebirth. A quick glance at historical maternal mortality rates had been all I needed to convince me of the value of obstetric intervention. The graph showing U.S. maternal mortality over the last hundred years plunges from Himalayan heights down to a gentle plain. In the early decades of the 1900s, between 600 and 900 women died from pregnancy-related complications for every 100,000 births. By 1997 that maternal mortality rate had fallen almost 99 percent to 7.7 deaths per 100,000 births. The most obvious change in the intervening years was that birth became more technological. Some have argued that this industrial revolution in the delivery room has saved more lives than almost any other medical innovation.
The rise of Caesarean surgery was a significant part of this change. In 2011 about one in every three pregnant women wound up having a Caesarean, making it the most common surgery in America. There is no hard data to indicate how many of these surgeries are performed due to actual emergencies, but doctors have estimated the number might be around 5 percent. The percentage of women requesting Caesareans is probably even lower: Despite scores of stories in the media about the rise in elective operations, surveys that actually asked the opinions of mothers, rather than their doctors, found very few who preferred surgical birth. The vast majority of Caesareans are nonemergencies done for medical reasons that often fall into a scientific gray area—some clinicians will insist on planning the surgery before the due date if a woman has had a previous C-section (though this is controversial), or if the baby is breeched (supported by randomized clinical trials), or if the baby seems too big (again, controversial). Many Caesareans are neither planned nor emergencies, but are done because the doctor and patient decide during labor that the operation seems safer than the uncertainty of a questionable fetal heart rhythm, or a cervix that remains closed hour after hour.
Birth presents a basic problem: There’s a baby inside, which needs to get out. A C-section is not usually the best solution to this problem, since it leaves mothers immobilized during the most challenging weeks of infancy and can have longer-term side effects, but it is the most reliable solution. The surgery is a literal shortcut, easy to teach and easy to perform, and it produces standard results. The same goes for the other technologies that have streamed into maternity hospitals. They’ve all worked to replace the unpredictable complexity of the body with uniform mechanical simplicity. It seems obvious from the rarity of death in modern childbirth that this industrial logic was improving health.
This might have been enough to convince me if I had been engaged in a disinterested inquiry: Historical statistics show that technology has made us safer—case closed. But when it came to my own family, this kind of broad-brush actuarial reasoning left me unsatisfied. This would be our first major family health decision and could very well determine our path going forward. I suppose I wasn’t ready to completely toss out my parents’ way of life. There was a part of me that, despite the persuasiveness of the raw numbers, could not be swayed from the sense that there was something wrong—fine, I’ll say it, something unnatural—about one in three women delivering their babies surgically. Another part of me scoffed at this prejudice. Why cling to primitive ways? Suppose we lived in a future in which babies were delivered by Star Trek beam-me-up technology, which has been shown to actually improve the health of both the baby and the mother. Wouldn’t I opt for the baby to appear effortlessly in a column of sparks and a splatter of amniotic fluid? I would, though not without a begrudging sadness to be giving up birth as a fundamental fact of life, as something that connects us to our ancestors and to our more distant animal relatives. Once I’d established that I’d accept that loss in exchange for easier births, however, all that was left for me to do was determine if we had already reached the glorious future. Had medical technology trumped our evolutionary biology?
There is, in fact, a vigorous debate over medical intervention in birth, and not just between the fringe and the medical establishment, but within the establishment. No one is suggesting that we revert to the practices of the 1900s, but many clinicians and scientists are warning that the medicalization of birth has gone too far. When I took a closer look at the data, I found one seemingly impossible statistic after another. Progress in reducing the infant mortality rate had advanced through the 20th century, but had stalled in the 21st century. This plateau, “has generated concern among researchers and policy makers,” according to a 2008 brief from the National Center for Health Statistics. “The U.S. infant mortality rate is higher than those in most other developed countries,” wrote the statisticians, “and the gap between the U.S. infant mortality rate and the rates for the countries with the lowest infant mortality [Japan, Sweden, Spain, and others] appears to be widening.” In addition, the numbers of preterm and low birth-weight infants had actually risen (a part of this increase was due to a higher number of twins and multiples, perhaps from the rise of fertility treatments, but the increase remained when researchers only looked at singleton births).
When it came to the health of mothers, the trends were even more troubling. A paper published in the Journal of Obstetrics and Gynecology noted a marked increase in severe injuries to women during birth: kidney failure, pulmonary embolisms, respiratory failure that required patients to be put on a breathing machine, and more. This increase had occurred between 1998 and 2005, including a 92 percent rise in the percentage of women who needed blood transfusions. Mothers hadn’t become less healthy in that period. The study had adjusted for the effects of hypertension, diabetes, age, and multiple births, but weeding out these problems hadn’t made much of a difference. What did make a difference was controlling for the mode of delivery: “For many of these complications,” the authors wrote, “these increases were associated with the increasing rate of cesarean delivery.” Most disturbing of all, national vital statistics showed that the maternal mortality rate was climbing. This, in particular, seemed too bizarre to be true, and most researchers initially chalked it up to “statistical noise”—the result, they said, of several states adding a checkbox to death certificates to note if a woman had been pregnant a year prior to her demise. But then the state of California made an inquiry that adjusted for these changes and revealed that there was still a consistent upward trend in maternal deaths. “After several decades of declining rates of maternal mortality in California, rates began to rise in 1999 and proceeded to double in the next seven years,” the researchers reported. Part of this rise was due to the fact that mothers had become older, sicker, poorer, and more obese—but not all of it.
The total number of women dying was still minuscule compared to the turn of the century: Maternal mortality had gone from 6 deaths per 100,000 births in 1999, to 14 per 100,000 births in 2006. But more troubling than the total number of deaths was the implication that the best efforts of obstetrical medicine to improve health had perhaps done just the opposite. When the California researchers, speaking at a conference, got to the slide showing a graph of this increase, there were gasps from the audience of obstetricians.
These numbers hit home when I did the math and found that it had been safer to give birth in 1978 (when I was born), than it would be for Beth to deliver in 2011, if the upward trend continued. The popularization of supposedly safe and reliable techniques like the Caesarean were meant to improve outcomes. In just the last decade, the Caesarean rate had increased from 22 percent to 32 percent, which amounted to half a million additional surgeries each year—an extraordinary investment of money and medical resources. And yet, when I asked experts what that investment had bought us, they said that there had been no corresponding improvement in the health of mothers or babies. The conventional wisdom has held that, while C-sections may hurt mothers, they reduce the number of babies who might develop cerebral palsy or die due to lack of oxygen. But cerebral palsy rates, like infant mortality rates, have been flat.
“If you look at the statistics, we don’t see much improvement in the last ten years,” said Debra Bingham, the executive director of the California Maternal Quality Care Collaborative, a partner in the state’s ongoing inquiry on maternal deaths. “What we do see is more women dying, and more women suffering birth-related injuries than we have in decades.”
I met with Bingham in her office on the Stanford University campus. She had worked for years as a nurse, and then as an administrator of a labor and delivery unit in New York City, before earning her doctorate in public health. Her short, neatly coiffed white hair framed an unlined face that radiated grandmotherly warmth. When I asked why our efforts weren’t improving health, she cleared her throat delicately. Administrators and clinicians were allowing their faith in progress to guide them toward presumptively beneficial technology, Bingham said. What they were not doing—for the most part—was allowing the numbers to change their minds when the evidence suggested the technology didn’t help. For example, she said, “Clinicians adopted electronic fetal monitoring with the hope that it would improve outcomes. Even after it became known that continuous fetal monitoring does not improve outcomes clinicians continue to use the technology.”
Bingham herself had been an early advocate of fetal heart monitors. The rationale for these machines made sense: Watch babies closely enough and you should catch a certain number whose hearts are slowing because they are desperately low on oxygen. She became an expert interpreter of fetal heart rhythms and spent much of her career teaching these skills to nurses. But when the actual data from randomized controlled trials came out, the comparisons among thousands of births showed that the babies who had received continuous heart monitoring were no more likely to survive (nor have less risk for cerebral palsy) than those who had not. The birth industry in the United States basically ignored this evidence, continuing to buy machines for hospitals and routinely using them in every labor (while other countries heeded the science). Years later, after looking at the evidence anew, Bingham began to suspect that in most cases these machines had done more harm than good: They tethered women down (a problem because the inability to move freely can make labor more uncomfortable), they provided fodder for frivolous lawsuits, and they prompted unwarranted surgeries with frequent false alarms of fetal distress.
Despite the lack of evidence to support them, some traditions in obstetrics perpetuate obstinately, Bingham said. She first began to question these traditions in 1981 after she herself gave birth in the hospital where she worked as a maternity nurse. Another nurse had taken her son away to the nursery shortly after he was born, as was routine. Bingham had done the same thing hundreds of times herself, but this time it felt unmistakably wrong. For months she’d been waiting eagerly to see and hold her newborn baby and, lying there without him, she felt a suffocating loneliness. She still gets emotional thinking about it. She waited anxiously, wondering if her son was crying, trying to hold the contours of his face in her memory until, after two hours, she’d had enough. She walked into the nursery and, despite the entreaties of her coworkers, refused to go back to her room until they agreed that she could take her son with her.
Bingham knew there was no scientifically valid reason to separate healthy mothers from healthy babies. There was overwhelming evidence, in fact, that babies who stay with their mothers do better (they cry less, stay warmer, and have lower levels of stress hormones). But, when she returned to work, she continued enforcing the hospital policy and telling mothers that the babies would be better off in the nursery. Years later, when Bingham reached a position of authority, she helped revise policies at several hospitals to keep mothers and babies together, but she was still troubled by the fact that she’d essentially lied to mothers to convince them to submit to a practice that she knew made no sense. Institutional inertia is powerful, she said. As of 2005, half the babies born in the United States were being taken away from their mothers before they were an hour old.
“My best explanation is that everyone involved, from me to the mothers, fathers, and loved ones, have been indoctrinated to be submissive in the face of authoritative hospital policies and practices,” Bingham said.
It seemed obstetrics had gotten stuck, awkwardly astride the fence between craft and industry. It had resolved to give up the artisanal excellence of the craftsperson in exchange for the logic of mass production, but its leaders had never stopped thinking like craftspeople, allowing their hunches, their traditions, to trump data. In a 1978 ranking of medical specialties according to their use of solid scientific evidence, obstetrics came in dead last. In her 2007 book, Pushed, journalist Jennifer Block compared the obstetric practices supported by evidence to the practices actually used and showed that a yawning chasm still separated the two. And, in 2011, the American Congress of Obstetrics and Gynecology published a paper showing that only 25 percent of its own clinical guidelines for obstetrics were “based on good and consistent scientific evidence.” The rest of the recommendations were based on evidence that was limited or inconsistent, or on opinion. The industrial logic, it seemed, had a momentum of its own. I wondered if this momentum was ultimately responsible for at least part of the rising maternal mortality rate.
Bingham suggested that, if I really wanted to explore the full complexity of this issue, I needed to look at the problem in context. Specifically, she thought it might be helpful if I listened to the stories of women who had almost been killed by childbirth, who could tell me with some authority what had happened and why. For every death there are dozens of near misses, and hundreds of women who are left with severe, life-altering injuries, she said. “This increase in deaths is just the tip of the iceberg.”
Michelle Niska has a friendly face marked by Scandinavian ancestry: straight blond hair, a high forehead, and a plumpness high on her cheekbones that squeezes her eyes to slits when she smiles, which is often. Her disposition is steeply inclined toward sunny guilelessness, which suits her role as an elementary school teacher (she teaches English to immigrant children) and as a Minnesotan.
I found Michelle in the pages of the Anoka County Union. The story was written with spare, newspaper bluntness, a style that derives its power through presenting both the incredible and the mundane in the same matter-of-fact tone. Michelle’s story was so extreme that I began to wonder if the facts were simply wrong. When Beth, who was working as a nurse, came home that evening, I asked her how unusual it was for someone to lose 115 units of blood.
“Fifteen?” she said, “Um, well, that’s more than most people have in their bodies.”
“No, one hundred and fifteen.”
“Don’t be ridiculous,” she said briskly.
Michelle had had a normal pregnancy, her second. Her first child had been delivered by Caesarean three years earlier, and the doctors recommended scheduling a C-section for this birth as well, which she did. This once-a-Caesarean-always-a-Caesarean rule is debatable, but it makes sense if you see the surgery as a nearly risk-free procedure. When Michelle’s contractions started (a week early) she checked into the hospital and the nurses rolled her straight to the operating room. Her obstetrician, Jeff Raines, was out riding with his cycling club, so it was his partner, Cephas Agbeh, who performed the operation and presented the eight-pound baby girl to Michelle. It was only when Agbeh reached into the incision to remove the placenta that he realized something was wrong. The placenta is a one-pound purple tangle of branching and rebranching vessels. It carries a prodigious volume of blood—a tenth of all the blood from each heartbeat flows to the organ. Usually, hormones cause its vessels to contract after birth, and the placenta separates cleanly away from the uterus. But this time, when Agbeh pulled, he felt resistance—a bad sign.
“It hits you very quickly,” Raines said. “It’s one of those things where the bottom just drops out of your stomach.”
Agbeh gave a few terse commands. Everyone started moving very quickly. The anesthesiologist held a mask up to Michelle’s face.
“We’re going to have to put you under,” he said.
There was a curtain over Michelle’s chest, screening her from the sight of her own viscera, but she knew something was wrong.
“That’s not good, is it?” Michelle asked.
The anesthesiologist searched for the right words, then settled on terse honesty: “No.” He pressed the mask over her mouth and nose.
Raines was still cycling when his pager buzzed. He called back and explained that he was at least an hour away, “Do you still want me to come in?” he asked. When the affirmative answer came without hesitation, he knew the situation was dire. He rode hard to his car, pulled on a pair of jeans, and went straight to the hospital. The sweat from the ride had barely dried when he jogged into the operating room.
Michelle was bleeding profusely. Her placenta had grown through the wall of her uterus, Raines said, snaking blood vessels into her abdomen, and these conduits acted as open spillways. Cups of blood gushed out with every heartbeat. The doctors were applying pressure with gauze to slow the flow, then removing the pads to close off the arteries. But as soon as they relaxed the pressure, Michelle’s blood pressure would fall to a whisper and the wound would flood before they could do much cutting or clamping.
“It’s kind of like walking up a sand dune,” Raines said. “Each step you take you slide back almost as far. The blood is pouring up and the suction device—you can hear, it’s not sucking air—she’s bleeding as fast as it’s sucking.”
More doctors were summoned to the operating room. A pair of trauma surgeons cracked open Michelle’s chest. One of them reached down, wrapped his hand around her main blood vessel, the aorta, where it curved down from the heart, and—in an effort to staunch the flow to her lower body—closed his fist tight.
Raines went to find Michelle’s family. Diane and Jim Niska, her parents, had been in the middle of a lake, fishing, when Michelle called them to say she’d gone into labor. They were still on the road when they got another call and learned that a little girl had been born and Michelle was still in the operating room because there was some bleeding. By the time Raines spoke to them they’d been in the hospital for hours and knew something was terribly wrong.
“She’s hemorrhaging,” Raines told them. “It doesn’t look good.”
After four hours in the operating room, Michelle was still bleeding heavily. The doctor squeezing her aorta closed had felt his hand slowly go numb with pain. There were seven surgeons working on her. They had removed her uterus completely and were cauterizing other points of internal bleeding, stemming the flow.
“We had gone from a fire hose to a garden hose,” Raines said.
The doctors were recycling blood—suctioning it out and pumping it back into Michelle—but it wasn’t enough. They were using up bags so quickly that it soon became clear that they would exhaust the hospital’s entire blood bank. Someone called the Red Cross, and police cruisers began shuttling blood from other hospitals. Nurses formed something like a bucket brigade to move the blood to the operating room. All told, they would use 110 units (the newspaper story I’d read had come out before the tally was completed)—more than all the blood circulating in the bodies of 11 large adults.
At 11:00 p.m. the physicians decided they needed to try something new. Michelle’s parents saw the gurney pass through the hall but, so thickly clustered were the doctors and nurses, they could not catch a glimpse of their daughter. Michelle was taken to the interventional radiology room, where another doctor fed a probe up through the blood vessels in her leg to her abdomen. There, it released a gel to stop up the leaks in her circulatory system. This artificial clotting worked. The bleeding slowed to a trickle.
Raines went to find Michelle’s parents. When Diane saw him, she stopped breathing. Raines simply nodded and smiled. “I’ve never been so happy to see a nod in my life,” Diane said. At 2:00 a.m. Raines collapsed in a bed at the hospital and tried to sleep. He was awakened by his cell phone at 7:00 a.m. Michelle was bleeding again.
When I began to talk to obstetricians, some of them stopped here. What we needed, they said, were more hospitals like the ones that Michelle was in, more blood banks, more expertise in interventional radiology, more surgeons. This was logical, but after Bingham’s admonition to be aware of the tendency to seek improvement through technology despite—rather than because of—the evidence, I was wary. It was only after I’d talked to the Niskas long enough to learn Michelle’s full medical history that I saw the problem with a knee-jerk impulse for more technology: Such recommendations are blinkered by a limited perspective—a tight focus on the catastrophe itself. To understand what had happened to Michelle Niska you have expand the scope of focus to encompass her previous pregnancy.
At the first indications of labor for her first child, three years before, she’d rushed to the hospital, where the nurses admitted her, got her set up in a bed, and then pretty much left her alone. Someone would come in every 15 minutes or so to take measurements and check the fetal heart monitor. They added Pitocin, a synthetic version of the hormone oxytocin, to her intravenous drip, which increased the force of her contractions. The doctor ratcheted up the dosage slowly. Even though Michelle had an epidural, the contractions were still intensely uncomfortable. And this discomfort only increased as the hours ticked by. With the catheter and the epidural, an IV in her arm, and the fetal heart monitor around her belly, Michelle was immobilized. Holding any position for hours is hard, she said. “Even when you sleep, I realized, you roll around. And when you are in pain and you can’t move, you just lay there and think about how much it hurts.” A survey of mothers found that 77 percent of those who were able to change position during labor said that movement was at least somewhat helpful in relieving pain (by comparison, 75 percent said the same of narcotics). Michelle had labored for 21 hours when the doctor asked if she’d thought about a C-section. She had been thinking about it for the last 10 hours or so. “If you don’t do it, I’ll cut him out myself,” she quipped.
The Caesarean has always held a certain conceptual attraction for me. I’ve often experienced an uncomfortable twinge when I see a massively pregnant woman. This feeling doesn’t spring from sympathetic pain, but from something like a simpleton’s thunderstruck disbelief: The notion of that entire bulging mass passing through pelvis and the vagina so utterly violated my sense of anatomy that I could not entirely believe it occurred. Birth seemed no less improbable than levitation. No wonder we have fables about storks and fairies delivering children. To the cultural theorist, Camille Paglia, the mystery of the female anatomy is a threat, a reminder that we are all ultimately prostrate before nature.
“Woman’s body is a labyrinth in which man is lost,” Paglia wrote in Sexual Personae. “It is a walled garden, the medieval hortus conclusus, in which nature works its daemonic sorcery. Woman is the primeval fabricator, the real First Mover. She turns a gob of refuse into a spreading web of sentient being, floating on a snaky umbilical by which she leashes every man.”
By this leash, nature draws us inexorably back to the earth: Birth rubs the primeval in our faces. It forces us to acknowledge the great mystery inherent in life-giving, the same mystery that inevitably overwhelms science and reason in the life-taking. The Caesarean incision is a stroke against the unknown. It makes what is invisible and circuitous, visible and linear. It replaces mystery with mechanics.
The use of the Caesarean goes back to mythic prehistory: Apollo (appropriately, the god of clarity and logic) used the technique to deliver his son, Asclepius, the god of healing. But it was historically the option of last resort, performed only when the mother could not be saved, because the operation nearly always killed her. Caesareans became safer after surgeons began to use antisepsis and anesthesia in the 19th century, so much so that some surgical authorities advocated for initiating the operation earlier, while the mother still had a chance of making it. But they still weren’t very good: Late in the 19th century, Robert Harris, one of those surgical authorities advocating earlier Caesareans, found it instructive to compare the prognosis of pregnant women who had been cut by New York surgeons to those who had been gored by bulls. Women were six times more likely to die after a Caesarean; “a far better showing for the cow-horn than the knife,” Harris wrote. As the years passed and surgical techniques improved (the discovery of penicillin provided a big boost), the survival rate increased dramatically. By 1970, Caesareans accounted for 5 percent of all births in the United States and had improved so much that doctors began using the surgery preemptively for breeched babies, for twins, and as time passed for women with chronic disease, and for women whose babies just seemed big. By the 2000s the likelihood that a healthy young woman would die during a Caesarean had fallen to less than 0.028 percent, making it one of the safest major surgeries performed. The operation had become so sure, so normal, that in 2006 a group of experts suggested that it might be an appropriate method for delivering the vast majority of babies.
The Caesarean has a simple Apollonian clarity in the operating room, but the risks and benefits grow complex in the months and years afterward. The surgery itself is an injury—women take between two and 12 weeks to recover, and the Caesarean wound becomes infected in 3 to 9 percent of cases. Then there are the adhesions, the internal scarring that develops in more than half of all abdominal surgeries. In rare situations these surgical scars can cause chronic pain, scramble organs, obstruct the bowels, cut off fallopian tubes, or—in subsequent pregnancies—increase the risk of stillbirth and of fetuses growing outside the womb. During Michelle’s second pregnancy it was the Caesarean scar that provided egress for the placenta to snake out into her abdomen. This condition is called placenta accreta—or in Michelle’s more serious case, placenta percreta. It used to be the kind of thing a doctor might see just once in his career, according to obstetrician Elliott Main, the principal investigator for California’s maternal mortality inquiry. Main told me, “It’s gone from being something that is extraordinarily rare to being something that is seen monthly at every large center.” In the 1950s the incidence of accreta was one out of 30,000 births; now it’s one per 533 deliveries. The risk of accreta increases with each subsequent Caesarean, Main said, adding that this epidemic of pathological placentas was caused by the rise in C-sections. On that point, there is scientific consensus.
We met at the California Pacific Medical Center, where Main is head of obstetrics. He rushed into his office, looking haggard, as if he were still keeping a medical intern’s schedule, and he collapsed into a chair. His smile is warmly, sympathetic perhaps honed to help anxious families relax. Main wore a short beard—reddish brown, peppered with gray. He answered my questions with complete sentences that could have been lifted from the pages of a peer-reviewed journal, while staring intently at the floor, as if the carpet contained a medical teleprompter.
Accreta and related conditions (there’s also placenta previa, where the placenta forms over the cervix, effectively blocking the exit) account for part of the rise in maternal deaths, he said, but how much is still unclear. When he’d started crunching the numbers, he’d first guessed that a suite of “usual suspects” might explain the increase in maternal mortality: obesity, heart disease, race, poverty, older mothers, fertility treatments—along with better accounting of deaths. But those factors had only made up for part of the increase. “That means,” he said, “that we have to start looking at what else has changed in the last 10 years of obstetric practice.” It’s hard to ignore the fact that Caesareans increased 50 percent—representing an intensification of medical treatment during childbirth—in the same decade that maternal mortality had spiked.
Again, the numbers here are small: The review that Main had helped lead in California identified 98 mothers whose deaths in 2002 and 2003 were directly related to their pregnancies. That’s about 50 more than expected based on the lower maternal mortality rate a decade earlier. A third of that increase was probably due to improved accounting, and at least a quarter was surely due to obesity and the rest of the usual suspects, which left between zero and 20 deaths that might be related to technological overreach. In the end, the reviewers firmly identified 15 deaths that were caused by some aspect of Caesarean surgery. It was a small number, but a small number with an extraordinary implication: An increase in medical care was killing people.
Jeff Raines was not optimistic when he began his second operation on Michelle Niska. She’d gone through a lot of surgical trauma; she’d received over 13 gallons of blood, which had surely put a lot of stress on her body; she was in a coma, and her systolic blood pressure had fallen to 30 (terrifyingly low). Raines sent word to her parents, who came down to say goodbye for the last time. Yet, somehow, Michelle held on. Over the next 24 hours the doctors twice more performed surgery to stop internal bleeding.
Michelle’s mother, Diane, came in again the next morning with two nieces who had joined the family in their vigil. She stared at her daughter, intubated, perforated with needles, and wired to monitors. Chances were she’d never wake up. Then, Michelle opened her eyes. “I just about peed my pants,” one of the girls remembered. Michelle tried to speak, but the breathing machine stopped her. Diane handed her a pen and paper. With a shaky hand Michelle wrote: Am I going to die? “No,” Diane said fiercely. Then she wrote: Did I almost die? “Yes.”
The most careful international comparisons of maternal heath show that the number of childbirth-related deaths are falling dramatically around the world. The United States, where the death risk is rising, is the one perplexing dark spot in otherwise sunny reports. We have a maternal mortality rate four times higher than Australia’s, twice as high as Canada’s and England’s, and on par with Belarus’—the dictatorship where medical technology has not been significantly updated since the Soviet era, and where the fallout from Chernobyl has challenged the capacity of the health system. And yet, the United States was probably the country best equipped to handle the emergency of Michelle’s second birth. After a six-month recovery (during which doctors monitored her fastidiously) she moved to New Mexico, where she is now thriving and raising two adorable children.
There are some problems the U.S. healthcare system handles very well: If you are going have a major medical emergency requiring high technology and the deft coordination of well-trained medical professionals who will not hesitate to make extraordinary interventions, you’d do well to schedule the crisis at a time when you happen to be in the United States. In a very real sense, the prevalence of surgical birth had saved Niska’s life. It had also been the thing that put her in danger in the first place.
This paradoxical pattern repeats across the field. First, proponents of technological delivery justify the need for intensive care by pointing to injuries (e.g., the claim that vaginal birth damages the pelvic floor and causes incontinence). Then, the partisans of natural birth claim that the injuries themselves were caused by technological intervention (e.g., the claim that such damage is the result of drug interventions to speed up labor). The format for this debate was already set by the 1800s, when doctors were arguing that hospital birth was necessary to combat the high rate of fever after childbirth. In response, the Austrian professor of obstetrics Ignaz Semmelweiss proposed that doctors themselves were the vector of the disease. At the time it seemed utterly wrongheaded—dangerous even—to suggest that an agent of healing might be a spreader of disease (Oliver Wendell Holmes Sr. also proposed this hypothesis 3 years earlier in 1843 and was met with a similar scorn). Semmelweiss was mocked for taking this position, but it turned out that he was absolutely correct: Doctors rarely washed their hands in those days, even after examining cadavers and, despite their good intentions, they infected thousands of women.
In hindsight, it’s clear that many of the attempts across history to assist women in labor have done more harm than good. When I looked up the causes of those sky-high maternal death rates from the beginning of the 20th century, it became apparent that the majority of the lives spared by obstetrical advances were not souls snatched back from nature’s devouring maw, but women who had been saved from bad medicine. In a review of mother and infant health between 1900 and 1999, the U.S. Centers for Disease Control and Prevention concluded that early in the 20th century, “Poor obstetric education and delivery practices were mainly responsible for the high numbers of maternal deaths, most of which were preventable.” Babies were delivered using “inappropriate and excessive surgical and obstetric interventions (e.g., induction of labor, use of forceps, episiotomy, and cesarean deliveries).”
All the evidence showing that human meddling can make birth more dangerous brought me back to my initial idea that birth was uncomplicated and safe until we mucked it up. There’s a tendency, however, for this line of thinking to spiral into absurdity: If medicine falls under suspicion so must nutrition and culture and women, themselves. Modern women are too weak and fragile to give birth, the argument goes; they are too terrified by their physicality, “too posh to push.” Perhaps it shouldn’t be surprising that women are blamed for their difficult deliveries and for rising C-section rates, since that’s essentially an updated version of the biblical position. The pain of childbirth, according to Genesis, is retribution for Eve’s apple plucking.
The impulse to cast blame is understandable: It seems unlikely that nature, or God, would have designed women so that they or their babies cannot survive birth—after all, if a baby (or worse, the mother) dies, so do the genes. And so I set out to learn if birth was dangerous before medicine, religion, poor nutrition, or patriarchy began to muddy the waters. What was birth like in Eden?
Birth is a recent innovation in the grand scheme of things. For most of history, creatures reproduced by splitting off pieces of themselves—bacteria, sea anemones, and many plants operate this way. Variations on the theme produced spores, seeds, and eggs. But eggs are defenseless, and a number of species began sheltering them within their bodies until they hatched and could fend for themselves: There are fishes and reptiles that give live birth, along with most sharks, and Seychelles flies sometimes bear crawling larvae, but mammals became birthing specialists.
The next innovation, some 100 million years ago, was the placenta: a feeding system, oxygen supply, sewage treatment plant, and diplomat all wrapped up into one temporary organ. The placenta provided life support for babies, kept their waste from poisoning the mother, and prevented the maternal immune system from attacking this growth as it would any other foreign body. It allowed longer gestations so that some babies, like the giraffe, could run from predators moments after birth. But longer development in the womb also meant bigger babies, and this started to cause problems.
Evolution makes compromises. If increasing the size of babies raises the risk (a little) that some will die at birth, but also raises the survivors’ chances (a lot) of going on to reproduce, then newborn babies will become bigger. Counterintuitive as it seems, the natural world is filled with examples of poorly designed birthing physiologies that cause death and injury. And of these examples, it was the spotted hyena that most thoroughly dashed my hopes of reclaiming Edenic natural birth.
The spotted hyena’s birth canal heads almost to the complete rear of the animal before making a hairpin turn back toward the belly. When pups reach this point during birth their umbilical cord detaches—it is only long enough to provide oxygen to the pups for the first third of their natal journey—and the clock begins to tick down toward suffocation. The pups then pass through their mother’s clitoris (!), which in hyenas comprises a seven-inch phallic tube. (This phallus is capable of erection and from some distance is nearly indistinguishable from a penis. Early biologists, including Aristotle, may be excused in thinking that the species was made up wholly of hermaphrodites.) The organ tears during the first birth, and maternal mortality among hyenas is as high as 10 percent. The fact that any animal must give birth this way seems the final proof that if nature had a designer, He—it seems unlikely, in this case, to have been a She—was vindictive or willfully negligent.
What recompense does nature provide for this horrible toll? Perhaps it has something to do with the relative value of testosterone: It makes the female hyenas masculine (the penis-like clitoris), but it also makes them fierce. The pups are born in pairs, and if both survive birth they immediately fight, often to the death. Under these circumstances, the aggression provided by high levels of testosterone would be indispensable. (Another hypothesis is that having a large phallus provides a social advantage in the hyena hierarchy; the scientists who proposed this were—what a surprise—male.)
Humans, of course, are not spotted hyenas. But, for me, the example of the hyena permanently exploded the argument that gentle birth was an evolutionary imperative. If natural birth requires tearing off the head of any phallus, count me out. Spotted hyenas, as a species, continue to thrive despite a maternal mortality 500 times the rate deemed unacceptably high for humans in America. The question is: How different are humans and hyenas? Each species appears to have made an evolutionary bargain, trading away the capacity for easy births for various other biological perks. Instead of testosterone, humans got larger brains and the ability to walk upright.
Authors making passing reference to the evolution of birth often explain that upright walking narrowed the pelvis. In fact, the exact opposite is true. The human birth canal is proportionally wider than that of a chimpanzee or any of the great apes, which have relatively effortless deliveries. Biological anthropologists who have studied the mechanics of two-legged striding think that walking stretched the hips wider from side to side, but in so doing, shortened the distance from front to back. The upright stature also required adjustment of the vertebrae, which went from being a horizontal beam—from which the body’s architecture was suspended—to a vertical center post. This pushed the lumbar spine and sacrum forward, under the center of gravity, and further squished the birth canal into an oval, wider from side to side.
The notion that broad “childbearing hips” make for an easy birth is a myth because it’s the front-to-back dimension of the hips that creates the tightest squeeze. A woman’s birthing conformation can be better judged by her height—a taller woman is likely to have more capacious pelvis. “I hate to say it, but it’s sort of the classic Hollywood body,” one experienced midwife ruefully admitted. Want to see what childbearing hips actually look like? Check out Heidi Klum.
Even in the best cases, birth is a tight squeeze for women, no matter how well hipped. Humans have the highest brain-to-bodyweight ratio of any mammal. The head of the average baby—4.4 inches by 3.7 inches—is close to the dimensions of the birth canal of the average woman—5 inches by 4.5 inches. Babies normally enter the pelvis sideways (facing the hip), then rotate as they navigate their shoulders though the bones. The upshot of this tortuous journey is that birth is difficult for humans, more difficult than for most other animals, according to Wenda Trevathan, an anthropologist who has studied the evolution of birth. It would seem that evolution would have had to either sacrifice walking efficiency or sacrifice in utero development (and settle for smaller babies) but, instead, the species moved in a third dimension: Some 60,000 years ago early humans must have begun helping one another during birth.
“Mothers probably did not seek assistance solely because they predicted the risk that childbirth poses, however,” Trevathan wrote with collaborator Karen Rosenberg. “Pain, fear and anxiety more likely drove their desire for companionship and security.”
This insight has extraordinary implications. It suggests that women evolved to feel birth pains, that anxiety was not an impediment, but a vital tool. While monkeys seek solitude for birth, the adaptation of anxiety nudges Aristotle’s social animal to seek help. Unlike the apes, we are literally built to require assistance. The terms of the hyena’s evolutionary exchange had been as simple as a straight trade in baseball—lose survival in birth, gain survival in infancy—lose some pitching talent, gain some bats. But the exchange our ancestors made was more nuanced, because they had come up with the game-changing strategy of cooperation. By working together, the mothers of Homo sapiens were able to make redundant a number of traits—easy births among them—that previously had been vital for survival. It freed up room for evolutionary change. This innovation was radical—to extend the baseball analogy, it would be like devising a strategy that made pitchers unimportant, which would allow a team to trade its bullpen for power hitters. It’s clear that social birth is one of the factors distinguishing our ancestors from their primate kin, which is to say that the practice of obstetrics is a fundamental part of what it means to be human.
The word obstetrics comes from Latin obstetrix, meaning a midwife, or “one who stays present.” Trevathan noted, however, that there is not a high premium on remaining present in modern delivery rooms. If you think of birth as a strictly mechanical process, prioritizing companionship seems perilously frivolous. But if evolution has truly programmed emotion into the physiology of delivery, then managing feelings would be the key to managing the physical process. Modern evidence bolsters Trevathan’s hypothesis. A 2011 review published by the Cochrane Collaboration, the foremost authority on evidence-based medicine, found that women who had the support of another person throughout their entire labor were 21 percent less likely to need Caesareans than women laboring in places where companions were not permitted. It would make sense from an evolutionary perspective that the cervix would remain closed until the woman was able to assemble the people she trusted to guide her safely through birth. “In other words,” Trevathan wrote, “women experience heightened emotion at birth, which leads them to seek companionship, which in turn, leads to the ultimate outcome of lowered mortality and greater reproductive success.”
Curiously, while embracing some technologies that lack scientific backing, modern obstetrics has resisted this older technology of simply staying present, despite the strong evidence supporting it. The authors of the Cochrane review wrote that “continuous support during labour has become the exception rather than the norm. This may contribute to the dehumanization of a woman’s childbirth process. Modern obstetric care frequently subjects women to institutional routines, which may have adverse effects on the progress of labour.” Trevathan’s submission that a woman’s psychic state matters, that the creep of mechanical aid—to the exclusion of the human touch—might be counterproductive, could explain the paradox of increasing mortality in American births. But the problem with studying the psyche is that it is invisible, impossible to measure in any quantifiable way. To test this idea, I would have to find some example of labor in which the birthing mother’s emotions were monitored as carefully as her vital stats. And that, I knew, would force me to wade into dark waters, out into the realm of feelings and intuition, far from the reassuring solidity of science.
There aren’t many birthing institutions in the United States that put emotional support first: Although administrators of every labor and delivery unit in the country would say they aspire to respect and honor their patients, respect is almost always trumped by the need to provide immediate access to the operating room, and by the economic imperative to provide beds and caregivers without going broke. As I asked around, I heard of a midwifery center in rural Tennessee that treated birth as almost a religious ceremony, as opposed to a medical treatment. This sort of thing would have been altogether too fruity for me, but Trevathan’s theory and the center’s exemplary (and blessedly non-mystical) statistics drove me onward. With some trepidation, I picked up the book Spiritual Midwifery, by the center’s head midwife, Ina May Gaskin, and began to flip through accounts of births. These stories, told by mothers, often referenced the importance of feeling psychedelic, or being telepathic with a partner. Along with this mental contact, there was a lot of eyebrow-elevating physical connection as well: Pictures of men kissing their laboring wives and squeezing their breasts as they pushed. For one birth, the prescription for a stalled labor turned out to be an impromptu wedding—once husband and wife were bound with traditional vows, the woman relaxed and the baby shot out.
I began growing impatient as I flipped through the pages. It’s not that I discounted this sort of thing—for all I knew telepathy was the key to facilitating birth. It’s just that there was no purchase from which to assess its validity. It bothered me for the same reason I was bothered by my father’s proclamations about birth therapy: Without some rational way to engage, I didn’t know how to deal with it.
But in its second half, this book turned into something you might find in a medical student’s backpack. The descriptions were unsparingly practical. And as I read onward I began to find some of those toeholds from which I could evaluate the far-out assertions in the first half: The stroking of skin, for example, and especially of nipples, causes women to produce oxytocin, whose synthetic analogue, Pitocin, is the most reliable obstetrical tool for prompting contractions. Was the Pitocin drip simply the crude mechanical override required by a culture unable to bring emotion—much less physical intimacy—into the delivery room?
The next morning, I happened to have an interview scheduled with Eugene Declercq, who studies birth at the Boston University School of Public Health, and I asked him if he’d heard of Ina May Gaskin. He had. “There’s a tendency for people to blow her off because she’s such a hippie,” he said. “That’s a huge mistake. She is able to read the science—and write it—as well or better than most academics in the field.”
When I called her, I was glad to have Declercq’s warning. Gaskin’s husband Stephen answered the phone in a blissed-out drawl, called me “man,” and squeezed in a reference to the military-industrial complex before handing me off. But the next voice to come on the line was different. It was a sharp, clipped voice that suggested a hard-bitten country pragmatism. By the end of our conversation I was convinced. I told her I’d like to visit her little pocket of Haight-Ashbury diaspora in Tennessee.
“Well, you’d be welcome,” Ina May said.
I met Ina May and Stephen Gaskin in Nashville. They were both tall, lean, and gray, comporting themselves with the deliberate plainness that comes with a renunciation of superficiality. Both wore their hair in loose ponytails. Stephen’s eyes were clouded with cataracts and mischief, while Ina May’s were a clear and piercing blue. Her mien was terribly serious: “If you’re not angry,” she told me as we navigated the interstate out of the city, “you’re not paying attention.” When she smiled she did so with a ferocity that wrinkled her upper lip and revealed her canines in a sort of happy snarl. While Stephen was bent like a dry branch, Ina May stood ramrod straight. She wore batik-print pants gathered with a drawstring at the waist, and a sleeveless, blue, V-neck shirt.
I sat in the backseat of their coupe, and as we drove south through fields and woodlots, the couple told the story of how they’d first made their way along the same route to the place now called The Farm. They’d met in the 1960s in San Francisco, where Stephen had developed a following delivering freeform speeches on psychedelics and spirituality. (My father went to one meeting.) In 1970 Stephen left San Francisco on a lecture tour, and 300 of his friends came along, forming a convoy of school buses. Some of the women, including Ina May, were pregnant, and when they reached Northwestern University, near Chicago, one of them went into labor. Ina May assisted the delivery. That first birth, luckily, was easy. Stephen, who was lecturing, announced that a new consciousness was appearing in the universe at that very moment, and part of the audience rushed outside to watch through the windows of the bus.
When they reached Rhode Island, an obstetrician named Louis La Pere knocked on the door of Ina May’s bus and asked if she would accept instruction. He’d heard that women were delivering babies on school buses and was hoping to prevent a tragedy before it happened. “He was just a wise man who’d read something in the newspaper about this woman with a master’s degree in English delivering kids,” she remembered.
La Pere spent the next few hours giving Ina May and two other women a crash course in delivery techniques, leaving them with an obstetrical textbook, a satchel full of medical equipment, and a sense of astonishment: Ina May and others had given birth previously in hospitals, and remembered their doctors without fondness. But this man was different—he instantly set the women at ease, comfortably joking and laying his hands on them with immediate intimacy.
“I’ve never seen someone touch Ina May that way,” Stephen said. “Just petting her, and squeezing her.”
“Touch was a big part of his practice,” Ina May said. “He’d probably get sued for that today. I went to his clinic and it was clear he was much loved by the people in that community.”
La Pere’s bedside manner, and his technical instructions, provided a foundation for the women as they began building their own version of obstetrics. In the very next birth, the umbilical cord was wrapped around the baby’s neck, and the mother hemorrhaged. Following La Pere’s instructions, the women unwound the cord, suctioned the baby’s airway, and gave the mother a shot of Pitocin from La Pere’s satchel, which contracted her uterus and stopped the bleeding. The doctor had come just in time.
Ina May’s own baby was the tenth to arrive on the buses, and the first to die. It was born two months premature and stopped breathing about 12 hours later. Ina May was grief-stricken, but didn’t blame herself. The child had exhibited all the symptoms of hyaline membrane disease, she said. The lungs of babies with this disorder become so coated with mucus that they lose the ability to take in oxygen. At that time there was no treatment for it. The death didn’t make Ina May question the wisdom of birthing on buses. Instead, she studied the obstetrical textbooks all the more avidly. It left her craving an infant to nurture, and she channeled that yearning into midwifery.
This reminiscing had carried us almost 70 miles south of Nashville, they talking over their shoulders, me craning forward to see, my legs folded sideways in the narrow backseat. We’d turned off the highway and were cruising between rolling green hills and the occasional farmhouse.
“When we first drove down this road, all the people came out on their decks to watch,” Stephen said. “They were announcing our route on the radio: ‘The hippies are moving down highway 20 now.’ They were so relieved when we passed by.”
“They thought we were the Manson family,” said Ina May.
Eventually the two cultures learned to live in peace. The Tennesseans, especially those without medical insurance, employed the mid-wives. Many were Amish, who sometimes paid for their healthcare in furniture. About one-third of the babies the midwives delivered were the children of these rural poor, another third were children of The Farm, and the final portion were children of well-to-do women who had read Ina May’s books and traveled from Atlanta or New York or places as far away as Hong Kong to give birth at the midwifery center.
We turned down the road leading to The Farm. Stately elms and bur oaks opened onto green-yellow fields of tall grass. The Gaskins lived at the end of a dirt road, in the house they’d built piecemeal around the tent they’d pitched in the 1970s—Stephen gleefully pointed to the original tent poles that had become part of the building. Above, at the ceiling line (and on almost every wall in the home) Stephen had built bookshelves into the walls. At the couches in the central kitchen-dining-living room were still more books in precarious stacks, strewn papers, and a silver laptop.
“Sorry about the mess,” Ina May said. “I’m trying to finish a draft of this book.”
She poked through the refrigerator and produced a pot of black-eyed peas, a cast-iron frying pan filled with cornbread, and some collard greens. We spiced the meal with nutritional yeast and liquid amino acids. It tasted unremittingly healthy. I felt right at home.
The Farm clinic, where the seven midwives practice, is a little yellow house shaded by tall oak trees and surrounded by a neatly mowed lawn. Ina May had arranged for another midwife to meet me there, and when I arrived a woman with gold wire-frame glasses and a pair of iron-gray pigtails resting on her broad chest was waiting. She beamed with pleasure and introduced herself as Pamela Hunt. Her manner was that of an especially kind school counselor.
On the inside, the clinic looked like a small-town doctor’s office, though the usual utilitarian decorating scheme of cabinets, examining tables, and medical posters was muted by soft touches. There were embroidered pillows on the examining table, couches or rocking chairs in every room, and the light blue walls were decorated by framed photos of infants. In the largest room a four-foot square tie-dyed cloth—a kaleidoscopic image of concentric rainbows—dominated one wall. When women come for their prenatal visits, Pamela said, the midwives spend most of the time simply listening to them.
“We’ll take their blood pressure, measure their fundal height, and all that, but most of the hour is spent sitting on these couches,” she said. “We pay close attention to each individual and try to get to know her mindset—what makes her laugh, what makes her cry, specifically, how is her relationship with her husband?” In other words, the midwives pay more attention to a woman’s relationships and emotional make-up than to her physical condition. In the course of labor, Pamela said, knowledge of the woman’s fears and desires is generally more useful than her vital statistics.
Clustered around the clinic are tiny cabins, where women stay while waiting for contractions to start. Two of these buildings were occupied, but when I asked if Pamela would introduce me to one of these mothers-to-be, she looked shocked.
“That’s a private space,” she said, gesturing toward a cabin. Then she sighed and smiled the kind, long-suffering smile that teachers give to particularly slow students. “These women are going through a very intimate, vulnerable process. It’s really not a good time to bring in strange masculine energy.”
I felt my throat constrict. I’d flown to Tennessee to see for myself if these self-taught midwives had rediscovered something that the rest of civilization had forgotten. I couldn’t very well make that assessment based on the impressions I got from this little tour. I’d known it would take a lucky alignment of stars to observe a birth, but I hadn’t expected that the midwives would categorically reject the idea, or deny my access to their clients without so much as talking with them.
“But I’m not strange,” I said, cocking my head in a way I hoped would look unthreatening and sympathetic, like a golden retriever.
“We just don’t do that here,” Pamela curtly replied, shaking her head. “Besides husbands, men usually don’t attend births.”
My gender would prove to be an unassailable barrier. Even classes for midwives in training were off-limits. The Farm’s birthing operations, it turned out, were even more sealed off (at least to me and my masculine energy) than privacy-law-hamstrung hospitals. When I explained my predicament to Ina May, she offered a solution that would allow me to watch a birth from a distance. After digging into the back of several over-packed bookshelves, she produced a stack of VHS tapes. I could view these video recordings of deliveries without the danger that my mojo would intimidate anyone’s cervix.
I stayed that night at The Farm’s Eco-Hostel, a collection of buildings and campsites housing earnest young environmentalists who’d come to learn about organic gardening and green building techniques. Also visiting were a pair of young mothers, Diana and Brydget, who had brought a gaggle of tiny daughters from Nashville. I waited until the girls were safely asleep before I slipped one of Ina May’s videos into the VHS player. A serene, Afroed mother named Janis appeared on the television, laboring to deliver a breech baby—the infant was sitting upright in the womb rather than diving out head first. Because of the danger associated with the head coming out last, breech babies are automatically scheduled for C-section in most hospitals. Yet, here was Janis, making an “Oh” of her lips to breathe, then smiling lazily at something one of the midwives must have said.
At that moment, one of the mothers, Diana, walked out into the living room. She choked on a horrified half laugh and asked, “What are you watching?”
I realized what she was seeing: Here was the tall bearded man who had seemed so nice at dinner, who had been so attentive to the little girls, so warmly solicitous of their opinions about the swimming hole, now sprawled out shirtless, sweating onto the grungy couch, while on the television a group of midwives in long dresses stroked Janis’s bulging nakedness. “It’s research,” I stammered, pathetically tongue-tied. At that particular moment in the video, Ina May reached up from her position between Janis’s legs to rub her nipples.
I was positively glowing with anxiety. Even if I had been alone I would have found it hard to watch the video with a purely clinical eye—there’s no getting around the fact that birth is a culturally restricted event, and I felt as if I had been caught in tiptoeing trespass. But against all odds, Diana accepted my explanation and joined me on the couch. There commenced a period of awkward silence.
“Her cervix is dilated to seven centimeters,” I finally said, like a sports fan updating the score. “It’s a breech.”
“Wow.”
“Yeah.”
Some long-hibernating defense system within my head, dormant since the ninth grade, woke with a start in the familiar glare of wincing sexual shame, and began trying to squirm out of the heat by offering up lame attempts at humor. We quipped back and forth, until we were joking convivially. By the time Janis had reached nine centimeters, Brydget had appeared, carrying a flask of vodka, which she passed around after settling in next to us. Alcohol wasn’t allowed at the Eco-Hostel but over dinner the three of us had shared complaints about the Byzantine policies restricting activities on The Farm (as hippies age they seem to transform from defilers of the rules to scolding enforcers). The booze’s illicitness made it all the more intoxicating, and the video kindled a thrilling sense of transgression.
In a way, it’s odd that images of birth make people so nervous. We’ve all been there, after all. But in another way, this anxiety makes perfect sense. The portal between nonlife and life stands at the nexus of all our great taboos: Excrement and genitalia entwine with the possibility of death and with hints of sex. This last is especially disturbing, but birth is inherently sexual. The same female organs are engaged during birth and sex, of course. And the same chemicals surge into a woman’s bloodstream, triggering a similar combination of agony and ecstasy, pain that can turn to pleasure and back again. Oxytocin—which floods into the bloodstream during orgasm, triggering feelings of love and contentment—is named from the Greek oxus, meaning swift, and tokos, meaning childbirth, a reference to its ability to accelerate labor by increasing the severity of contractions; oxus also translates as sharp, a coincidentally apt double meaning. Women have compared especially traumatic birth to rape, and others have experienced orgasms during delivery and while breastfeeding. It’s no wonder we are reluctant to accept the sexual aspects of birth: Acknowledge that a kind of sexuality is at work during labor, and the intimation of incest is not far behind. Who knows what other terrors wait in the dark?
“I don’t know how much more of this I can take,” Brydget said after an hour.
I felt the same way. I cringed sympathetically as the women moaned and babies inched out on the screen.
“How are all these women so calm?” Diana marveled. “She’s smiling! Oh, there’s no way, look at her face, she’s totally stoned.” She turned to me. “You’ve got to do an exposé, and find out if they are feeding them some narcotic tree bark or something.”
The beatific state of the laboring women was indeed striking. Whatever the midwives were doing to help them manage their psychic state, it was working. If there had been some psychoactive bark, then that would have made my job easier—physical interventions are more easily studied than the magic the midwives were working. I could understand, at least in part, why modern obstetrics gave short shrift to the psychology of birth. My eyes were tuned to physical action; I didn’t know how to watch for feelings.
After Diana and Brydget went to bed, I stayed up assembling my impressions of these births. The first video had made the delivery of a breech baby look effortless. But, during the next recorded birth, something had gone wrong. The infant’s shoulder had locked in the mother’s pelvis behind the pubic bone, a shoulder dystocia. I’d leaned forward with interest. In New Jersey, an obstetrician had told me, juries consider shoulder dystocia so terrifying that, when sued, many hospitals have found it cheapest to simply sign the settlement checks without so much as contacting the lawyers. But there was no alarm in the video. The midwives asked the woman to turn over and crouch on all fours. Moments later, the baby slid free.
When I looked up the technique online I learned that it was called the Gaskin maneuver. The next day I asked Ina May if she was the eponymous Gaskin. She seemed a little embarrassed to admit that she was. She’d learned the trick from a Central American midwife who worked with Mayan women in the Guatemalan highlands.
“I didn’t invent it,” she said. “It really should be called the all-fours maneuver.”
Birth attendants generally learn several other techniques for freeing shoulders: In the McRoberts maneuver, they push the woman’s knees hard back to her chest while striking the area just above the pubic bone with a fist; in Wood’s Screw maneuver, they snake a hand up into the woman and try to rotate the baby’s shoulders; in the Zavanelli maneuver they push the baby back up and perform a Caesarean. All except the last are generally accompanied by what obstetric literature calls—with grim poetry—a “generous episiotomy,” performed by inserting the open mouth of a scissor near the bottom of the vagina and cutting down toward the anus.
In each of these treatments the woman is passive. The secret of the all-fours maneuver is the unconsidered ability of the mother to take charge: When she turns over, gravity shifts the infant enough to allow first one shoulder, then the other to slide free.
This technique seemed preferable, at least worthy of trial. The one formal paper on the Gaskin maneuver showed that it took an average of two to three minutes and completely resolved the shoulder dystocia in 83 percent of cases—a better record than any of the other methods. There has been little further study of the technique, in part because it’s hard for patients to turn once they are hooked up to an epidural (not to mention an IV, catheter, and fetal heart monitor). But Ina May thought the method hasn’t spread due to an obstinate refusal by the medical establishment to cede any piece of authority to an outsider—to admit that Mayan elders know something the obstetricians should have been using all along. “Why couldn’t you have the best of the modern world and not throw away what people used to know?” she asked.
The cultural amnesia extends even further when it comes to the psychology of birth, Ina May said. On her computer she pulled up a photograph of a sculpture: a human figure, smiling, and reaching under its knees to hold wide a gaping opening. Ina May found this figure carved in the roofline of Kilpeck Church in Herefordshire, England, built in the 12th century. These Sheela-na-gigs, as they are called, are scattered throughout the British Isles. Ina May thinks they are miniature visual obstetrical texts:
“I think this is a form of neurovisual programming; it would be tremendously helpful for women to see this,” she said. “She’s squatting, unladylike; her mouth and eyes are open. This is a woman who won’t tear, because this is a woman who is smiling.”
“Why is that?” I asked. “I don’t see the connection.”
“If your throat relaxes so will your cervix,” Ina May said. “That’s why holding your breath and pushing is so harmful.”
No causal link between the throat and cervix has ever been documented, but it does make some sense that a woman who is calm enough to unclench her throat would be more able to allow loosening elsewhere. Obstetricians often learn that successful birth depends on the three Ps—the passage size, the passenger size (the baby), and the power available to push the latter through the former. But the metaphor is facile. It does nothing to illuminate the most opaque and, arguably, the most important part of birth: the fact that the passage changes in size. Pregnant women are literally shape-shifters—one birth hormone (named, awesomely, relaxin) softens the cartilage between the pubic bones, morphing the shape of the pelvis, while others ripen the cervix and stimulate contractions. And the release of these hormones may be slowed or intensified by emotions. At the very least, it seems safe to hypothesize that Sheela-na-gigs are a salute to the transformative power of the female body—a simple documentation of the fact that women can “get huge,” as Ina May put it.
Ina May has found comparing reproduction to excretion is far more apt than comparing it to an overloaded tractor trailer charging toward a tunnel. To replace the three Ps, therefore, Ina May has proposed what she calls the sphincter law. Like the sphincters that control excretion, the cervix does not respond well to conscious commands, she said. Instead, like a sphincter, it responds to subtle cues that all is well in the world and that the moment is right (a locked door and a little running water perhaps). Sphincters contract when they are startled or frightened, Ina May said. Laughter helps them open.
I stopped her: “Laughter?”
“Yes,” said Ina May; she paused. “But you really have to get to know the woman’s sense of humor.”
If the joke does hit the right notes, she said, it can provoke infectious giggling—teenage-sleepover laughter that grows until it overwhelms the conscious mind. I was intrigued. What is laughter, after all, but the release of tension? And what is a comedian if not the person you trust to see you safely through forbidding terrain, to trespass on taboos and then puncture anxiety with a well-turned punch line? In one sense, the midwife and comedian perform the same service, guiding their charges into forbidden territory while expertly dispelling fear.
“So, do you have any standbys?” I asked Ina May, fishing.
“Well, poop is usually funny,” she mused. “And it’s usually present. It’s hard to relax down there without relaxing everything—I try to make it clear that it’s no big deal, so the woman doesn’t get embarrassed and tense up. Also, I’ve been working on my juggling act.”
She waved me into the bedroom, fished around for a silken bag, and then, Ina May Gaskin, solemn matriarch of midwifery, high priestess of natural birth, and bitter critic of the medical establishment, began juggling plastic chunks of fake dog shit.
“These are hard, because they’re uneven,” she said, bending to pick up a fallen plastic turd. “I think they’re the schnauzer model. Maybe I should go for something more like a fox terrier.”
As wonderfully strange as they may seem, such techniques have served The Farm midwives well. After some 3,000 births, their Caesarean section rate stood at 3 percent (in these cases the midwives had driven the laboring woman to the hospital)—against the national average of 32 percent. Their infant mortality rate of 3.94 deaths per 1,000 births was also lower than the national average of 6.61, and their maternal mortality rate was zero. These statistics, however, were surely canted: The average woman who gave birth on The Farm was far less likely than the average American to be obese, and anyone with a serious condition like placenta previa would go to a hospital rather than The Farm. All the same, it seemed unlikely that these factors could increase the Caesarean rate tenfold.
There are other examples of midwives beating the national averages amid a much less healthy population. In the Navajo Nation, where obesity and diabetes are rampant, the local maternity services, which are midwife-centered, had a Caesarean rate of 13.5 percent as of 2007. And the mid-wives at the Family Health and Birth Center, who serve mostly low-income minority women in Washington, DC, had a Caesarean rate of 10 percent. Washington’s infant mortality rate was 12.2 per 1,000—twice the national average, while the mortality rate at the Family Health and Birth Center stood at zero. There was also another example: the grandmother of all the American experiments in midwifery, a few hundred miles north, in Kentucky. As long as I was in the area, I figured I should visit.
As I drove northeast from Tennessee, the land on either side of the road grew steeper and greener, and by the time I reached Hyden, Kentucky, I felt I was at the bottom of a well with walls of beechwood and kudzu. This was true Appalachia, where dwellings clung to the rare plot of level ground—a doublewide up on a hillside ledge, a Dairy Queen in the bend of a river. The crook between hills provided enough resting place for the town of Hyden: a handful of brick buildings clustered around a crossroads. The house I was looking for was tucked a mile back into the forest, a manorial building of black logs and white chinking that stood above the Middle Fork of the Kentucky River. Hollyhocks were blooming in the yard. It was Mary Breckinridge’s house, and home of the Frontier Nursing Service.
When Breckinridge came here in 1923, the U.S. maternal mortality rate was 870 per 100,000. And in these deep hollows, where people were cut off from medical treatment, women were even more likely to die in childbirth. Breckinridge changed that. In under a decade it would be safer to give birth in her corner of eastern Kentucky than in the best hospitals in New York. It was as pure an experiment as you could ask for: There were no rich women flying in to deliver, no hospitals to catch the most dangerous cases, just a group of midwives making improvements. What’s more, the data were sterling: Breckinridge, a woman of great chutzpah, knew the world would doubt statistics generated by midwives in the mountains, so she recruited Dr. Louis Israel Dublin, vice president and statistician at the Metropolitan Life Insurance Company (now MetLife), to do the numbers.
The results, published in 1932, were astounding. The women the Frontier Nursing Service cared for, who were desperately poor and usually gave birth at home, were 10 times less likely to die in childbirth than the average American at the time. The nation would not reach the standard of care available in this corner of Appalachia until the 1950s, after the widespread acceptance of antiseptic and the discovery of antibiotics.
Breckinridge did not quite know what to make of these statistics. “The question that will arise in every thoughtful mind is why there should be this discrepancy between the Kentucky mountain woman and her city sister,” she wrote. “Doubtless there is too much deliberate obstetrical interference in city hospitals but not so much, I am convinced, as people might think.” Then, in what seems like an uncharacteristic lapse of reasoning, she laid out a theory that drew on eugenics: Rather than crediting her own work, she praised the racial stock and sturdy birth canals of the population she served. These explanations are no longer scientifically relevant, but even if the racial hypothesis had held up, it did not explain the radical improvement that had occurred among this population. Breckinridge had transformed one of the poorest parts of the country into a model for maternity care, and I wanted to know how she’d done it.
When I arrived a caretaker advised me to watch for snakes (“rattlers and copperheads”), and showed me where I’d stay until my meeting with Michael Claussen, the development coordinator for the Frontier Nursing Service. Just inside the house was a photograph of Breckinridge, who died in 1965. She stood before the camera among blooming rose bushes, a wooden cane in one hand, a pail of chickenfeed in the other, a white apron around her waist and, on her face, an expression of impish humor. The Breckinridge family was Southern aristocracy. Mary’s grandfather had been James Buchanan’s vice president and, later, the last secretary of war for the Confederacy. Mary Breckinridge remained nostalgic for the old South, outfitting her nurses in Confederate gray and giving her staff special dispensation to see the opening of Gone with the Wind. This Southern sympathy is inconvenient for most modern sensibilities, and it perhaps explains why her work has been largely forgotten.
Claussen arrived right on time, his hair buzz-cut, and his tie decorated with an eagle grasping an American flag. It became clear, as he walked through the grounds, that there was no miracle-working behind the drop in maternal deaths in rural Kentucky, unless it was a miracle of common sense.
During World War I, Breckinridge divorced her husband and reassumed her family name. After the war, she volunteered to serve as a nurse in France, where she assisted women and children. When she returned to the United States, the plight of Kentucky mothers stirred her noblesse oblige, and she resolved to muster a cavalry of midwives who could ride over the roadless terrain to reach homes that were days away from a hospital. She advertised in the United Kingdom, which had begun producing nurse-midwives (that is, midwives formally trained according to the current medical standards), with advertisements like the following, which appeared in the Glasgow Times.
ATTENTION! NURSE GRADUATES
With a sense of adventure!
Your own horse, your own dog, and a thousand miles
Of Kentucky mountains to serve.
Join my Nurses Brigade and help save children’s lives!
Write to: M. Breckinridge, Hyden, Kentucky, USA
This excited a certain breed of daring woman, willing to work for next to nothing in exchange for freedom and a genuine opportunity to make the world a better place. One of these young women was Betty Lester, who left London on her own, crossed the Atlantic in a steamer, and then took the train until the rails ran out in Hazard, Kentucky. A nurse named Billy met Lester at the train station and told her to fill one saddle bag and leave the rest of her luggage behind.
“We rode straight up the mountain, and the rocks looked so big and the trail so bad that I wondered if I would topple over the horse’s head,” Lester wrote in a letter home. “We went straight down the other side and came to the river. I thought, ‘Now what do we do?’ Billy splashed right into the water so I did the same.” She started work the next day and immediately lost her sense of direction on the branching horse trails. Eventually, however, she learned her way around the 700 square miles under the midwives’ aegis. As promised, Lester was outfitted with a collie pup, which she named Ginger.
Lester also got the adventure she had hoped for. She and the other midwives would ride out into the mountains in snowstorms to deliver babies by candlelight. And, by virtue of being the closest medical providers available, they treated snakebites, fevers, and men shot in feuds. When attending births in mountain cabins, the midwives could not summon a surgeon or rely on the latest perinatal equipment, but what the Frontier Nursing Service lacked in heavy technology it more than made up for in care. The women made frequent house calls—18 prenatal visits and 12 postpartum checkups were standard for an uncomplicated pregnancy. They were also passionately committed: Betty Lester would spend most of her life in Hyden, and considered the people she served to be her family. (She was transformed by the work, from the dazed girl who had arrived with too much luggage, to a forceful presence who was nicknamed “The General.”)
The Frontier Nursing Service slowly replaced the coterie of self-taught birth attendants who had lived in the mountains. The evidence suggests that some of these country grannies—as they were called—did not understand antisepsis, and they relied on superstitious techniques (like placing an axe under the bed to cut the pain of labor). The British form of nurse-midwifery that Breckinridge imported to Kentucky was, by contrast, a resolutely scientific form of medical technology. But it was also fundamentally different from the dominant obstetrical technology in America. British midwives learned that birth is a physical event, performed by the mother, while Americans learned that birth was a medical event performed on the mother. And it seems that this is where Breckinridge succeeded: At a time not too many years after it had been better to be gored by a bull than have Caesarean surgery, the Frontier Nursing Service nurse-midwives were able to simply support mothers while doing no harm.
The Frontier Nursing Service’s low-tech armamentarium of time and attention was highly effective. When Louis Israel Dublin made his accounting in 1931, eastern Kentucky was suffering from a year-long drought and famine, and tuberculosis was running rampant. And, yet, maternal health was improving. Dublin concluded that if this style of maternity care became a model for the nation it would save a million lives within 15 years:
“If such a service were available to the women of the country generally, there would be a saving of 10,000 mothers’ lives a year in the United States, there would be 30,000 less stillbirths and 30,000 more children alive at the end of the first month of life,” Dublin wrote.
Dublin’s vision never came to fruition. When we’d finished at the Breckinridge estate, I followed Claussen into town to the campus where the Frontier Nursing Service now runs a school, which sends some 200 nurse-midwives to work in underserved areas around the country. The midwives often work at the margins, where more technological care is unavailable. Rather than remaking obstetric practice in its image, the place of midwifery in the medical hierarchy hasn’t changed much since 1925.
As my research progressed, I became annoying: At a party I caught myself giving unsolicited advice to a pregnant pediatrician. She responded with a story of her own about a Bay Area midwife who had opted to treat a Group B streptococcus infection by stuffing the woman’s vagina with garlic rather than using antibiotics. The baby contracted the bacteria during birth and developed permanent brain damage.
Beth put voice to my worst fears after I complained to her about a case that seemed to me a particularly egregious example of obstetrical ignorance. Beth frowned at me quizzically and said, “There are some really great OBs you know.”
I quailed at the implication: In questioning the solid ground of medical orthodoxy, I had begun to sound irrational.
“Oh my God,” I said. “I’m not one of those people, am I?”
“Of course not,” she laughed, circling her arm around my waist.
But I was. Despite myself, I’d grown shrill. I was especially miffed by the fact that when I criticized the maddeningly unscientific practices I observed in obstetrics, I was the one who seemed irrational. The incident that made me complain to Beth occurred after I visited, in the same day, two Southern California hospitals with widely divergent practices. In the morning, I went to a hospital where a public relations agent proudly explained that they strictly followed the Friedman Curve for every birth; and in the afternoon I talked to the medical director at the other hospital, who explained that the Friedman Curve had been obsolete for decades. You could tell that one of the hospitals was missing something, even if you didn’t know what the curve was (a graph developed by Emanuel Friedman in 1955, charting the progress of labor, which obstetricians used to determine when to intervene). It irked me that some doctors still swore by routine fetal heart monitoring, the obligatory episiotomy, and the separation of mothers from babies, despite the fact that the evidence supporting these practices was about as good as the evidence for curing infections with garlic. I wanted to know why these practices persisted while others, supported by better evidence, like the provision of emotional support throughout labor, were ignored. Why had the Frontier Nursing Service been all but forgotten, and the all-fours maneuver overlooked?
There were thousands of small answers to these questions, all wriggling off in different directions, like so many sardines. The one answer, however, that captured the whole school of fish had to do with the way American obstetricians see—or, as it were, refrain from seeing. An article in Medical Anthropology Quarterly describing this problem pointed out that in three influential trials weighing the risks of Caesarean surgery against vaginal birth, none had counted the Caesarean cut itself as an injury, though each diligently documented the other lacerations. For the mother who has to cope with the pain, it’s obvious that the Caesarean wound, though perhaps lifesaving, is an injury. The researchers, on the other hand, who relied on the Caesarean as an instrument of healing, were blind to this fact. Claire Wendland, the author of this article, was herself an obstetrician, and she admitted that this “breathtaking move in the selection of evidence” had also been invisible to her until a midwife had called it to her attention. Unless doctors can recognize that incentives and ideologies are guiding them toward some data and away from others, Wendland wrote, they will be doomed “to the blindness in which, for example, we cannot see the pelvis-wide cesarean wound.”
Wendland’s point was that the obstetrical idea of birth was obscuring important information about the way birth really worked. The spire of medical science may be a powerful place from which to view birth, but certain parapets block key portions of the panorama. Another revealing example, Wendland wrote, was the fact that researchers considered operative laceration to be a major injury, and infection a minor injury. An accidental laceration is “major,” sometimes requiring additional surgery. But abdominal infections sometimes require a woman to keep the wound open for weeks, during which time she must rely on her family or a nursing home staff to change dressings. “Scarring can be major, and recovery painful and prolonged, if predictable and uneventful from a clinician’s perspective,” Wendland wrote. The reason operative injury was classified above an infection was that the injury is almost always the result of surgical error, while an infection is not. The real morbidity in this example was the injury to the doctor’s honor. Though the science was correct in its limited fashion, the perspective of the surgeon was so dominant that the mother—along with her pain and emotions—had been blocked from view. It’s impossible to see what lies behind these obstructions—or even to be aware that they exist—unless you are capable of stepping back to observe your own position. For doctors unaware of their own subjectivity, papers on the all-fours maneuver might as well have been written in Swahili.
Just about everyone is complicit in ceding priority to the surgeon’s perspective. America honors those who take swift, independent action more than those who empower someone else’s agency. Even grammar bows to surgical authority: Surgery is performed on, not with the patient, though, of course, the patient must participate by healing the wounds the surgeon makes.
The obstetrical perspective also creates the blind spot I’d noticed while talking to Michelle Niska: Because doctors are responsible for—and more likely to be sued by—patients who experience an injury in their care, they may see only short-term consequences. One of the researchers studying this blind spot was Aaron Caughey, chair of obstetrics at the Oregon Health and Science University. Caughey’s research clearly showed that the increase in surgeries was hurting women. When we met in his small, jumbled office (he was still teaching at the University of California, San Francisco, at the time), he initially lounged with one leg over the arm of a chair, but he couldn’t sit still for long, bouncing up to find a paper or sketch a graph on the whiteboard. He was handsome—smiling Asian eyes, square American jaw, rugby-player’s frame.
Everyone agrees, he said, that complications from Caesareans (like Michelle Niska’s placenta accreta) crop up years down the road—there the science is clear. But it’s hard for patients to weigh those dangers: When faced with a decision that requires the assessment of small risks and future trade-offs, people make bad choices.
“This is what economists call discounting,” Caughey said. “We’re really bad at it when we start looking into the distant future. It’s almost like a glitch in the human brain.” He added, “I get really into this sort of thing.” Caughey was so captivated by behavioral economics that he ended up getting a PhD in the field after he became a medical doctor. Consider, he continued, the risk of a Caesarean to a baby: Many obstetricians think that C-sections increase risk for mothers, but decrease risk for infants. That seems logical, he said.
“I do feel like if you just did a C-section on everybody you might decrease this kind of acute neonatal morbidity and mortality. We don’t know, but you might. We know that some babies are injured during the labor process, so it makes sense. But, but, there’s a really nice paper by,” he snapped his fingers, pulling the name out of the air, “Gordon Smith, out of Cambridge, that shows that a prior Caesarean increases the risk for fetal demise in subsequent births. So, if everyone has a C-section on their first baby, then you might see another 1,000 dead babies overall.”
The risk of stillbirth at term is low, on the order of 5 per 10,000 births. Gordon Smith, a British obstetrician, had found Caesareans increase that risk to 11 per 10,000 births, presumably because the uterine scar can interfere with the attachment of the placenta.
To provide a similar comparison for maternal health, Caughey had built a statistical model, bundling all the risks associated with Caesareans, then letting it run projections for the future. If C-sections continue their current upward trend until 2020, he said, every year they will kill 50 more women than would otherwise die in childbirth.
“If you can stop the rate where it is, you’ll still get more deaths because the Caesareans we did yesterday are going to cause some more maternal deaths. And then what if we turned it around? What if we were able to get it to go back down to where it was in the mid-nineties? Which should be really easy. Then we can start preventing maternal deaths.”
When we’d finished, Caughey walked me out, and we continued talking as we rode the elevator down through the hospital. Released from the formal structure of the interview, I found myself spilling the story of my birth and confiding that when it came to making decisions about my own family I felt stranded in the no-man’s-land between the idea that birth was a pathology and the idea that birth was an ecstatic, danger-free, natural event. He offered his commiseration, then asked me where I lived and, when it turned out to be on the way to his house, gave me a ride home.
I hadn’t realized it until I started blabbing to Caughey, but there was clearly another reason—the real reason—that I was miffed about the state of obstetric science: Beth was becoming more and more obviously pregnant, and I hadn’t hit on any practical way of applying the information I was learning. I’d succeeded in making myself anxious, and not much else. We hadn’t managed to pick a place to give birth, so by default we’d started prenatal visits at St. Luke’s, a hospital a few blocks from our home, and it was there we had our first ultrasound.
According to my sources, which admittedly consisted almost entirely of Hollywood dramas, the ultrasound is supposed to be a mini-religious experience in which that grainy sonogram becomes a window to the chain of life stretching forward and back for eternity; then—as the father—I’m struck at once by my cosmic insignificance and newly interconnected importance, and I weep. Instead, I squirmed and silently repeated, “Is this absolutely necessary?” over and over, fighting to keep the words from coming out of my mouth.
It never occurs to most sane people (or cinematic characters) to fear an ultrasound. I shouldn’t have worried either: I probably knew more about the risks and benefits than the ultrasound tech who was pressing the wand to my wife’s belly, and I had come to the conclusion that there was almost no cause for concern. Which meant that I was not only anxious, I was annoyed at myself for being anxious.
The thing is, though the risks of an ultrasound are just about nil, so are the benefits. Studies comparing populations that got ultrasound screening with those that didn’t found that the screened group was no healthier in the long run. Still, it seems obvious that you’d want to get in there and take a look to see if everything is all right. The question becomes, however, what happens if everything isn’t all right? The doctors didn’t bring this up. They’d simply told us we should come in on such and such a date. It had been up to me to ask what would happen if the ultrasound found something, and to start the hard conversation about what we’d do if the baby was missing organs or likely to develop Down syndrome. We’d grappled with that terrible prospect and finally decided that we wanted to know, so that ultimately we’d have the option of (gulp) ending the pregnancy. I’d loved the obstetricians we’d met with, but it bothered me that no one had uttered the word “abortion,” or explained the cascade of tests and worries if an ultrasound found something, or acknowledged that every screening adds moral complexity to medical decision making. Instead, the ultrasound was treated as an automatic, risk-free (not to mention cost-free) part of pregnancy. And this initial one-size-fits-all assumption made me feel just a tiny bit like a widget on a conveyor belt, about to be incorporated into the system.
I also had a distressingly nonrational fear that the ultrasound would damage my baby’s brain. After more than 20 years of regular use, and several long-term studies, no one has linked any deficiency in children to scans. Yet, in medical science there is no such thing as a sure thing. When fetal mice are exposed to more than half an hour of ultrasound, some are born with slightly malformed brains. And the mainstream consensus holds that the scans should be employed as infrequently—and at as low a power—as possible. I don’t like to think of myself as the kind of person who becomes petrified at the slightest suggestion of risk, but I still wanted the scan to be over quickly.
Our ultrasound technician, a short woman in her fifties with a strong Eastern-European accent, babbled on in a mixture of cooing and medical jargon as she probed Beth’s belly and produced a grainy image on a screen.
“Baby is anterior, see?”
She rattled the keyboard and zoomed in.
“This is heart. Cute. I will show you face. There. Cute.”
This seemed to go on for a long time. I wondered if her accent wasn’t a bit sinister, and immediately afterward added xenophobia to my growing list of reasons to hate myself. Was she providing a lingering tour for our benefit? Maybe I should ask her to keep it short? After our conversation with the doctor, I had thought it would be quick: Find the baby, check the heartbeat, measure the thickness of its neck, go home. But the tech clearly had other work to do. She punched notes into the computer and printed a chain of photos for us. Then she zoomed in, so that we were looking directly into the top of the baby’s head.
“This. Brain. Left hemisphere, right hemisphere. We are looking down into brain.”
The two halves of my own brain were locked in combat. My urge to interject was tackled by my desire not to sound like a crazy hippie, and was held down by an impulse of empathy for this blameless woman, who undoubtedly was following practice guidelines established by higher-ups. And so, as frequently happens when I enter a hospital, I sat there feeling nervous, abashed, and totally out of control.
I didn’t want an industrial birth, but I also didn’t want to slide all the way over to the other extreme. I’d found a few birthing centers in San Francisco: Jade Lotus, Rites of Passage, Sage Femme. But I’d nixed each of these, perhaps unfairly, because of their names. I was looking for something more like No Nonsense Evidence-Based Midwifery. I wanted to live in a world where the model midwife-led birth—the model pioneered by the Frontier Nursing Service—was the norm, but where women and babies who needed it could get the miraculous, high-tech treatment that, say, interventional radiology and neonatal intensive care can offer. I wanted the hippie midwives and numbers-driven doctors to exist, not in oppositional worlds, but together in the same space. As Beth and I were asking around about our local hospitals, I found myself thinking of the story of Daedalus’s escape from Crete: I wanted to employ technology’s wings, without suffering from their overuse.
There are organizations that have managed to make use of technology without overusing it. In 1999, Utah-based Intermountain Healthcare, employing the same concept of quality improvement that Toyota used to rationalize its factories, began to review its labor and delivery practice. The conclusion of Intermountain’s industrial audit was counterintuitive: Instead of calling for more medical surveillance or more mechanized labor, it recommended more “low tech, high touch” births. The statistics had shown what the human eye couldn’t see: that the industrial logic had pushed past the point of diminishing returns.
At first, a successful new technology offers a massive bang for the buck: When the Frontier Nursing Service built a hospital and started making C-sections available to the women around Hyden, Kentucky, each surgery was likely to save a life. But, like Icarus’s flight, the returns derived from the increasing reliance on technology often form an inverted parabola. Increasing use of an innovation is intoxicatingly profitable at first. Then the cost grows steeper—to save one life you must perform 100 Caesareans instead of one, then 500, then 1,000. The curve flattens out, then tips down. The wax begins to melt, and more vigorous flapping only damages the wings. Increase the Caesarean rate again, and the lives you lose start to outnumber those you save. The logical thing to do in this type of situation is to slow down, which is exactly what Intermountain did.
The hospital system made a few small changes, focusing first on reducing the number of women they induced into labor for no medical reason. The effects were wholly positive. Mothers were able to go home sooner. Complications and admissions to the neonatal intensive care unit decreased. But there was also a hitch: Because the hospitals were performing fewer treatments and keeping women for less time, revenues fell. The reforms were saving patients around $1 million a year, money that came directly out of Intermountain’s bottom line.
“Intermountain is nonprofit and that makes it easier for us to take such steps,” the company representative told me. “But the incentive for most organizations is to provide more care, not less.”
St. Luke’s, despite my misgivings after the ultrasound, turned out to be close enough to what we were looking for. Like Intermountain, it was owned by a nonprofit, and discouraged early inductions. Like the Frontier Nursing Service, the deliveries there were attended by nurse-midwives. The building was old and scuffed, but the policies were up to date. The midwives at St. Luke’s, however, weren’t going to stay with Beth for her entire labor, let alone juggle for her. They suggested hiring a doula if we wanted a professional there to manage the emotional elements of birth. Doulas, however, aren’t cheap—most of the people we looked up charged between $1,000 and $3,000, or around $500 if they had very little experience. We interviewed three, and each meeting was a bit like an awkward first date: It’s hard to determine, in 45 minutes, if someone will have the calm-in-crisis compatibility to make a grueling experience less, rather than more, stressful. We couldn’t agree on anyone we both liked and eventually decided that my presence would be enough. But, in the end, I think our decision not to hire a doula came down to money—if the hospital had offered to have someone there to provide support as part of the package, we would have accepted without a second thought.
A week and a half after the 40-week due date, the baby showed no signs of budging, and we reluctantly went to the hospital to start labor artificially. Neither of us liked the idea of an induction, but there is a slight statistical increase in the risk of stillbirth for babies after 42 weeks of gestation. The risks were small, an increase of one in a thousand, but the risks of C-sections were even smaller and I couldn’t very well use the statistics to argue against the latter while ignoring the data for the former. All the same, it felt wrong.
The night before the induction, Beth started crying. She wasn’t worried about being induced to labor, she explained, but being induced into the role of a patient, of firing her body as head manager and giving control to a team of medical professionals. I commiserated—it certainly didn’t seem like there was anything wrong with her body, I said.
“My body has been awesome,” Beth said, laughing through her tears. “My body rocks.”
She had had a radiant pregnancy. There had been minimal morning sickness, she’d slept easily, and felt none of the aches and pains that other women complained of. The baby was squirming vigorously and making inverse footprints on her distended belly. The notion that there was anything wrong with the pregnancy, that it was becoming dangerous, ran counter to intuition. For the induction, she’d have to be hooked up to an IV drip of Pitocin and wear fetal heart monitors throughout. I didn’t want medical technology to transform my vibrantly healthy wife into an invalid.
The midwives patiently talked us through the decision. If we wanted to wait (to avoid an induction) we’d have to go to a hospital with a high-level neonatal intensive care unit. St. Luke’s, following a protocol developed by Aaron Caughey and other researchers, did slow inductions over 24 hours or more, which, unlike standard inductions, did not increase the chances of a Caesarean. After that conversation, Beth was ready to move forward, as was I—or at least the part of me that could be convinced by data. Still, I was disappointed. I liked the idea of this improbable process happening magically rather than mechanically. I’d imagined Beth and me staying in our homey little apartment until the last possible minute, putting on music, dancing between contractions, making something good for dinner, then catching a cab to the hospital when active labor began.
Instead, we walked to the hospital, carrying a mason jar of flowers to brighten the room. After a night of fitful sleep, the contractions started in earnest. Beth handled them with aplomb, but as the hours ticked by she grew tired and tense. She was struggling, fighting each contraction, and it twisted my insides to watch her. My efforts to soothe were inevitably misguided, and my suggestions began to sound like hectoring, even to my own ears. When night fell again, Beth took some morphine to help her sleep and was able to catnap between contractions. I remained wide awake. Somewhere in the haze of night she got up to go to the bathroom, but the cords from the fetal heart monitors had twisted around her arms to tangle with the surgical tubing attached to the intravenous needle in her wrist. She pulled at this snarl foggily, then indicated she would make do, and lay back again.
In those hours I began to sympathize with American obstetricians: The desire to do something, to help, was overwhelming. I could understand, for the first time, how alien it felt to submit to the frustratingly obtuse impulses of a body in labor. My mind buzzed frantically, generating one plan for action after another. Obstetricians are trained to save lives, to take charge, to turn tragedy into triumph, to perform miracles—it only makes sense that they deploy these skills when confronted with what felt like a problem. It must take nerves of steel for a doctor to sit on her hands, to stay out of the miracle’s way, so to speak. At the same time, I resented the fact that Beth was literally bound by medical technology, and that the nurses were monitoring the fetal heartbeat so carefully while paying scant attention to guiding her (or perhaps it was me that needed guidance) through the psychological labyrinth of birth. I rehashed our decisions: The induction had been a mistake, I decided. In fact, we should have opted for a homebirth—and really all my research had been for naught. It had become clear in that my mother’s postpartum hemorrhage, the emergency that had launched my investigation, really hadn’t been so terrifying: I’d learned along the way that that particular complication is routine enough so that any well-trained midwife can resolve it. Perhaps I should have forgone all the facts and data and had faith in nature. Or perhaps my mistakes had started even earlier, and I should have married a woman who trusted her body enough to give birth outside a hospital. It was at this point that I realized I was going a little bit insane. My nerves too jangled to remain still, I found a nurse and confessed my anxiety. She nodded knowingly.
“Whenever there’s uncertainty or discomfort, people tend to want to fix it,” she said. “We have absolutely no tools in this culture for simply accepting, but that’s what you have to do sometimes.”
Somehow, this made me feel better. I returned to Beth’s side calmer, and this jittery peace lasted through the night. Early in the morning Beth started pushing. I stood at her side, humbled and quiet, distrustful of my brain’s power to produce anything useful in its shocked state. Beth didn’t need my help. She simply slipped into the urgent current of birth. But then the nurse began having trouble finding the baby’s pulse, and when she did find it the midwife muttered that they needed “to get this baby out, now” and my raw nerves began convulsing once again. Then I could see the baby’s hair, and then another push and a face and shoulders and tiny flailing hands burst free, and—as she began to caterwaul, and I held her shocking warmth, and she suckled at my finger—my fear began to expand into something new. It wasn’t that the terrifying uncertainty ended with the birth of my daughter, I think, but merely that I was coming to terms with the fact that this child was, and would always be, an engine of uncertainty: No matter how strenuously we worked to protect her during labor or afterward, sooner or later she would be hurt, she would suffer, and eventually she would die. Somewhere along the line I’d allowed myself to stop grasping and to simply tumble with a little more grace. Later, as I walked home, squinting in the early morning light, punch-drunk with exhaustion, my heart fluttering, I realized the frantic buzz of planning and organization—and had started when I’d first called my parents to ask about my own birth, which had reached its fever pitch during my vigil the night before—was gone. In its place was a buoyancy in my chest. I recognized this sensation. I’d felt the same dizzying mix of fear, elation, and hope before: when walking home once on a similar sunny, sleep-deprived morning as a teenager; again in college; and once more the morning after I’d first kissed Beth. Improbably, the acceptance of the suffering and uncertainty that comes with new life felt exactly like falling in love.