Book Excerpt: Pushed

Jan. 8, 2008 — -- Author Jennifer Block wrote a book about childbearing and pregnancy called "Pushed: The Painful Truth About Childbirth and Modern Maternity Care." In the book, Block writes about how hospitals have transformed childbirth into a business for no other reason than speeding up an unpredictable process.

For more from the book, check out the excerpt below.

WILLING AND QUALIFIED

On the last day of the breech conference, as organizers packed up leftover juice bottles and tossed stale bagels, a dozen or so stragglers stood in a cluster in the lobby. They were peering over the shoulders of two Toronto midwives, who were sitting on a couch with a laptop, a blue light cast across their foreheads.

I squeezed in between the rapt audience to see the image of a Snow White-featured woman with an enormously rotund, sagging belly sitting naked on her toilet in an unremarkable, windowless bathroom. "It's the porcelain birth stool," a midwife whispered in my ear. In the video, the woman has her hands on the seat, shoulder-length hair falling in her face, and she's moaning and moving through each contraction, sounds that are somewhere on the pleasure-pain continuum. In the interim her head is up, eyes wide, and she's talking to her partner or smiling at a blond toddler we see walk over in his pajamas and put his hands on the round belly. Another contraction, and as it subsides she reaches a hand down between her legs and mutters something about a head.

Someone finally tells me this is the video of a woman in California, Mindy Goorchenko, who gave birth to twins on her own, with only her husband present. This was Goorchenko's third pregnancy, but because she was having twins she had difficulty finding a home-birth attendant.

In the video, Goorchenko moves to the floor and kneels, towels spread out beneath her. She's moaning louder, breathing heavier, the phone rings, and we see the baby's face appear. Goorchenko touches the face, and before the ringing stops a boy slides out into her hands. She lifts him to her belly and greets him with singsong hellos. The baby lets out a few cries and kicks his limbs around, but he is mostly silent. "Hi honey, hi honey," she says, laying him down in front of her, cradling his head and touching his chest. "I felt his head descend quickly, got down on all fours, and let my uterus push him out into my hands," Goorchenko later wrote about the birth. "This was our first arrival, a little boy named Psalm Victor, who cried just enough to let us know he was okay, but otherwise settled into a deep calm. . . ." He weighed 7 lb, 10 oz.—average size for a singleton baby.

The video then fades briefly to black (husband Alex had put the camera down to help cut the cord and wrap the newborn in blankets), and next we see Goorchenko back on the toilet moaning and grunting, sipping water from a sports bottle, the phone ringing again in the background. Of the second birth, she writes:

My friend Kari thankfully arrived at this point to help Alex, who was now watching our 2-year-old, holding Psalm, and filming the birth, all at the same time! I reached inside me once again to check on my progress, and felt momentarily confused as to what body part was presenting itself. It felt like a hand, possibly, tucked up near the head, but then I realized it was our daughter's foot. . . . I wasn't afraid, just surprised. My husband asked what he could do and I responded, "Nothing. Just film." A foot and leg quickly came out, followed by a second foot and leg (I could feel her literally pushing her knee out of me). Next came her body, hands, and arms, as I supported her with my hands reaching under me. Her head popped out and our daughter Zoya Olga was born, with spurts of blood coming with her and a train roaring by outside. . . . After 10 or 15 minutes, I clamped the cord with shoelaces, gave her to my husband, and birthed the placenta into a big glass bowl. Their two placentas had fused into one big butterfly with two cords emerging from it. (The girl was 8 lb, 11 oz.)

Goorchenko didn't set out to have an unassisted birth, at least not initially. She'd gone back to the midwifery practice that had attended her second pregnancy, but when her belly started measuring suspiciously large and an ultrasound confirmed twins, she was "risked out" of their practice in accordance with California licensing regulations. By law, the midwives had to refer her to an obstetrician.

"They gave me a couple names of OBs," says Goorchenko. "I remember looking at them and thinking, this isn't an option. Because in California, a twin pregnancy pretty much means you're going to have a cesarean section and a NICU stay for your babies even if they don't need it. That was really painful for us to imagine. And I had very little interest in surgery for no good reason." Indeed, there is no evidence to suggest that routine cesarean delivery of twins improves outcomes.

Goorchenko was now in her third trimester, with twins, and had no care provider. She started calling midwives. Most said they couldn't take twins or didn't feel comfortable doing so. Finally one said yes, but with certain provisos. "She wanted a small team—a second midwife and an assistant and paramedics waiting. She had no breech birth experience. And I thought, what is she bringing to the table? Plus she was going to charge me the full fee even though it was about 8 weeks before my due date."

Goorchenko did meet with an OB with whom she was familiar and asked if she would support a normal vaginal delivery in the hospital. "She said, 'Sure, I will. But nobody else in my practice will,'" says Goorchenko. "She even said to me, which I'll never forget, because it sounded so strange coming out of a doctor, 'You know, it just sounds like you really want a home birth.'"

Goorchenko's first baby was born at the hospital. She was an unexpectedly pregnant 19-year-old and got "one heck of an episiotomy," she says. "I had a mirror set up so I could see the birth and all of a sudden I'm watching my vagina being cut with scissors." It took years to get over the psychological trauma. "And on top of that it just fucks up your vagina," says Goorchenko. "I had incontinence. I could barely feel sex for a year and a half." She intended to have a home birth with her second child but went into labor at 35 weeks, too early to give birth safely at home. The hospital birth was fine, but the NICU experience wasn't.

With this pregnancy, Goorchenko had a month to go, and still no provider. "We just decided there was no one willing to help us or qualified to help us," she recalls. "At that point, we just made the decision that we needed to be home alone. It was actually a very easy decision to make." Goorchenko had been a childbirth educator for years, and her husband was trained as an EMT. "I felt very confident in the birth process," she says. "I believe that women instinctively know how to take care of their babies. If you can be in that state of primal knowing—I hate to sound all cave-womanesque, but I think we have that wisdom still. But mostly what I wanted to do was protect the babies from intervention and interference with a physiological process."

There was one midwife, though, that someone had mentioned in passing, a woman who lived 3 hours away, had 25 years of experience, including twins and breech, and somehow ignored licensing regulations. Goorchenko and her husband met with the midwife and felt a connection— she was both qualified and willing. But everybody knew there was a good chance she wouldn't make it to the birth in time. "This is going to sound petty, but one of the major benefits I had was telling my family we had a midwife," says Goorchenko. "I didn't mention that she was 3 hours away and that my births tend to be really fast. But there was definitely that psychological peace of getting everybody off my back. I was worried that they were worried."

Goorchenko went a full 40 weeks. "I was the size of a small house," she says. (She gained 80 pounds during the pregnancy—and by the looks of her in the video, all belly.) Toward the end, she invited to the birth a close friend who also happened to be a labor and delivery nurse with experience in neonatal resuscitation. Goorchenko finally went into active labor at 7 a.m. on January 25, 2004. She called the midwife, called her friend, and gave birth to the first baby at 9 a.m., before either had arrived. She told me that even in labor she had a "strong awareness" of her decision and an overwhelming sense of relief that she had stayed home. "When I felt my daughter was a footling, I knew that minute that I would have been in surgery, knocked out on general. Even if we were having a vaginal breech birth, there would have been hands all over her, and that's when it gets really dangerous. Instead it was this wonderful experience." The midwife arrived 45 minutes after the babies were born. Goorchenko was soaking in the tub, taking turns bathing each baby.

DO IT YOURSELF BIRTH

There are no reliable data on planned unassisted births. Most births classified as unassisted are those attended by cops and cab drivers, and in states where midwives are illegal, many midwife-attended births end up being recorded as unassisted. The number of intentional solo-birthers is small, but many believe it is rising—some are calling it a movement—based on several very active bulletin boards and e-mail lists dedicated to "freebirth" or "U-birth." On motheringdotcommune, the bulletin board of Mothering magazine, which has a robust 75,000 active members, there are 1500 threads in the "Unassisted Birth" forum. The members are women like Goorchenko, who can't find a care provider willing to support a normal birth; women who feel so traumatized by their previous birth that they don't trust any care provider; and women who are religious and feel that birth should be a private affair to which only the husband is privy. Then there are women like Laura Shanley, who simply believe that any outside interference with birth is unnecessary and potentially harmful. Shanley is the author of Unassisted Childbirth, published in 1993, and founder of the high-traffic website of the same domain name. If you simply search "childbirth" on Google, her site comes up sixth.

Unassisted birth isn't new. In the 1960s and 1970s it was often the only alternative to a hospital birth—a strapped down, separated from husband, guaranteed episiotomy birth—and the women who did it also gave birth to organized midwifery. "That's what we were doing in the 1970s before there were any midwives," says Peggy O'Mara, editor of Mothering. "It was part of the whole back-to-the-land movement and commune movement." It was also a natural extension of the early feminist, grab-a-speculum-and-mirror-and-reclaim-your-body ethos, she says. "And I consider it a really legitimate response to certain environments. Where I lived in southern New Mexico, for instance, the choices were so poor that we just wanted to figure it out ourselves."

Laura Shanley gave birth to her first child, with her husband and friends present, in 1978. But she came to unassisted birth a bit differently. Shanley was heavily influenced by the New Age you-create-your-own-reality principle. You get where she is coming from in the first paragraph of her book:

In 1976, my husband David and I became aware of the concept that we create our own reality according to our desires, beliefs, and intentions. Undesirable events are neither punishments handed out by an angry God, nor chance happenings that originate from without the self for no apparent reason. They are instead the result of an untrained mind that has not yet become aware of its own abilities.

For O'Mara, unassisted birth was the best women could do under the circumstances; today, midwives outnumber obstetricians in New Mexico and attend nearly one-third of all births. "Now, unassisted birth here would seem extreme," she says. Shanley, on the other hand, says there's "no such thing as a casual observer." She doesn't see most midwives as much of an improvement over the hospital. "The midwives will say, 'Doctors are not gods, but we are goddesses. We have the knowledge, we will hold your hand and help you,'" says Shanley, mimicking a good-witch tone. "Well, what if I don't want to hold your hand? What if I think I have the knowledge? I think there are people with big egos who like laboring women dependent on them," she says.

You can hear echoes of Shanley's own ego on the Yahoo group list C-birth, in talk of midwives "spoiling" the birth energy or "feeding off " birth energy and "taking over" births. "If you understand how your mind affects your body, and if you understand that birth is inherently safe, then it can be as natural and easy as going to the bathroom or making love," says Shanley. "You don't need help with those things, so I don't believe you need help giving birth—provided you are healthy and in right frame of mind." Shanley talks of a birth intelligence that healthy women need only tap into, an intelligence she feels is basically retarded by the hospital and is often supplanted by a midwife, who brings her own intelligence into the room. "There is an intelligence within us that knows how to grow a sperm and egg into a human being, and that consciousness knows how to give birth," she says.

It is likely that there has always been a tiny minority of women who felt confident enough to birth without professional assistance. But now, the unassisted movement feeds off the increasingly restrictive obstetric environment. O'Mara says U-birthers appeared on her radar only in the past 5 years, around the time when VBACs started being denied. Restrictions on midwifery care have contributed as well: in several of the states that offer licenses, such as California and Washington, midwives are under the same pressures as their cooperating physicians. Instead of inducing with Pitocin and Cervidil, they are often doling out herbs and castor oil at 41 weeks to "get labor going." If a client hits 42 weeks, they will be forced to transfer her out of midwifery care.

Goorchenko has become somewhat of a poster girl for the unassisted community, a defiant hero who blew the cover off birth—see, look, it works just fine by itself, even twins! She speaks to childbirth education classes and sells her video via her website. "Looking back at the birth of our twins, it was extraordinary yet so perfectly normal at the same time," she writes. "I realized how much of a big deal birth is turned into, when in actuality, it is such a straightforward and ordinary event."

The Discovery Channel got hold of Goorchenko's video and included it in a show titled "Amazing Babies" (one of the babies was born on a small plane, another had robotic surgery). Goorchenko sent me copies of both—the original video and Discovery's makeover. Her footage is notably absent of fear; there are smiles and laughter during and between contractions. There's excitement; the contractions themselves elicit distinctly orgasmic sounds. At one point Goorchenko actually says, "This is so fucking awesome." The produced piece notably edits out these moments, depicting her as though in constant agony. There's the obligatory mood music—ominous high notes that bring to mind the strings from Psycho, particularly with the shower in the background. With editing and voiceover, the program somehow reframes the labor as if on the brink of disaster at every moment—"Plans for a home birth go terribly wrong," the baritone narrator begins. After baby A slides out "too fast," we hear, "the baby wasn't making any noise." With baby B, "her left leg was actually sticking out of the birth canal, but her head was trapped inside!" The image of the dangling foot is stretched over nearly two suspense-filled minutes, when in real time the baby emerged, toe-to-head, in 60 seconds flat. When disaster never comes, it's presented as a dodged bullet. "Even when faced with dire complications, they took it all in stride."

Just as there are no data on the frequency of unassisted birth, there are no data on its safety, only anecdotes. The issue is extremely divisive for midwives. "Frankly, it's a sticking point," says Angelita Nixon, a midwife in Charleston, West Virginia. "If pressed, I'd have to say that I have some reservations—I don't think that every woman who chooses it is necessarily as informed as I would want her to be. But on the other hand, in terms of women's rights, it is a decision that women should be able to make. And we have so much culturally prescribed fear around childbirth, I really admire a woman who's been able to actively resist that, who believes in her body's ability to give birth." Lisa Block-Wieser, a midwife in Tucson, Arizona, is less charitable. When I mentioned Goorchenko's video she shook her head and raised her voice. "You know, I'm happy that it went well for her, but it's really irresponsible of her to put that out there," she said. The story reminded her of an unassisted birth of twins in Tucson just before her arrival in 2001— one of the babies died. Even though there was no midwife present, "it cast a cloud over the whole midwifery community," she said. "They think of it as all the same."

"Look," she went on. "There are people who can do it with Zen and finesse, but they're setting other women up for failure. Most women need support. These people are forgetting what midwifery is about, which is supporting women."

In a sense, Shanley believes she is the über midwife, empowering women to be completely independent. The notable lack of support and not infrequent hostility from midwives initially came as a shock to her. "These are women who really encourage women to trust themselves, to listen to themselves—but only to a point," says Shanley. "I have more faith in women."

Women who feel wholly disempowered and demoralized by an interventive birth often find power in that sentiment, and yet I find a sad militancy, too, in holding up a woman alone in childbirth as the ideal. Giving birth is a natural bodily function, but even in the best of environments it is not always easy and not always harmless, and historically, across cultures, women have sought support. It's part of what separates us from animals: our babies are helpless, neonatal. Easing out that evolved brain from a narrow bipedal pelvis is more of a challenge than it is for other mammals. We can recognize ourselves as animals and take some hints from animal behavior during labor—rarely do mammals lie down on their backs for the duration, and rarely do they stay put. But our brain size is what makes human birthing a bit more complicated, and it's what makes us smart enough to get the village in on it.

Shanley argues that the growth of unassisted birth is just one aspect of "the psychological revolution" taking place. O'Mara, on the other hand, sees it as a marker of regression. "I think it's a sign, just as it was in the 1970s, that the births available to mothers have become over-medicalized, that the hospital is being perceived as a dangerous place, and that women don't have options."

Excerpted from Pushed: The Painful Truth about Childbirth and Modern Maternity Care by Jennifer Block (Da Capo Lifelong Books, 2007).