A recent press release details some of the lengths that the American College of Obstetricians and Gynecologists (ACOG) is willing to go to preserve its near-monopoly over maternity care in the United States.  In an effort to deter growing numbers of women from seeking out-of-hospital maternity care, ACOG urged its members to submit anecdotal, anonymous “data” (i.e. horror stories) about women who planned out-of-hospital births. This represents an effort to develop an unscientific case against out-of-hospital birth.

ACOG is not a protector of maternal or fetal life – it is primarily concerned with avoiding competition from midwives that could negatively affect the incomes of its members.  A campaign to expose ACOG’s efforts to collect unscientific evidence used social networking tools like Facebook, Twitter, and email to encourage thousands of women to submit their own stories about healthy births in private homes and freestanding birth centers on ACOG’s website.  How did ACOG respond?  It “quickly moved to scrub its website and placed its request for unsourced data from members behind a password-protected firewall” (http://www.thebigpushformidwives.org/_ccLib/downloads/8-31-2009_PushNews_RELEASE_Viral_Internet_Campaign_Exposes_Bogus_Research.pdf).  The survey is still there, in the members-only section, where it is “protected” from the public.  What is likely to happen is that ACOG will then use the unscientific anecdotal data that it can collect from members to support lobbying campaigns directed at denying access to out-of-hospital birth and the midwives who are trained to provide it.

Will this work?  Unfortunately it might, because ACOG has professional legitimacy and receives a lot of respect from members of the media and the general public.  That’s why advocates of reproductive rights – which includes the choice of where and with whom to give birth – must increase awareness of what ACOG is doing.  Otherwise ACOG will bring out their “data” to support opposition to out-of-hospital birth whenever the press offers them some attention.  More people need to recognize that ACOG is a trade association (i.e. a cartel) that tries to protect its members from competition.  Its primary goals do not include promoting science or evidence-based maternity care – obstetrics is one of the least evidence-based specialties in all of medicine.  In fact, the cherry-picked horror stories are designed to discourage women from examining the evidence and making rational decisions about where, and with whom, to give birth.  Meanwhile, two recent well-designed, scientific studies of homebirth in the Netherlands and Canada, both published this year, provide solid evidence that planned out-of-hospital births have comparable perinatal mortality rates, lower rates of serious maternal and neonatal morbidity, and fewer interventions than hospital births among women who meet eligibility requirements for homebirth.  These studies were well-designed scientifically because they compared women with the same level of “risk.” (See Amy Romano’s excellent summary of the results here, or a press release on the Canadian results here.)  Given an opportunity to examine real evidence, like that in these recent studies, many women may rationally choose to give birth outside a hospital setting, and that’s exactly what ACOG is going to desperate measures to prevent.

Obviously birth activists who want pregnant women to have the option of midwifery are interested in this, but really everyone should care about ACOG’s self-serving behavior, which violates principles of anti-trust and is also relevant for the health reform debate.  Maternity care in the U.S. is much more expensive than any other developed nation and has far worse results – higher infant and maternal mortality, more premature and low birth-weight babies, and more infants in the NICU.  Having a baby is the most common cause of hospitalization, and cesarean sections are the most common surgery in the United States.  Out-of-control cesarean rates (around 1 in 3 births) and high-intervention obstetric care for low-risk women represent huge cost burdens on the system as a whole.  The health reform debate has said little about maternity care, and that is a major omission.  One of the best ways to reduce health care costs while improving results is to better integrate midwifery care and out-of-hospital birth into the health care system.  But ACOG clearly doesn’t want that to happen, since it would reduce its members’ bottom lines.  It’s time for this cartel to be broken up.

Yet another ruling is providing legal support for the false belief that obstetricians are infallible, and stripping pregnant women of basic civil rights that are accorded to other individuals.  In the case, New Jersey Division of Youth and Family Services v. V.M. and B.G., the New Jersey appellate court found that V.M. and B.G. had abused and neglected their child, based on the fact that the mother, V.M. refused to consent to a cesarean section and behaved erratically while in labor.  The mother gave birth vaginally without incident, and the baby was “in good medical condition.”  Then she was never returned to her parents, and the judge in the case approved a plan to terminate their parental rights and give custody of the child to foster parents.  What, beyond the obvious, is wrong with this picture?

First, from a legal perspective, individuals have a right to informed consent and bodily integrity.  In obstetrics, informed consent is a blurry concept since many hospitals perform obstetric procedures on laboring women without informing them of the evidence concerning those procedures or their risks.  Perhaps this legal case illustrates how paternalistic hospitals can be with respect to pregnant women – assuming that the hospital staff know best and that informed consent is unnecessary.  Never mind that hospitals tend to be run with organizational efficiency, rather than patient interests, in mind.  In this specific case, one obstetrician who tried to convince the mother to consent to a c-section concluded that she was not psychotic and had the capacity for informed consent with regard to the c-section. It is clear within the law there is no informed consent without informed refusal, so this obstetrician’s conclusion should have made V.M.’s refusal to consent to the c-section her decision alone.  If this mother is not legally permitted to refuse major abdominal surgery, then she is clearly stripped of her civil rights to informed consent.

In fact, individuals are not legally required to consent to invasive procedures even to save other individuals, including fetuses that lack full legal status.  But in this case the district and appellate courts subverted a pregnant woman’s informed medical decision-making in the name of fetal rights, arguing that her refusal was a form of abuse and neglect of the child that had not yet been born.  This is another dangerous precedent, along with other court-ordered cesarean cases, that will allow all pregnant women to lose their rights to bodily integrity and informed consent. It may be understandable, if not excusable, that the courts don’t understand medicine or recognize that medical judgment is fallible, but it is hard to understand how they could so fundamentally misinterpret the law, in which performing surgery on an individual without that person’s permission can constitute criminal “battery” under common law.

The court’s opinion also suggests that lawmakers have no concept of what it is like to be in labor. Women in labor tend to find themselves on a different mental plane, where they have to focus inward and work with their bodies to give birth.  As midwives know, some women become belligerent.  Some seek privacy and seclusion.  Most women in labor are likely to find the routine and usually unnecessary procedures of hospitals to be invasive and unwelcome. Yet the courts that decided this case didn’t seem to be aware that women are unlikely to behave the same way when they are in labor than when they aren’t. The decision cites hospital records that describe the mother, V.M., as “combative,” “uncooperative,” erratic,” noncompliant,” “irrational” and “inappropriate.” Also, her husband indicated that the way she was acting was not her “normal manner and that she is not as ‘tranquil.’” Why would anyone expect a woman in labor to be compliant, tranquil, or rational?  What kinds of expectations does our society have for women undergoing a powerful physiological process, often with an absurd amount of poking, prodding, and general interference?  This mother was uncooperative with hospital staff, but clearly her uncooperativeness had nothing to do with the well-being of her baby.  There is no reason to believe that she did not have the well-being her baby as her top priority, even though she was not a model patient.  There is also no reason to believe that everything the hospital staff wanted to do was essential or even beneficial for the well-being of either mother or baby.  In fact, typical obstetric care engages in many procedures that are unnecessary and often harmful, more out of habit and for the convenience of hospital staff than in the best interest of patients.

While the court opinion also focuses on the parents’ psychiatric diagnoses (which are fallible medical judgments) and their history of care in determining their fitness as parents and abrogating their parental rights, their psychiatric state would never have been questioned if the mother had not refused invasive abdominal surgery – which was entirely within her rights. The tragic consequence for this family was separation from their infant daughter from the moment of her otherwise uneventful vaginal birth.  That kind of injustice can’t have been good for the psyche.

On the June 24 edition of The O’Reilly Factor, Dick Morris said that “right now the government is telling people, cut back on cesarean sections, go through natural childbirth. It’s a lower cost.”  Aside from the simple fact that this is false, there’s a lot wrong with this picture, especially given that he chose the example of cesarean sections.

It would be understandable that Americans are worried about the rationing of health care, except that private insurance companies do a lot more rationing of care than single-payer systems in other developed countries.  But it’s especially interesting that Morris made his false claims about childbirth, since American maternity care is unnecessarily expensive and has very poor results. The U.S. pays twice as much per birth as other developed nations.  The American infant mortality rate is the second-worst in the developed world and ranks 37^th in the world, behind South Korea and Cuba. Maternal mortality rates have been rising since 1982 in the U.S., which currently ranks 41^st among 171 countries. In August 2007, the CDC reported that the number of women dying in childbirth in the United States increased in 2004 for the first time in decades. National data on infant mortality rates in the U.S. also reveal an increase in 2005 and no improvement since 2000.  In fact, countries with universal health care systems have much better maternal and infant outcomes, as well as lower cesarean rates.

The correlation between poor outcomes of the American maternity care system and high cesarean rates, which have risen from 4.5% of U.S. births in 1965 to 31.8% in 2007, is not spurious.  Morris implies that cutting back on cesareans and encouraging natural childbirth would do a disservice to the health of mothers and babies – an implication that is patently false.  Cesarean can be a lifesaving procedure, but it also increases the risk of neonatal respiratory problems and carries a much higher risk of maternal complications and a four times higher risk of maternal death than vaginal birth. Based on scientific evidence, the World Health Organization (WHO) recommends a cesarean rate of 10-15%: below 10% the benefits of the surgery outweigh the risks to the health and life of mothers and infants, while over 15% the risks of surgery outweigh the benefits. According to the WHO, the rate of cesarean section should not exceed 15% in any country because maternal deaths increase at higher rates. However, the cesarean rate in the contemporary United States is more than double this recommended upper-limit.

As Media Matters reported with respect to Morris’ absurd claims, the AMA and five other health care organizations issued proposals to address the overuse of certain procedures on June 1. “In its attachment to the letter, the AMA stated that the ‘AMA-convened’ Physician Consortium for Performance Improvement (PCPI) recommended addressing ‘the overuse of certain services or procedures,’ including ‘Induction of labor/Caesarean Sections.’”  The proposals addressed overuse, and it is clear from the medical research literature are that labor induction and cesarean sections are over-used in the United States, and that this overuse is detrimental to the health of women and babies.  If healthcare reform in this country leads to fewer c-sections, it will save money and lives.  Aside from a few obstetricians who prefer the surgical route, whatever its ultimate health consequences, who can really complain about that?

On Friday’s episode of Real Time, Bill Maher introduced one of his “new rules,” “Lactate Intolerant,” in which he argues against breastfeeding in public. As he explained, he doesn’t want women showing their tits in public unless they are appropriately packaged for heterosexual male consumption. (Revealing what he thinks is appropriate, he made a snide reference to Britney Spears’ body in one of the other new rules, drawing a good laugh. My goal here is not to defend her, but only to point out that Bill Maher’s idea of an acceptable female body, along with many members of his audience, is incredibly narrow.)

For someone who claims to believe in science, Bill’s queasiness around breastfeeding seems more than a little bit irrational. A huge body of evidence suggests that breastfeeding provides incredible health benefits to both infants and mothers. (For the FDA statement on this, click here.) It not only provides babies with antibodies that help them avoid illness, it also may protect mothers against breast and ovarian cancers later in life. There is evidence that breastfeeding provides psychological benefits to infants and that breastfed infants develop higher IQs. There’s even evidence that breast-fed babies are less prone to obesity later in life – and obesity is something that Bill Maher is clearly against. Breastfeeding saves on healthcare costs, and it is clear that advocating in favor of breastfeeding is in the interest of public health. And yet the vast majority of mothers do not breastfeed for the full 12 months recommended by Health and Human Services. In fact, less than 30% of mothers are breastfeeding when their babies reach 6 months of age.

Given that it’s so good for their babies and themselves, why don’t more mothers breastfeed? One reason is that there is inadequate maternity leave for most women, making it hard for women who want or need to work outside the home to establish breastfeeding. Another reason is that many employed women don’t have enough privacy at work to pump milk. Then there’s the fact that formula is readily available, and hospitals and pediatricians give out free samples. But we shouldn’t underestimate the impact of people like Bill Maher who are squeamish about the fact that humans are mammals. Coworkers who don’t want women leaving icky breast milk in the office refrigerator because it grosses them out. Those who can’t handle the idea that babies should also get to eat when the family is at Applebees, even if they are having something healthier than what’s on the menu. So Bill Maher says that breastfeeding mother’s are too lazy to plan ahead, presumably because they can arrange it so that their babies don’t need to eat while they’re out. Obviously he has never had to manage life within small windows of opportunity between feedings or he would know that timing a baby’s hunger is just not possible. Perhaps he would prefer that breastfeeding mothers never leave the house – another recipe for reducing breastfeeding rates. Sometimes people, especially those without children, seem to forget that mothers are people too – we need to have friends, social lives, and activities beyond the confinement of our living rooms.

Bill Maher obviously doesn’t understand the benefits of breastfeeding to public health, since he claims that breastfeeding is not worthy of activism. He says that it’s “petty and parochial.” Apparently he also doesn’t understand that supporting breastfeeding is not only good for public health, it’s also part of reproductive justice – along with the availability of contraception, the legality of abortion, the right to informed consent or refusal of medical procedures when giving birth – all rights that many women currently do not have. When he claims that women’s reproductive activities are yucky and should go underground, he is colluding with the people who want to control reproduction and sexuality – not normally the folks he counts among his friends (with the possible exception of Ann Coulter). He may be in favor of the kind of sex he wants to have with the kind of bodies he wants to have it with, but his attitudes toward women are stuck in the Dark Ages.

Of course, so are his attitudes about babies, which he says are not special because creating a baby is “something a dog could do.” First, Bill, dogs don’t make human babies. But all babies, including puppies, are adorable – they have to be so that we want to protect them. It’s a survival thing. Beyond that, we can all respect that Bill Maher doesn’t want to have children and perhaps we’re all better off for that. But Bill needs to respect the fact that other people’s children are the ones who will be paying into Social Security when he reaches retirement age. If anyone is going to make the scientific discoveries that help to resolve the problems that Bill cares about, like global warming, it will be other people’s children. Parents, and especially mothers, are providing a public good by taking care of their children’s health and development. So instead of criticizing them for making you queasy, maybe you should cheer them on.

A recent Washington Post Article describes a movement toward “freebirth,” or unassisted home birth. It says, “Some experts worry that vulnerable or gullible women will be misled into thinking that giving birth alone at home is a viable, even reasonable, alternative. These mothers, they maintain, may not understand that calling 911 — which many homebirthers cite as their emergency backup — is a poor contingency plan when every second counts.”

What really alarms people about “freebirth,” or unassisted home birth?  Is it the fact that women are shunning the hospital birth experience and choosing to give birth at home, or is it the fact that it is unassisted?

Obstetricians and the American College of Obstetricians and Gynecologists (ACOG) are against any home birth, claiming that it is unsafe. As the article states, “The college “strongly opposes” all home births on safety grounds.” But what is the evidence? In fact, the scientifically-sound evidence all suggests that homebirth, when assisted by a qualified midwife, is safe. In fact, the scientific evidence shows that homebirths assisted by midwives are safer than hospital births attended by obstetricians, and countries where more women give birth at home with midwives have lower maternal and infant mortality rates than the United States. What ACOG doesn’t want the American public to know is that maternal and infant mortality rates in the U.S. are actually going up – largely because obstetricians engage in interventions that are not evidence-based and haven’t been approved by the FDA or the scientific community. (For example, the use of Cytotec against label to induce labor is common, in spite of explicit warnings against ever giving it to a pregnant woman. There is no evidence that the drug is safe for labor induction, and yet many doctors use it anyway, often without informing women of what they are doing.) Marsden Wagner, an MD and perinatal specialist has written a brilliant expose of the obstetric community that discusses these issues, and the scientific evidence, in Born in the USA: How a broken maternity system must be fixed to put women and children first.  I’m surprised that the obstetric community doesn’t have a price on his head.

That women are choosing to give birth unassisted suggests that many women know that something is amiss with the maternity care system. They want childbirth to be an experience that honors their personhood and doesn’t turn them into patients when they are not sick. They don’t want their birth experience to be dictated by surgical specialists who are not even in the hospital when they are in labor. But the scientific evidence suggests that it is births assisted by midwives, whether they occur at home or in independent birth centers, that are the safest alternatives to hospital birth – not “freebirths.” I had both of my sons in a birth center, attended by wonderful midwives who knew what to do when complications arose, and I felt honored and empowered by the experience. Women have always needed the support of other women in childbirth and the anthropological record shows this. As a culture, we need to affirm that fact, as well as women’s needs to control birth rather than having it controlled by doctors, by educating the public about midwifery and making midwifery services a more integral part of the maternity care system.

On May 27, I gave birth to my second son.  He was born in a large bathtub at a birth center, where I had the assistance of a doula and a certified nurse midwife (CNM).  I gave birth without drugs or an epidural.  Fewer women give birth this way, or even can choose this type of birth, because birth centers have been closing – in spite of the fact that birth centers and CNMs provide quality woman-centered care that is much more cost-effective than standard obstetrical care.

You may be thinking “So what?  Natural childbirth is over-rated anyway.  Why would anyone want to go through the pain of childbirth?”  I remember hearing someone I know talking to a pregnant woman and saying that giving birth without drugs doesn’t make you a better mother.  I agree.  I have given birth twice without drugs and I am still an imperfect mother.  But the claim to superiority is not what made natural childbirth the right choice for me.  Being able to give birth to my babies without medical interventions was empowering.  I used to teach four aerobics classes in a row, but giving birth was the most strenuous physical challenge of my life.  I did it.  I have no need now to do Iron Man.  And my sons were born in a softly lit room, both of them so calm that they didn’t even cry.  You forget the pain so quickly – all you remember is the beautiful experience of bonding with your baby right from the start.  Most women who choose this type of birth describe it as a positive and empowering experience.  (In contrast, many women remember their hospital births as horrible experiences.)  And it is well known that birth centers provide safe and effective care with a much lower incidence of cesarean sections, even accounting for the fact that they only deal with low-risk pregnancies.

So why are birth centers closing?  Why has the natural childbirth movement been dying out?  With all of the talk about “choice” – the choice to have a cesarean, the choice to have an epidural, the choice to induce early to avoid stretch-marks or to accommodate the schedule of one’s doctor or relatives – why is the choice to give birth outside a hospital becoming less common and increasingly scorned?  People have largely forgotten some of the abuses of the 1950s and 1960s, which led to the natural childbirth movement in the first place.  There seems to be greater cultural acceptance of the choice to have a surgical birth than there is to have a natural one.  Perhaps the prevalence of cosmetic surgery leads people to think of surgery as no big deal.  Some of the reason that the movement is dying out is that women are reluctant to trust their own bodies or are discouraged to do so.  And mothers don’t want to do anything to jeopardize the well-being of their babies.  (Of course, the evidence suggests that natural childbirth, especially in a birth center setting with physician back-up, is as safe as hospital birth, although most people don’t know this.)

Another reason that we are losing birth centers is because they, and CNMs more generally, face rising malpractice insurance costs that make continued operation financially infeasible.  Midwifery care costs insurance companies less that hospital births, but this makes it harder for birth centers to offset the rising costs of their insurance.  Also, obstetricians are increasingly discouraged from working with CNMs by medical malpractice insurance companies, making it difficult for birth centers to find physician back-up.  Ignoring the evidence about safety and cost-effectiveness, medical malpractice insurance companies view CNMs as risky.

In January I attended a conference of the National Advocates for Pregnant Women on reproductive justice.  Many of the birth activists there attend or encourage homebirths, but only 1% of American births occur at home.  Most women are simply too frightened of what would happen if there were complications.  Birth centers offer the opportunity for a woman-centered natural birth experience, with hospital and physician back-up in the case of complications.  One of the other scholars who studies birth asked me what women who use birth centers would be likely to do if they didn’t have access to a birth center.  I replied that most of them – including me – would choose a hospital birth over a homebirth.  This is all the more reason that we need birth centers as an option for women who want natural childbirth.  The loss of birth centers is a tragedy for reproductive justice, which involves the right to choose where and how to give birth as well as the right to decide when to have children and how many to have.