Jessica Mitford has gifted us with a witty and incisive exposé of the politics and economics of American birthways. The writing of this carefully researched book-three years in the making-took her on a quest across the American cultural landscape in search of the ironic, the mechanistic, the exploitative, and the hopeful dimensions of American birth.
Her own four birth experiences, with which she begins her book, provide a microcosmic mirror of birth's 20th-century technological transformations, as they "progress" from her tranquil home birth in Britain in 1937 to increasingly interventionist hospital births in the U.S. Her interest in today's birthing scene was sparked when the midwife-daughter of friends was prosecuted for practicing medicine without a license in California. Investigating, Mitford was surprised to discover the contemporary midwifery renaissance ("Hadn't they completely disappeared from the scene some fifty years ago?"), as well as its equally contemporary medical persecution-a situation whose historical roots she concisely traces in Chapter 2.
Chapter 3, "Fashions in Childbirth," reminds us of the horrors and abuses of decades of "twilight sleep" and the persistent pathologizing of birth by Joseph De Lee and colleagues. Then, through a series of witty anecdotes and examples, Mitford traces the advent of natural childbirth and the concomitant "fad-izing" of fathers in the delivery room, Leboyer births, and champagne dinners, all the way up to water birth, the "empathy belly" (worn by the father so he can see what it feels like to be pregnant) and in utero education of the fetus.
Chapters 4-8 give the book the muckraking bite we would expect from the author of The American Way of Death. They scan the financial abuses of our obstetric system-its differential coverage of the wealthy and the poor, its shockingly inadequate prenatal care for low-income women, its ripoffs of the insurance system, and the widening gap in infant mortality between blacks and whites. Interviews with competent health care professionals who have concrete recommendations for improvement of the system make this section much more than an exposé. And interviews with politicians who are in denial of the problems show us in part why the system is so difficult to change.
The chauvinism and money-grubbing endemic to obstetrics are scathingly revealed, as are the scientifically unjustified obsessions with the high technologies of ultrasound and EFM. A chapter on forceps leads into a chapter on Cesareans, accurately linking the decline in forceps use in the 1980s to the rise in Cesarean sections. She does not fail to cover the all-too-frequent performance of Cesareans for convenience or financial gain, or the many iatrogenic abuses that lead to Cesareans, including catch-all diagnoses like "dystocia," "fetal distress," and "failure to progress," and too-narrow medical protocols like Freidman's curve and over-reliance on EFM. Her section on malpractice appropriately highlights the medical flight from obstetrics spurred by rising insurance premiums which leaves many rural areas with no obstetric care at all. Here she drops tantalizing hints that "things are not as gloomy for doctors as they might seem at first blush"; in 1990, almost 40 percent of all claims were dropped or settled without payment; OB/GYNs won 68.6 percent of the claims that went to arbitration or a jury; and the average amount paid on obstetrician claims was $311,378-a far cry from the multi-million-dollar verdicts that we all suppose drive the increase in insurance premiums. Such revelations point up the need for more comprehensive studies of the "malpractice crisis."
Chapters 9-14 provide a generally sensitive overview of midwifery today, from the remembrances of southern grannies to the dilemmas faced by contemporary CNMs. Mitford delivers well-earned kudos to Sheila Kitzinger for the transformations of birth she has wrought in Great Britain and around the world, and to Ina May Gaskin for her innovations in midwifery techniques and the increasing use in medical and midwifery training in many countries of the information she provides. Additionally, Mitford describes the midwife-operated Childbearing Center of Morris Heights in New York's South Bronx, established to serve a poor, inner-city population and doing an extremely good job of it. A chapter on "Midwives Under the Gun" presents the painful struggles many midwives are forced to engage in with a medico-legal system that ought instead to welcome and cooperate with them in the best interest of mothers and babies. And a fascinating appendix presents a "dialogue" between WHO and the California Medical Association (constructed by Mitford from letters she received from each group) regarding a California Senate bill on direct-entry midwifery.
Part of Mitford's journalistic gift is that she entertains even as she horrifies. (Occasionally I find her wit to be misapplied, as when she makes fun of the "hyperbolic descriptions" of women outraged by their Cesareans, or the "mushy malarky" of Spiritual Midwifery.) While not much of Mitford's overview will be new to readers of this journal, for those new to birth, this book will be an invaluable consciousness-raising tool. I sincerely hope that it has come into the hands of Hillary Rodham Clinton's Task Force-it would be hard to find a clearer or more readable statement of what is wrong, as well as what is beginning to be right, in postmodern American birth.