Born in the USA

BORN IN THE USA

HOW A BROKEN MATERNITY SYSTEM MUST BE FIXED TO PUT MOTHERS AND INFANTS FIRST

MARSDEN WAGNER, MD, MS

University of California Press, one of the most distinguished university presses in the United States, enriches lives around the world by advancing scholarship in the humanities, social sciences, and natural sciences. Its activities are supported by the UC Press Foundation and by philanthropic contributions from individuals and institutions. For more information, visit
www.ucpress.edu
.

University of California Press

Berkeley and Los Angeles, California

University of California Press, Ltd.

London, England

© 2006 by The Regents of the University of California

Library of Congress Cataloging-in-Publication Data

Wagner, Marsden, 1930–.

Born in the USA : how a broken maternity system must be fixed to put mothers and infants first / Marsden Wagner.

     p.        cm.

Includes bibliographical references and index.

ISBN
-13: 978-0-520-24596-9 (cloth : alk. paper)

ISBN
-10: 0-520-24596-2 (pbk. : alk. paper)

1. Obstetrics—United States.      2. Childbirth—United States.      3. Maternal health services—United States.      4. Midwifery—United States.      I. Title.

RG
518.
U
5
W
34     2007

362.198′200973—dc22                                   2006018090

Manufactured in the United States of America

15    14    13    12    11    10    09    08    07    06

10    9    8    7    6    5    4    3    2    1

The paper used in this publication meets the minimum

requirements of
ANSI
/
NISO Z
39.48–1992 (
R
1997)

(
Permanence of Paper
).

Preface

1.   Maternity Care in Crisis: Where Are the Doctors?

2.   Tribal Obstetrics

3.   Choose and Lose: Promoting Cesarean Section and Other Invasive Interventions

4.   Forced Labor: Induction or Seduction

5.   Hunting Witches: Midwifery in America

6.   Where to Be Born: Here Come the Obstetric Police

7.   Rights and Wrongs: The “Malpractice Crisis,” Legal Protections for Pregnant Women, and Regulation by Litigation

8.   Vision of a Better Way to Be Born

9.   How to Get Where We Need to Be

Notes

Index

To remain silent and indifferent is the greatest sin of all.

ELIE WIESEL, NOBEL PRIZE WINNER

You can't change the status quo by being appropriate.

SUSAN SARANDON, ACTOR

Much of what is in this book will come as a shock to women and families in America. There are two reasons for this. The first is that accepting that our present maternity care system is as abusive as documented here is a hard pill to swallow. No society wants to believe itself capable of putting its most vulnerable members—pregnant women and babies—at such risk. The second reason is that the American obstetric profession has managed to keep a big secret from the public for fifty years.

When I was a medical student, decades ago, I was shocked when I first became aware that obstetricians don't attend women during their labor but instead rush in at the last moment to catch the baby (and the money). I talked about the situation with other students, and we all thought it was a terrible scandal, particularly since the laboring women had never been told that their doctors were not going to be there. But at the same time we were learning to be doctors ourselves, and that meant we were learning that great power is available to doctors who are willing to play by the rules—and rule number one is never talk about medical mistakes or bad practices.

Think about it: How often have you heard of a medical whistle-blower? It is a rare occurrence in medicine, and it is a rare occurrence in maternity care, where medical students, obstetricians, midwives, nurses, and everyone else in the field is under pressure to keep their mouths shut or risk losing their ability to practice. For me, however, there came a time when it was no
longer possible to stay silent. The final straw was my horror at the widespread use of a drug called Cytotec for inducing labor—a drug that is not approved by the Food and Drug Administration (FDA) for this purpose and has resulted in unnecessary complications and even death for women and their newborns. As it became clear in the 1990s that the use of Cytotec to induce labor was not going to stop and was for the most part being kept secret from the American public, I knew it was time to pick up the whistle (or pen) and start blowing.

In blowing the whistle on American maternity care, I have an important advantage in that I have a range of experiences in the field. After some years of clinical practice as a perinatologist (obstetrics and neonatology), I became interested in science and engaged in two years of full-time study as a National Institutes of Health Scholar to become a scientist specializing in perinatal epidemiology (the scientific evaluation of events surrounding childbirth). The fact that I have both clinical and scientific experience has been especially helpful in my role as whistle-blower, as there is often tension between practitioners and scientists.

In part, the tension is caused by the misconception among those outside the medical field (and among some inside the field) that the two areas are closely related—that medical doctors are also trained in science. This is not true. There is a fundamental difference between the practice of medicine and the practice of science. To generate hypotheses, scientists must believe that they don't know, whereas to have the confidence to make life-and-death decisions, practicing doctors must believe that they
do
know. Medical doctors receive little or no training in scientific methodology, either in medical school or as residents in specialty training. For this reason, it can be difficult for practicing obstetricians to understand the basis on which scientists give advice. In my experience, the tension between practitioners and scientists can be constructive, as long as mutual respect remains, and I have come to believe that no group of practitioners can do without close collaboration with scientists. However, we are not there yet in American maternity care, and many of the serious problems described in this book are directly and indirectly the result of practitioners going seriously astray because they do not have adequate direction from scientists.

Like many medical scientists who started as practitioners, I have continued some clinical practice to keep my clinical thinking realistic and up to date. I travel frequently to hospitals and clinics where I speak, work with groups of staff, and consult on individual cases.

When evaluating maternity services, I have also drawn on my years of
experience as a public health specialist—in the Department of Public Health for the state of California and on an international level with the World Health Organization. Working in health policy has shaped my perspective by forcing me to consider issues such as cost, training, manpower, and distribution of services—issues that, whether or not we like it, profoundly affect what happens to a woman receiving maternity care and her family.

More recently, I have also worked as an expert witness or consultant on a number of maternity care legal cases. This too has broadened my perspective on our maternity care system and has given me the opportunity to get to know firsthand some of the families who have been damaged by it. Some of their real-life stories have been used as examples in this book. I have also drawn on cases I have encountered in hospital consultations and on cases I have learned of through doctors, midwives, and families who have contacted me over the years. Though I feel concrete examples are critical to getting the message across, I have changed names and other details to protect the privacy of these families.

I believe that an important part of the struggle for control of maternity care described in this book is gender-specific—that there has been a paternalistic takeover of territory that rightly belongs to women and that did belong to women until relatively recently. For this reason (as well as for convenience), I've chosen to use the pronoun “he” when referring to obstetricians, though approximately 38 percent of American obstetricians are women.

Finally, though I am writing a book about childbirth, I acknowledge that I, like every other man involved in maternity care, will always be essentially an outsider on this subject, since I will never give birth. I once asked a well-known feminist and scientist, a friend of mine, if I could be a feminist. She replied, “I have bad news and good news. The bad news is, no, as a man you can never be a feminist. The good news is if there could be male feminists, you would certainly be one.”

We do not see childbirth in many obstetric units now. What we see resembles childbirth as much as artificial insemination resembles sexual intercourse.

RONALD LAING, PSYCHIATRIST

Scene: A large hospital in Oregon. (This is a real-life story, as are the other stories in this book.)

Grabbing the telephone from the maternity ward secretary, the nurse blurts out, “Doctor, I have tried and tried to find the baby's heart beat and then I got my charge nurse who tried and tried. We can't get a fetal heart tone at all. We need you. Please come quick!”

The obstetrician replies, “Right. I'm leaving home now. I'll be there in fifteen minutes, depending on traffic.” Click.

“But doctor, what should we do in the meantime?! Oh damn, he's gone.”

The nurse rushes back to the labor room, where a woman lies moaning in pain, her face pale and sweaty, classic signs of shock. The nurse throws yet another blanket on and turns up the flow of oxygen in the mask over the woman's face. Sadly, the nurse never consults another doctor, even though there is another obstetrician in the doctor's lounge just down the hall, perhaps because, in general, nurses are discouraged from consulting another doctor if it is a private patient.

The woman's obstetrician arrives twelve minutes later and quickly determines that there are indeed no fetal heart tones, and the woman is in shock. He realizes this is almost certainly a case of uterine rupture, a situation where the woman's uterus, after an especially hard contraction, blows out like a tire. Uterine rupture is a known risk of Cytotec, the drug he has
used to induce the woman's labor. Now it is his face that turns pale as he finds himself confronted with the most feared of all birth catastrophes—one that could kill the woman and the baby. “Set up for emergency C-section,” he shouts.

It takes twenty minutes to prepare the operating room for an emergency cesarean section, enlist the obstetrician in the lounge to assist, find the anesthesiologist, and get scrubbed. By the time the laboring woman's belly is finally cut open, the baby is floating free in the abdominal cavity, having escaped from the uterus through a large rip in the uterine wall.

Handing the deep blue, flaccid baby to the waiting neonatologist, the obstetrician orders, “Now let's cut out the damaged uterus.”

The assisting obstetrician objects: “But we can repair it.”

“No, it's quicker and easier to just remove it.”

“But the husband is just outside the operating room door,” replies the assisting obstetrician. “We should at least discuss it with him. Removing the uterus means they can't have another baby.”

Perhaps because he doesn't want to face the husband, the obstetrician stops all discussion by turning back to the operating table and starting the removal of the damaged uterus.