Was it a good birth?

In my quest to get a sense for what women are exposed to in terms of contemporary literature on pregnancy, birth, and postpartum, I like to read what voices are being published and consider how those voices can shape, help, or hinder women’s knowledge/preparation/agency. So, this week I have been working through “A Good Birth: Finding the Positive and Profound in Your Childbirth Experience” by Dr. Anne Dapkin Lyerly, published in 2013. Dr. Lyerly, an obstetrician and associate professor, conducted a qualitative research study on how women talk about, experience, and framed their births. She includes reflections from other folks who work in birth, including doulas, midwives, and other obstetricians.

Truth be told, I opened the first page of the book with the bias that an obstetrician/researcher could tell me little about what a good birth looks like. I have been working in the birth world, first as a “labor and delivery” nurse, and then as a nurse-midwife, for over 18 years. I have attended births in hospitals, birth centers, and at home, and seen patients/clients in county-owned clinics, federally qualified health centers, boutique-like birth centers, corporate healthcare settings, and in private practice. My experience has been that obstetric policy both nationwide and locally frequently does a disservice to pregnant folks and babies. (I have seen obstetricians attend births in kind, respectful, and evidence based ways, but sadly it wasn’t the norm.) Unnecessary interventions are commonplace, medical rituals are often harmful and not indicated, and the general attitude is still dominated by patronizing discourse about women’s choices, bodies, and agency.

Lyerly calls out conventional obstetric practice in the United States for its short comings in a frank, brief, and unemotional way. The first step IS acknowledgement. Yet she does not outline the degree to which that care can and does traumatize families physically and emotionally. And that is one of the biggest short comings of this book. To get to a “good birth,” women often have to struggle through and process a really shitty birth experience. In my practice, if I am meeting someone for the first time, I ask them “what has your women’s health or pregnancy/birth experience been like up until this point?” Some women start with “my birth was OK I guess” or “my birth was fine.” With continued listening and time, I often hear common themes of being told to hold still, get in bed, or change positions to accommodate hospital staff. I hear “I really wish they would have had a birth tub for me to labor in” or “it seems like a thousand different people came into my room” and “I felt bullied into doing things that I didn’t want to.” “I had an episiotomy and my OB didn’t really tell me why or ask me if it was OK before cutting.” “My baby went to the NICU because I had a fever during labor. I heard that can happen with an epidural. She didn’t act sick, but they took her anyway. It made breastfeeding impossible and resulted in a $12,000 bill for her care. All of her tests were negative for infection.” My response is usually, “that sounds really hard,” and most women start to cry. “I guess my birth wasn’t great, it kind of sucked.”

By Lyerly admitting that mainstream obstetric culture has goofed, without really owning how it has harmed generations of women, and continues to do so, the book falls short in my eyes. Bad outcomes or disparities in care are real and barely addressed by this author. She seems to have no skin in the game when she admits that obstetric training encourages physicians to disregard what women want.

My next beef is about the language Lyerly chooses when outlining differences in philosophy and practice between midwifery and obstetrics. She uses words such as “tussle,” “birth wars,” “squabbles,” and “professional agendas” that encourage “mama guilt.” “According to the so-called midwifery view, it is not just medicine’s approach to birth, but its use of and reliance on technology that is at the root of modern women’s dissatisfaction.” It makes her feelings about midwifery very clear, that the decades long call by midwives to mainstream obstetric practice to change is not legitimate. Makes midwives sound like disruptive whiners. It doesn’t acknowledge that use of and reliance on technology in birth has not resulted in better outcomes for most women. And she is not listening to women’s voices who feel that “safety” and the forced employment of technology were used to coerce them. Women in my practice frequently draw a direct line between previous dissatisfaction and the indiscriminate use of interventions/technology in birth.

Lyerly also indicates that “efforts to improve maternity care have been stymied by divergent views [between midwifery and obstetrics] about the nature of quality and the goals of care.” I would correct her and state that efforts to improve care have been impeded by obstetrics’ death grip on the birthing environment, hospital policies, avoidance of responsibility that interventions have led to worsening outcomes, and the persistent oppression of midwives in hospital. The efforts to improve care have resulted in continuous monitoring for all, IV access for all, birthing in lithotomy position to measure/catch bleeding for all, decreased availability of water birth “for the sake of research and safety,” and prohibition of VBAC and vaginal breech birth. Those are all efforts that obstetrics said would improve care, make us safer, improve outcomes. But they haven’t.

And then there is the language…

Describing birthing women as the “star of the show” or “queen for the day” lends more to a Disney princess vibe than real women, doing hard work, and being well supported. “Her birth was good, she told me, because she felt like she was ‘in a spa.’” Yes, those are women’s words and voices, but no, I don’t think that is where obstetric culture needs to go. What was more interesting still were the words and voices she decided to print. I began taking a tally. Many more stories about how women found their cesarean sections to be more pleasant, where they were “more present.” Only a smattering of stories about women who had low tech and high touch births, that were empowering and intimate. I wonder how all of the women with accretas or placenta previas due to repeat cesareans would describe their pregnancies and births? Maybe in less of a Disney way? Less like a day at the spa?

Big breath. Do I believe that a good birth can involve intervention and technology? Yes. Do I know that seemingly noninterventive births can be traumatizing or unsafe? Yes. What I believe and know is that this book is not about mainstream obstetrics taking a knee and owning the broken parts of our birth culture. Nor is it about improving birth so that women are safer and better cared for. How women weave their stories about what a good birth may look like is truly complex, and individual. But the way the Lyerly patches women’s stories together, along with quotes from “notoriously popular” obstetrician friends, further encourages women with often times needlessly difficult births, to make lemonade from lemons, rather than take aim at conventional obstetrics. Told by someone who is firmly rooted in a power structure that she has no intention of stepping out of, this is a Disney tale that obstetric America has been playing on repeat, in hopes that we will stop dreaming of a better birth.

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