They’re fed up with the unwanted C-sections, the endless tests, the dubious interventions, and the scary advice from overworked, malpractice-spooked doctors. And Boston women are shunning the area’s world-class hospitals to go to surprising…
By Tina Cassidy
Lugging hungry preschoolers and makeshift dinners of animal crackers and granola bars, five frazzled mothers gather in a fluorescent-lit conference room on the second floor of the Falls Boulevard Roche Bros. in Quincy. It’s getting dark outside, and the parking lot lights cast an eerie glow over the mums and dried cornstalks set out for sale in front of the supermarket. For the next two hours, these women will vent, seethe, commiserate, and plot. Unwittingly, they have found themselves on the front lines of a new battle over reproductive rights.
Caroline Kelley, a slight, 34-year-old brunette, listens to a round of harrowing childbirth experiences-unwanted cesareans, failed vacuum extractions, forced Pitocin drips-and nods as she cuts deep into the flesh of a small ripe tomato. When it’s her turn, she recounts her own unexpected, gruesome cesareans; during the first one, she says, the anesthesia didn’t take, and she could feel the scalpel slicing through her belly.
None of the moms at this monthly meeting of the International Cesarean Awareness Network’s local chapter are shocked by her story-the group was founded to support women who have had unwanted C-sections, which for all their newfound Hollywood glamour are major abdominal surgeries that can lead to infection, numbness, and painful months of recovery. “When I joined three years ago, it was 200 people. Now it’s over 1,000,” Kelley says. “And we’re angry.”
They’re not the only ones-all across the area, mothers are expressing outrage over the shift toward highly medicalized births. During a 90-minute Next Step Baby Group at Isis Maternity in Arlington, women compare notes on false-positive tests, feeble breastfeeding support, and incorrect (and therefore needlessly scary) predictions from doctors about dangerously large babies. Similar grievances are voiced in prenatal appointments held in the basement of a Cape Cod-style house in Needham, where local midwife Nancy Wainer, herself a victim of an unwanted C-section, meets with anxious women hoping to avoid hospital births altogether. At still another event, held in a Mount Auburn Hospital auditorium, pregnant women looking for an alternative to standard obstetric care pepper a team of midwives with questions.
The statistics back up their concerns: In October the advocacy group Childbirth Connection released an unprecedented national study that reported healthcare workers are pushing pregnant women to have procedures they may not want or need. Twenty-five percent of the mothers who’d had a cesarean felt unduly steered to do so, and nearly 20 percent of those who’d been induced said they felt pressure from a doctor to jump-start their labor. A whopping 73 percent reported they’d had no say in their episiotomy, a procedure in which the opening of the birth canal is widened by a scalpel. More than half the women who had wanted a vaginal birth after a previous cesarean said a doctor or a hospital denied them that option.
Now Boston women-among the best-educated and oldest first-time mothers in the country-are fighting back. They’re sick of sitting by helplessly as doctors decide what’s “best” for them and their babies, as well as enduring the scant one-on-one attention at the city’s big three hospitals-Beth Israel Deaconess, Brigham and Women’s, and Mass General-where more than 17,000 infants are born each year. A quiet storm of discontent has brewed into a mommy uprising that has lots of pregnant women seeking alternative, often high-risk approaches to childbirth. They’re hiring hands-on midwives, and passing on the hospital to give birth at home.
“Are we at the beginning of another pendulum swing?” asks Maryann Long, director of the Midwives at Mount Auburn. “That’s exactly what I’m wondering. Women want more choices, and more control.” Long’s growing practice would seem to answer her question: In 2005, her midwifery group performed 456 births. This year it’s on track to surpass that number, without any marketing beyond a website and a few T-shirts.
When Jennie Gryczka was pregnant with her first child, Nathaniel, she was diagnosed with placenta previa, a condition in which the placenta lies over the cervix, effectively blocking the baby’s exit. It eventually moved out of the way, as often happens, but not before she had gone through four ultrasounds and been urged to undergo a Down syndrome test. “It was a very fear-oriented practice,” Gryczka says. “All along I felt very uncomfortable, but they’re the doctors, so you start questioning yourself.”
The 36-year-old declined the latter test-and got “attitude” from her doctors in the process-and eventually decamped for Mount Auburn, a hospital known for supporting natural birth. But when the Waltham mom-to-be arrived in labor, a nurse immediately told her she should be strapped to an electronic fetal monitor. These decades-old machines were invented to detect potentially troublesome drops in a baby’s heart rate, but because they frequently give false readings, the monitors also increase the chance of having a C-section. (In the Childbirth Connection study, 94 percent of the mothers surveyed said fetal monitoring had been used on them.)
Gryczka wanted more control the second time around. She hired local midwife Miriam Khalsa and planned for an at-home birth. Several months later, her 9-pound daughter, Isabelle, was born. “It was so comfortable,” Gryczka says. “We went for walks. I ate when I wanted to. There were no interruptions. I had the baby on my own bed and she spent the night right there with me. When I had my son in the hospital, they took him away.”
Most M.D.s are vehemently opposed to home births, yet large studies have repeatedly found them just as safe as hospital deliveries. And unlike in the hospital, where mothers in labor are generally refused all food save ice chips, at home births, midwives cook mothers eggs and toast, involve the entire family, and use their own ears and eyes, rather than a fetal monitor, to check the baby’s progress. Khalsa, a past president of the 22-year-old Massachusetts Midwife Alliance (MMA), says that while she hasn’t seen an increase in first-time mothers seeking the services of her affiliates, the number of second-time mothers calling the MMA has jumped by 40 percent in the past five years. Clearly, it’s the women who’ve been stuck with IVs and rushed through a hospital birth-often with a stop in a surgical suite-who are now opting for a back-to-basics, more personal approach. “When I met Miriam,” says Gryczka, “she would ask me questions about nutrition and lifestyle, not ‘Have you had this test? What about that test?’”
Of course, not every home birth is as easy as Gryczka’s; many are fraught with complications and require serious medical assistance. Some women seeking a compromise between a home birth and the standard hospital route are turning to birth centers as a middle ground. Staffed by midwives and nurses, facilities like the Cambridge Birth Center and the North Shore Birth Center in Beverly came of age in the early ’70s as a safe compromise between organic home birth and stultifying in-patient routine. They don’t offer epidurals or other interventions, but do provide amenities like queen-size beds, kitchens, and hot tubs. (The required newborn-resuscitation equipment is tucked neatly out of sight.)
But with malpractice fears leading many birth centers to adopt more-
stringent policies, women who don’t want restrictions-just sound judgment-hanging over their labor have no choice but to push forward with a home delivery. Such was the calculus Susan Martinson-Zuercher, a midwife at the Cambridge Birth Center, confronted when she had her son, Miles. She decided to try to deliver him in her Arlington Heights apartment. But Miles was big (8 pounds, 12 ounces) and facing the wrong way, with his head cocked in the pelvis. After several exhausting days of labor, she ended up at Newton-Wellesley Hospital, where she had once worked. Another 15 hours of labor later, she underwent a painful cesarean. Hospital staffs will generally let a mother push for only so long; if a fetal monitor registers distress, doctors intervene and call for an emergency cesarean, and that’s that. These rules, Martinson-Zuercher says, “are dictating what’s possible.”
Dr. Benjamin Sachs stands before a dry-erase board on Beth Israel’s delivery floor. The bespectacled chairman of the hospital’s obstetrics and gynecology department is monitoring 27 women in various stages of labor, and the list is sobering: There are birth defects, sepsis, preeclampsia, and 13 premature labors. There’s a diplomat’s wife with cancer, a type 1 diabetic, a woman recovering from cardiac shock, and a case of triplets. Four women are being induced, three of them past their due dates. Placenta previa is forcing another to have a cesarean. Only two women are having normal labors, and both are doing it with epidurals. (In Boston hospitals, the rate of epidural use is around 80 percent, slightly above the national average. Hailed as the greatest pain-relief method ever invented, epidurals are associated with an increased chance of a baby’s getting stuck the wrong way in the birth canal-which in turn heightens the likelihood of a cesarean.)
I ask Sachs if those last two women belong at the hospital at all.
In his soft British accent, he answers with some questions of his own. “How do you offer support to a low-risk woman who is seeking natural childbirth, but wants to deliver in a very safe environment?” he says. “Should they be here? It constantly challenges us.” Ironically, the cases to which Sachs alludes often aren’t medically challenging at all-yet many of these women are subjected to interventions such as IVs, inductions, and C-sections. In 1960, only 3 percent of birthing women had cesareans; since then, the figure has skyrocketed to 30 percent. Though Sachs insists there’s little difference, risk-wise, between a C-section and a natural birth, in fact there is: A September 2006 study of 6 million elective cesarean births found that an infant’s chance of dying was twice as high as with a vaginal birth. So why are so many women still receiving cesareans?
“This is where it gets interesting,” Sachs says. “What’s an appropriate
C-section? Has the mother been adequately counseled, and is it her right to make the decision?” In other words, how risky is too risky? Who makes that call-and exactly whose risk are we talking about? Since they have charitable immunity granted by the state, Massachusetts hospitals are exempt from malpractice suits, so it’s individual doctors-who pay $60,000 to $150,000 out of pocket for malpractice insurance each year-who get served with lawsuits. In 2005, a jury found two Mass General OBs negligent in the 1996 case of a girl born with cerebral palsy. The family was awarded nearly $24 million, one of the largest malpractice verdicts in state history. Eager to avoid similar suits, many local doctors may be opting for the easy way out. “I think there are physicians worried about the medico-legal environment who may be encouraging the cesarean route,” Sachs says. As for women adamant about not wanting medical interference: “I suspect they are just going elsewhere.”
“She’s pushing! She’s pushing!” screamed Nancy Wainer as she barreled down the halls of Brigham and Women’s, propelling 35-year-old Jessica Pisano in a wheelchair. Pisano’s husband, Paul Sackley, emerged from the back of Wainer’s SUV and raced after them. The couple’s baby was just an inch from being born, and the hospital staff was ready with a vacuum extractor. They injected Pisano with an epidural, delivered her son, then quickly whisked him away. He was convulsing with seizures.
Two days earlier, Pisano and Sackley had been preparing to give birth on a futon in the spare bedroom of their house in Sharon. They’d already been through one cesarean, the result of a faulty reading from a fetal monitor. For their second baby, they hired Wainer, a certified professional home-birth midwife who specializes in vaginal births after cesareans, or VBACs.
“We don’t do anything simply because it’s the norm,” says Pisano, who composts, cosleeps, and breastfed her oldest son until he was three. Nor did she and her husband make the decision lightly-the couple thought long and hard about having an at-home VBAC, known in industry-speak as an HBAC. But on March 5, after a day of labor and nearly seven hours of excruciatingly painful pushing, and despite Wainer’s careful monitoring of the baby’s heartbeat, all three knew it was time to enlist obstetricians. Brigham and Women’s was 30 minutes away.
“The NICU nurses were incredibly critical of my home birth,” Pisano says. It’s still unclear exactly why little Anton, now recovered, had seized, but in any case Pisano maintains she’ll never second-guess her original decision. Plenty of others would-VBACs are one of the most controversial areas of modern childbirth. In the past five years, an increasing number of studies, including a December 2004 New England Journal of Medicine report, have shown that a woman’s risk of a ruptured uterus during a VBAC is about three-quarters of one percent, or seven out of every 1,000 cases. If that happens, there’s a 5 percent chance the fetus will suffer oxygen deprivation or death. The risk of the mother dying is even lower. Not particularly shocking data-but it’s plenty worrying to obstetricians, who expect to eventually contend with a complication. And therefore, a lawsuit.
Indeed, five months before the Journal report, the American College of Obstetricians and Gynecologists (AGOC) had issued new guidelines advising hospitals to offer VBACs only if they were “equipped to respond to emergencies with physicians immediately available.” Hospitals had already been moving away from VBACs; however, in light of the one-two punch of the ACOG and Journal papers, many facilities stopped offering the procedure because they didn’t have-or didn’t want-the burden of additional staff or liability.
As more and more doctors refused to perform VBACs, women got increasingly angry. Locally, the breaking point came in May 2004, when 35 people-mostly mothers with their children-responded to the Southcoast Hospital Group’s new VBAC ban by protesting outside one of its member hospitals, St. Luke’s in New Bedford. Similar pickets were occurring at other VBAC-banning hospitals around the country, garnering headlines from Maryland to California. In Santa Cruz, a 2003 rally outside the Sutter Maternity and Surgery Center compelled the hospital to continue to offer VBACs. But other bans have held strong. The national VBAC rate, which peaked at 28 percent in the late ’90s, has dropped to about 10 percent, and the prohibition is actually far more extensive than the numbers let on: Obstetricians are discouraging women from attempting vaginal birth after they’ve had a C-section, not only out of lawsuit fears, but also because a second cesarean is often easier and more efficient for most hospitals to perform.
Late one night this June, 40-year-old Barbara Resendes gave birth to her third child in the master bedroom of her Marlborough ranch house. Despite two previous cesareans, the only safety net she had was a shower curtain to protect the mattress.
Four years ago at Brigham and Women’s, Resendes had experienced the now typical modern delivery: Slow labor. Pitocin. Epidural. The staff broke her water, and she began to push; two hours later, they wheeled her into an operating room. For her second baby, in the hopes of feeling less like a number, Resendes chose Winchester Hospital. She was pushing through contractions when, according to the fetal heart monitor, the baby’s heart rate plummeted. Her doctor called for a cesarean, despite Resendes’s pleas for a natural birth. “He then basically threatened me,” she remembers, “and said, ‘If you don’t have a C, you’re going to sign this form that says you won’t sue me if something happens to the baby.’” She had the surgery.
For her third pregnancy, Resendes wasn’t taking any chances. Or, put another way, like more and more outraged women she was willing to take a big chance in order to do things her way. “My doctor wouldn’t even consider letting me have a VBAC,” she says. So though her health insurance would have covered another hospital delivery, she ditched her OB/GYN and paid $5,000 out of pocket for a midwife. “With the third pregnancy, I told my husband, ‘I am not going to the hospital,’” Resendes says. “I said, ‘I’m tired of all the intervention and I can’t have a normal birth unless I’m at home.’ He wasn’t thrilled, but he also wanted me to be happy. And he didn’t want to see me cut open again.”
Dr. Laura Riley, the director of labor and delivery at Mass General, doesn’t want women to have needless operations, either. Of the roughly 3,500 babies born at her hospital every year, 30 percent enter the world by cesarean. “C-sections really stretch our resources,” she says, adding that those patients must remain hospitalized for four days, twice as long as a woman with an uncomplicated vaginal birth. “We are chronically short on beds.”
In her office, Riley sits in front of a neat stack of documents. Ready to be distributed to the hospital’s maternity staff, the flow charts spell out alternatives to induced and cesarean births. They alone, however, won’t solve the problem. There are still those notorious fetal monitors: “If there’s an embarrassment in medicine, this is it,” Riley says. “It’s so ingrained now, and no one has the guts to pull back.”
And more than just medical practices, Riley suggests, cultural attitudes need adjusting, too. “Everyone’s expectations are so high,” she says. “Women believe they deserve a perfect baby, and they should get a perfect baby. The vast majority will have a beautiful delivery. But not all of them.”
Tina Cassidy, a former staff reporter and editor at the Boston Globe, is the author of Birth: The Surprising History of How We Are Born (Atlantic Monthly Press, $24). She has given birth once, by cesarean, to her son, George.
Originally published in Philadelphia magazine, February 2007
Tags: Arlington Heights, Beth Israel, Beverly, birth, Boston, c-sections, cesarean, Dr. Benjamin Sachs, General OBs, hospital, international cesarean awareness network, interventions, Jessica Pisano, Massachusetts, Miles, Miriam, Nancy, Paul Sackley, roche bros, Sharon, Susan Martinson-, tina cassidy