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Pushed: The Painful Truth About Childbirth and Modern Maternity Care

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Exactly 3 years ago I walked into one of the finest maternity hospitals in NJ to deliver my first baby. I was low risk - under 30, no complications - and was expected to have a smooth delivery.

11 hours later I was laying in a bed by myself staring at a ceiling, completely shell shocked, and without my baby, husband or family, I was immobilized in a recovery room with a gaping wound in my belly while my new daughter was off in the nursery. I had no idea what went wrong. It seemed that I had simply stopped dilating or "failed to progress."

As I read Jennifer Block's book, I just nodded as it all became very clear - the insistence by the staff that we would just hurry things up a little by performing an amniotomy (breaking my water) when I was still in early labor. That was followed by pitocin (to "really" get things moving), stadol (a narcotic pain reliever), an epidural and finally, a c-section. My labor was simply one of many completely over-managed and over controlled labors in American hospitals. They finally decided that a c-section was the only way to end my labor. I was lead to believe my labor was a "problem" and a "complication" and surgery was the only answer.

I wish this book could become mandatory reading for all women who are planning a hospital delivery. Contrary to recent reports (as discussed in this book), very few women are actually requesting a c-section on a completely voluntary basis. Years ago I was "pushed" by the obstetrical community into an unwanted delivery experience.

Today I am pregnant with my second child. And I am pushing back.

This engaging journalistic expose was a real eye-opener, and a must-read not just for women, but for anyone considering becoming a parent, or really anyone concerned with the direction health care in the U.S. is headed. The cesarean rate in our country is over 30%, nearly three times that of some European countries. Are our bodies really that different? Somehow, I doubt it. Ms. Block explores the troubling trends that push doctors to perform often uncalled-for major abdominal surgery, and shows how this is harmful both to mothers and babies. With stylish, riveting prose, an exciting first-hand account of traveling "underground" with an illegal midwife, and tales from the operating table, Block skillfully takes stock of the current state of birth in America. Not to be missed.

Not only was this an amazing book packed full of easy-to-understand statistics and little-known information on what hospital birth is like in the US, but it is an absolute page-turner with plenty of gripping real-life stories from all types of people (physicians, nurses, midwives, mothers, lawyers, activists, etc.) with experience in this system.

I used to have a vague idea, before this book, of some of the interventions I would absolutely not allow if I were to give birth in a hospital, but since reading this book and doing some additional research (via other books and internet) my eyes have really been opened. I could never watch TLC's "A Baby Story" the same way again!

I think this book is a must-read for any woman contemplating childbirth. It is such a shame that SO FEW women know that there are options OUTSIDE of the hospital, and that they don't have to be forced by physicians to submit to procedures and interventions (e.g., episiotomies, continuous fetal monitors, cesareans) to which they DO NOT consent.

Read this book (and others) to prepare yourself.

Block's central thesis is this:

"What's best for women is best for babies. And what's best for women and babies is minimally invasive births that are physically, emotionally, and socially supported. This is not the experience that most women have. In the age of evidence-based medicine, women need to know that standard American maternity care is not primarily driven by their health and well-being or by the health and well-being of their babies. Care is constrained and determined by liability and financial concerns, by a provider's licensing regulations and malpractice insurer. The evidence often has nothing to do with it."

Block paints a depressingly grim picture of modern maternity care in which only a handful of women experience physiological childbirth. The rest give birth plugged into machines. Drugs and hormones course through their veins; scalpels and scissors cut them open, often after coercion and frequently despite the woman's expressed refusal. Almost everyone she interviews admits there's a problem, but no one seems to be able to change the system. Those who buck the system altogether--home birth midwives and unassisted birthers, for example--face legal harassment, imprisonment, fines, or loss of custody of their children. Block's book points out several captivating ironies that, if they weren't so depressing, would be laughable:

1) ACOG recently decided to support elective "maternal request" cesareans--surgery for no medical reason--as ethically justifiable (even though the medical evidence shows that cesarean sections for no medical indication lead to higher morbidity and mortality for mothers and babies, rising sharply with each successive surgery) yet refuses to allow women to choose out-of-hospital birth, direct-entry midwives, or, in many hospitals, VBACs (even though the medical evidence clearly shows that these choices are safe & reasonable).

2) Although physicians and midwives tout the importance of evidence-based medicine, less than 2% of American women received "optimal maternity care" that consists of these six basic aspects, all of which are well supported by the best evidence-based medicine:
1. Labor begins spontaneously
2. Women have freedom of movement during labor.
3. Interventions are medically justified rather than routine.
4. Women have continuous emotional and physical support.
5. Pushing occurs in any position but flat-on-back.
6. Mother and baby are not separated.
In other words, 98% of women received sub-optimal care.

Surprisingly, this book gave me a greater sympathy towards obstetricians (well, some of them at least). Many of the physicians Block interviewed held great respect for the natural, physiological birth process; bemoaned the current state of malpractice litigation, VBAC bans, and the dogma of automatic surgery for breeches; and secretly supported home birth midwives--often facing censure from their peers for their views.

Pushed shows a maternity care system that has gone malignant. Instead of being a tool to aid women when pathology arises, it is now our master. Obstetricians, nurses, midwives, birthing women and unborn babies are all slaves to the machines and the technologies that they have created. Birth, for most women, is managed by drugs, hormones, and clocks, rather than being a chaotic but gloriously intricate and rewarding physiological process. In this system, no one wins. Instead of being bathed in a complex "cocktail of love hormones," as Dr. Michel Odent puts it, women are on morphine drips in post-operative wards. Their babies are intubated, suctioned, and injected. Mothers are separated from babies, vaginas are separated from birth, and birth is separated from labor.

I want to share a final excerpt from the book, which illustrates so exquisitely why a "natural birth" is so difficult to attain in a typical hospital setting. The vast majority of American births involve myriad kinds of medical devices, all of which tether the woman to an obstetric bed and deprive her of the ability to move freely during labor: IV, automatic blood pressure cuff, pulse oximeter, electronic fetal monitor, epidural catheter, urinary catheter, intrauterine pressure catheter, and circulation stockings. The latest device, just approved by the FDA, consists of two electrodes inserted inside the vagina that automatically measure cervical dilation. Judith Lothian (PhD, board member of Lamaze International, and professor of nursing at Seton Hall University) explains: "If we put women in hospitals with restrictive policies--they're hooked up to everything, they're expected to be in bed--of course they're going to go for the epidural, because they're unable to work through their pain." British midwife Tricia Anderson writes:

"Let us bring them into harsh rooms with bright lights. Let us make them lie on their backs on hard narrow beds. Let us tether them to machines so they cannot move. Let us make them stay silent and make no noise with their pain. Let us expose their most private parts and threaten them with cold steel. Let us make them push their babies upwards, against the pull of the earth...In these conditions, labour swiftly becomes unbearable and pain relief becomes a woman's only hope....This is not the natural cry of a woman in labour bringing a child to birth, although if you have only ever witnessed childbirth in a medicalized setting you might be forgiven for thinking so. This is the screaming plea of a tethered animal in pain."

I'm a mother of a toddler and expecting my second baby at Christmastime. I was blessed with a beautiful (for a hospital) birth with my son and hope that I'll have the same experience with this baby -- but I know from experience that I may have to push for it. I may have to argue with the nurse who wants me to lie on my back or kick out the annoying resident who wants to break my water.

Why do women who want a natural, hands-off birth (without induction, without epidurals, without C-sections) sometimes have to fight for one in a hospital setting?

"Pushed" is a very well-researched, readable look at how we got to this point. Block talks to mothers, midwives, doulas and doctors and, I think, really presents all sides of this issue.

I particularly appreciated her interviews with doctors who were sympathetic to moms who want VBACs or vaginal breech deliveries but unable to offer them because of insurance liability reasons. (If I were a doctor, I wouldn't want to risk losing my home or my kids' college fund so that someone else could have a VBAC, honestly.) This is an issue that I think gets the short shrift in many books and articles on modern birth -- it's not that doctors are necessarily trying to manage birth so that they can get to the tee times or make a few extra bucks from a C-section. Many of them want to help mothers have their ideal births but just can't take the risk, from a legal standpoint.

I do wish that Block had presented more solutions -- ideas for solving the current problem weren't really addressed -- and had also taken more of a look at why the insurance industry seems so reluctant to cover doulas, midwives and birth centers, when they usually result in a substantial savings. (My first birth was in a hospital, and my second will be as well, because we don't have the almost $4,000 to pay out of pocket for the local birth center.) She does mention that some moms have hospital births because they can't afford the out-of-pocket expenses of a homebirth or birth center birth, so it seems like it would have been a small jump to investigate why that is.

Now, here's my one complaint: In the final chapter, "Rights," Block took a very obvious pro-abortion-rights stance that I thought was out of place in the book and could likely offend a good number of her readers. (Many of the "crunchy" moms I know are pro-life.) Not to get into an abortion debate here, but I don't know why we can't assert that a fetus (particularly a full term one) has rights, as well as a mother -- especially in light of the argument that Block presents that VBACs, vaginal breech births, etc. AREN'T dangerous to the baby; it doesn't seem like an either-or argument to me. At any rate, the "fetal rights" cases that Block addresses feel crammed in and not at all relevant to the rest of the book, from my perspective. Not to mention, ending the book discussing abortion, after spending the entire thing talking about what's best for mothers and best for babies, was extremely jarring.

Overall, though, this was a great read and definitely a must for any pregnant woman or anyone at all who's interested in why American women are giving birth the way they are right now.

As a labor and delivery room nurse I applaud the writer of this book for getting this valuable information out there! I want to hand the book out to every pregnant woman, every obstetrician, and every labor and delivery room nurse. We have to stop the nonsense. I love what I do, but hate the technology that has taken the natural process of childbirth away from women. Women have to stop fearing the most incredible experience you can have and those in the medical fields have got to stop fostering the belief that if it can go wrong it will. This book is wonderful! Jennifer you rock! =)

I knew our current obstetric system in America to be flawed, but I didn't realize how flawed it truly is until I read this book. Block presents her arguments clearly, with plenty of statistics and footnotes to back up her claims, and the information she provides on the limited choices women have when birthing a child is frankly astounding. I think everyone (including men, and women who don't plan to have children) should read this book so that they can pass along the knowledge to other women who are pregnant who may not know what they might face during birth. If you're pregnant and have been told you must be induced, or schedule a c-section, or are not a candidate for a VBAC; if you had a c-section that was for CPD or failure to progress; if you've been told your baby is getting too big or your amniotic fluid too low, et cetera, I encourage you to read Pushed. I think there needs to be a revolution in maternity care and childbirth and the only way that revolution can begin is with pregnant women demanding that they be treated better. Block shows that a majority of cesareans aren't necessarily safer for either mother or baby, while remaining objective and non-judgmental. Thank you to the author for revealing important truths about modern obstetric care.

First, as far as the safety of Homebirths, you can find your own data supporting home birth safety over hospital. There is tons out there and the studies that they keep doing, keep repeating themselves all saying it's safe. The infant and mother mortality and morbidity rate is less than or equal to hospitals. Yes you need to me with a skilled midwife, just as you would a skilled OBGYN. Mother's often walk away with babies in better condition and more breastfeeding success and less postpartum and neonatal issues.

Second, as far as "back when, women died in childbirth when babies were born at home" Is a load of crap. Women died for reason such as infection, poor health, and preexisting high risk conditions, all of which only happen very rarely in homebirths due to midwives focus on nutrition and exercise, sanitizing medical equipment (they didn't believe in germs or bacteria back then) and they refer high risk patients to OBGYNs where they belong. When births were moved TO the hospital back in the day, away from home births, COMPLICATIONS, MORTALITY AND MORBIDITY RATES WENT UP NOT DOWN!!!!


Third, Heb B vaccine is not necessary AT BIRTH unless you feel your baby is going to be sharing dirty needles or having unprotected sex. Later in life, do what you want, it's your choice. Antibiotic cream is only necessary if you or your partner have an STD. If not, then don't worry about it. Denying either of these medications does not increase the amount of pertussis cases. That is a ridiculous connection. And in case you were wondering, Pertussis is still around today (50% of the kids who get it as FULLY vaccinated with all routine vaccines, not just DTaP) and your best bet is for you and your partner and any other person with close constant contact with baby to get the vaccine and of course as always, wash your hands a lot.

Fourth, prosecution for bad home birth outcomes? Seriously, the emergencies that arise in a home birth are the same as that of a hospital birth. (Most are also screened out in pregnancy like breech, low lying placenta or placenta previa.) As far as other life threatening outcomes, they happen hospitals too, and most women are directly upon noticed wheeled to the OR, it takes a little while for "set up". This same "set up" can be done when the midwife calls the OR that she is associated with and tells them she is on the way. Also, most of these cases are bleeding due to the placenta detaching and drugs are given, just like in hospitals to stop bleeding. If caregivers were prosecuted every time a mother or baby has an injury or death in childbirth, malpractice premiums would be MUCH higher than they are today and everyone would be out of business. And what about prosecuting DRs who give the only option for Csec due to "fetal macrosomia" (baby over 4500gm) and the woman has a 7-8 lb baby but major surgery, delayed or eliminated breastfeeding, a scar and the high costs that follow? What about that, let's start there.......

Lastly, this is evidence based, if you want to see MORE evidence and studies and facts, I encourage you to do so. The Thinking Woman's Guide to Having a Baby is another great book with facts, studies, and number, and not as much mumbo jumbo over so called "hippie talk". Get your facts and YOU decide what you want to do, don't have the decision made for you.

I have read many books regarding this issue and I appreciated the chapters which addressed the effect of the liability crisis on the practice of obstetrics on Long Island, NY. This system is ruining obstetrics and profoundly affecting the paradigm of obstetric care. Obstetricians are now caught in a no-win situation regarding technology and expectations. I disagree with the authors assertion that lawsuits settled out of court are done so due to their merit; it is more like it would cost $300,000 to defend in court, so in some cases is cheaper to settle and not worth defending.
The issue of overmedicalization of birth is difficult to resolve when midwives are uninsurable, the cost of delivery is greater than the reimbursement; and the system is designed to profit the insurance companies and the legal profession. Who do you think is making the laws?

I am the least crunchy person on the planet, but this book (among other things) convinced me to do what I could to go natural.

PROS:
1) The book accurately describes the infantilization of women in the OB office. I had a hard time believing this was accurate when I was reading the book, but meeting with the doctors was totally humiliating and horrible. MANY if not most treat you like a) an idiot with no reasoning facilities, b) a vessel for your baby and c) an obstacle. Be prepared. The book will prepare you to expect this and give you information necessary to be strong.

2) The book is fairly well-researched, and gives lots of facts, statistics, and best- and worst-case scenarios.

3) The book is relatively fair in terms of presenting some situations in which home birth turns gruesome.

4) The history section really gives you a sense for how things got this way. The author presents the information in a way that grounds the present in the past, which makes it pretty convincing. It doesn't sound all "I'm a hippie and doctors are the male establishment!" hysterical, it simply shows how at certain times in history it was in the best interest of different parties to change the birthing process in a way that led to how things are done now.

What I most liked about this was how it pointed up the dearth of actual scientific analysis backing up the current hospital MO.

CONS:
1) The writing style is a little sensationalistic and heavily anecdotal. This personalizes the information, but at the same time undermines the starkness of the data. Which is not to say the facts aren't there, but the anecdotes take up more room, so it's easy to lose data in the anecdotes. A more skeptical reader may be put off by the pages of emotional stories and thus not really SEE the facts also there.

2) I agree that the stuff at the end about abortion is extraneous. On the good side, I think it was useful to point out the failure of the women's movement to embrace mothers' and babies' rights, but on the down side, it might offend some friends of mom and baby rights. I'm totally pro-choice myself, but I didn't think it necessary to the main point of the book.

3) What could have replaced some of the anecdotes and pro-choice stuff? I would have prefered to see more suggestions for how to handle the facts on the ground. Most moms cannot afford to pay out of pocket, so I'd have liked to see suggestions of how to have a hospital birth and work around the system. All hospital births come with the posibility of being delivered by someone not amenable to your way of thinking (as the book states). So then what? How do you avoid getting on the clock? How do you talk to your doctor at your last OB appointment when they start talking about induction? How can you encourage your baby to come sooner so that induction is less likely? Etc.

For various reasons, I did not know until my third month that I was pg. I read this book right away, but when I finished, I was at my fourth month, and no other OB would take me, though I had DEFINITELY figured out that the OB I initially chose was a bad choice. So I had to manage the doctor. And it ended up having a happy ending, but with a lot more sturm und drang on the way than there needed to be. I figured out how to avoid making apointments and checkups by walking out without talking to the apointment desk, by rescheduling appointments at the last minute, by not answering the phone. Seriously. And just FYI, check around for the home remedy induction methods, e.g., oils, teas, etc. It really helped me to ripen so that, though genetically predisposed to long labors, my whole process lasted 3.5 hours. Much easier to have uninvasive delivery when it goes fast.

I figured out my own ways of avoiding intervention, but I would have really liked some information from the author on avoiding intervention when you have an invasive doctor.

End of the story though: this is a book that needed to be written, and is basically a necessity for any woman considering pg. Take the anecdotes for what they are, but make sure you read the facts and figures carefully, and pay particular attention to the history section. It will make you stronger.