About the Author
Jennifer Margulis, PhD, is an award-winning journalist and Fulbright grantee. Her work has been published in The New York Times; The Washington Post; O, The Oprah Magazine; Parents; Parenting; Brain, Child; Mothering Magazine; More Magazine and on the cover of Smithsonian. A Boston native, she lives in Ashland, Oregon with her husband and four children.
Excerpt. © Reprinted by permission. All rights reserved.
The Business of Baby Introduction
Twenty-nine years old and pregnant for the first time, Marijana Picton noticed her nausea only went away when she took long walks and ate stapci, Serbian-style salty pretzel sticks. It was 2009. Marijana and her husband, Richard, had been living in England but they moved back to Šipovo, the small town in Bosnia and Herzegovina where Marijana grew up, when she was seven months along. Šipovo’s bars were filled with unemployed men and two of the town’s four factories had not fully reopened for business—tangible signs of the war that once tore the former Yugoslavia apart.
After taking a birthing class in England, Marijana and Richard had a long list of questions for the staff at the Mrkonjić Grad clinic where they would have their baby: Would her husband be allowed to stay with her? Most husbands in Serbia don’t, they were told, but the staff could make an exception. What kind of pain medication would they provide? None, the doctor answered, unless you need a C-section. What about epidurals? “If you want it, you have to buy it yourself,” the doctor responded. “Most people get them from Italy. And then you have to find the anesthesiologist to give you the injection.”
Marijana’s water broke that November on her birthday. She called the clinic to tell them she and Richard were coming so they could turn on the heat in the labor room.
Two years earlier in Oaklyn, New Jersey, twenty-eight-year-old Melissa Farah, a special education teacher at Avon Elementary School, was pregnant for the first time. Melissa and her husband, Dan, were planners: They had been married for almost two years and had begun trying to start a family on their first wedding anniversary. Melissa felt especially lucky because a close girlfriend, Valerie Scythes, was pregnant too. Both women planned to have their babies at the same hospital in Woodbury, New Jersey.
Here’s the question: Which young woman would be better off, the one in a small Balkan country still recovering from a brutal civil war, or the mom in the richest and most powerful country in the world with state-of-the-art medical equipment and know-how?
The answer: Marijana.
According to the most recent reports, the likelihood of a mom like Melissa dying due to pregnancy or childbirth in the United States is more than four times higher than in Bosnia and Herzegovina and seven times higher than in Italy or Ireland; the likelihood of her dying as a result of childbirth is five times greater than in Germany and Spain, and fifteen times greater than in Greece.
The United States also lags behind most industrialized countries when it comes to the health and well-being of infants. Eight American children per 1,000 live births will not live to age five.
Fact: A child in the United States is more than twice as likely as a child in Finland, Iceland, Sweden, or Singapore to die before her fifth birthday.
We feel great sadness and shock when we hear about a baby dying: Avery Cornett of Lebanon, Missouri, who was ten days old when he died on December 18, 2011, of a bacterial infection thought to be contracted from contaminated infant formula; a two-week-old unnamed baby boy who died in September 2011 from complications due to an out-of-hospital circumcision; six-week-old Ian Larsen Gromowski, who died of a severe reaction to the birth dose of the hepatitis B shot on August 10, 2007. We stop in horror, our hearts in our throats for the grieving parents. But we consider these deaths isolated incidents, rare occurrences that garner our sympathy, sure, but that certainly won’t happen to us.
Fact: The United States has one of the highest infant death rates of the industrialized world. It is safer to be born in forty-eight countries than in the United States.
Fact: Of the some 4.3 million babies born in America each year, more than 25,000 will die in their first year.
Fact: The maternal mortality rate in the United States is among the highest in the industrialized world.
After taking that birthing class in England, Marijana had been scared of giving birth and was sure she wanted an epidural. But the clinic in Mrkonjić Grad was the only hospital she and Richard could find in Bosnia and Herzegovina where Richard would be allowed to stay with her. So Marijana ended up having no pain medication and no fetal monitoring during labor. When she was fully dilated and climbed onto the ratty operating table, her contractions slowed. The doctor and midwife heaved her upright and told her to walk around the room some more. Her son was born vaginally about three hours after her water broke. The doctor joked you couldn’t find another baby like him in all of Bosnia. Richard is half English and half Nepali and the baby, whom they named Stanley, looked to Marijana “like a little Chinaman.”
Twenty-eight years old and in good health when she went into the hospital, Melissa Farah gave birth to a healthy baby girl via C-section in April 2007. But the birth did not go as expected: Melissa was transferred to another hospital due to complications from the operation. Doctors were not able to stabilize her and Melissa bled to death the next day. She is not alone: More than seven hundred American women die in childbirth every year, though most of these deaths go unnoted. The vast majority of maternal deaths in the United States are never investigated in any true sense: In 2007 only slightly more than half the deaths related to pregnancy or childbirth were autopsied, and there’s evidence that autopsy rates in hospitals are declining; a review of the death is almost always conducted behind closed doors by a committee comprised only of hospital staff, and the information garnered is not released either to the family or to the public; journalists and other outside investigators are often hindered from accessing information because (they are told) of patient privacy concerns. When there is obvious wrongdoing, hospital lawyers work tirelessly to cover it up, negotiating financial settlements that include gag orders so the details of what happened cannot legally be made public. Only twenty-four states require hospitals to report adverse maternal outcomes to the state government. And only a handful of these states—including Ohio, New York, and California—require that this information be available to the public. But even when the reporting is mandatory and the numbers are submitted to the state (noncompliance is an issue), most states have no system in place to investigate maternal deaths. A 2010 investigation revealed that twenty-nine states and the District of Columbia have “no maternal mortality review process at all.” Melissa’s case became national news because it was the second death at Underwood-Memorial Hospital in Woodbury, New Jersey, in two weeks. Her good friend Valerie Scythes died two weeks earlier after having a planned C-section. Her husband told the BBC that doctors scheduled the operation because Valerie was thirty-five and had had ovarian cysts in college.
How is it possible that a country as wealthy and medically advanced as the United States has a higher maternal mortality rate than a much less affluent country like Bosnia and Herzegovina? Are the high maternal and infant death rates in America really isolated events, or are they mounting evidence that something in our country is going terribly wrong?
Many obstetricians in America throw up their hands and say that our high rates of maternal and infant deaths are either the patient’s fault or “an act of God.” They argue that our increasing infant mortality rates are due to the rising use of fertility drugs and a greater number of older women having first babies, both of which lead to an increase in twins and premature births. They also point out that more American women are overweight or obese when they get pregnant, making labor more dangerous. While maternal age, obesity, and multiple births can contribute to higher maternal mortality, these factors are only a small piece of the puzzle. If we look at the best evidence, and if we compare American practices to countries where moms and babies enjoy safer outcomes, we find that the science tells a different story.
This book is about how what happened to Melissa points to a larger problem with the way we are treating women and their babies in the United States. “Obstetrics is an ugly business and it’s our most primitive medicine,” says Stefan Topolski, M.D., assistant professor of Family and Community Medicine at the University of Massachusetts in Worcester. “We say it in meetings in our department all the time. It’s the least evidence-based discipline.” As this book will show you, time and time again corporate profits and private interests trump what is best for moms and babies. The science is consistently ignored, and practices proven to be harmful are continued. Doctors—even though most have the best possible intentions—often unwittingly go along with a broken and sometimes dangerous system.
Few American parents could imagine deciding what car to buy just based on the ads they see during the Super Bowl or on the first package the car dealer offers. Instead, we do our homework, talk to friends about options, research safety history and gas mileage on the Internet, and read Consumer Reports. Ultimately we choose the car that’s best for our family after carefully weighing (and usually declining) all the little things the salesman tries to slip in.
But most of us are much more naïve when it comes to parenthood. While it is acceptable to haggle over cars, it’s almost unthinkable in the United States to go against what is considered routine when it comes to pregnancy, childbirth, and raising an infant. We defer to the person we believe is the expert, wearing a white coat with a stethoscope around her neck. We are conditioned to trust doctors, to accept that what they tell us is true, and to believe that they only have our best interests in mind.
Like most American children in the 1970s and 1980s, my brothers and I grew up eating Froot Loops, Apple Jacks, and Count Chocula for breakfast. Zach and I sprinted home from school every day to watch ABC After School specials and sing along to Jell-O commercials while our teenage brothers blared Janis Joplin upstairs. We attended public school and received the recommended vaccinations on the recommended schedule.
My parents may have been unusual in that they both had Ph.D.s (my mother was a microbiologist, my father a chemist), but our family was conventional. My parents basically did what everybody else did, fed their children what everybody else fed theirs, and conformed to the values and standards around them. I never thought to question American culture. I always assumed that Wisk could solve ring around the collar, that doctors knew better than I what would keep me healthy, and that government officials always had my best interests in mind.
But during my first pregnancy, when I was twenty-nine years old, I found myself sobbing in the car in the parking lot after every prenatal visit. I felt I was being bullied rather than cared for. My husband, who accompanied me on these prenatal visits, would let me cry in his arms and try to hide his worry from me. We were both graduate students and we felt we couldn’t change providers because the one we were using was the only practice in Atlanta, Georgia, that our insurance company would pay for. We knew we would not choose to abort, so my husband and I tried to forgo some routine prenatal testing. We weren’t trying to be difficult or rebellious—we were just seeking to avoid unnecessary stress. But our health providers did their best to scare us into compliance. One hospital midwife in Atlanta told me I would “buy” myself a C-section if I refused the test she insisted on.
We switched from the hospital midwives to the doctors because, ironically, they seemed less rigid. But toward the end of my pregnancy a doctor ordered an “emergency” ultrasound because she believed I was measuring small. She turned to go to her next client before I could talk to her about it, muttering that she suspected “intrauterine growth retardation.” We sat in the waiting room, flooded with anxiety. The scan showed the baby was fine. It wasn’t until years later when I started researching and writing about pregnancy that I learned that ultrasound scans have not been shown to be any more effective in predicting intrauterine growth restriction (doctors these days try to avoid using the word retardation) than palpation of the pregnant woman’s abdomen by an experienced clinician. The same summer my daughter was born, Marsden Wagner, an obstetrician and scientist, and former director of Women’s and Children’s Health at the World Health Organization, wrote: “There is no justification for clinicians using routine ultrasound during pregnancy for the management of IUGR.”
Mine was a low-risk pregnancy. I was young, strong, and healthy. When six months of nausea finally abated it was like someone washed the windows. I exercised daily, zooming past other cyclists on the bike path on Atlanta’s East Side. I had been heavy when I first got pregnant, so I only gained a total of twenty pounds. I should have had a straightforward labor and delivery. But my husband and I knew very little about birth; we did not have a great relationship with our health care providers; and we did not have the support we needed in the delivery room. After hours of being left alone while in active painful labor, I was accosted by a brusque nurse who burst through the door, put on a glove, ordered me on my back, and stuck her fingers roughly in my vagina to assess the dilation of my cervix. “Nothing! Not even a dimple,” she scolded before rushing out again.
When I vomited during labor and my husband started panicking, nobody reassured us that vomiting was a good sign, an indication that my hormones were kicking into gear and that my body was cleaning itself out to make room for the baby. Instead, the staff acted disgusted that they had to clean it up. I have a family history of low blood sugar, and as the contractions continued hour after hour I felt myself getting weaker. I begged for something healthy to eat. The nurses refused. The doctor on call when our daughter was born was a floater in the practice, the only man, and the only one we had never met before. Knowing I didn’t want an epidural or Pitocin (a synthetic hormone that stimulates the uterus to contract), he chastised me for selfishly putting my family through “so much waiting,” and told me, while I was having an intense contraction, that I should stop thinking only about myself. I ended up giving birth on my back with Pitocin and an epidural, needing stitches for a badly torn perineum, and having side effects from the anesthesia (one of my legs went numb) that lasted for months.
After our baby was born the nurse bustled into the room with a tray. “Time for the hep B vaccine!” she announced. I knew enough to know that hepatitis B is a sexually transmitted disease; I felt totally protective of the skinny frog-legged baby whose life was my responsibility. We told the nurse we wanted more information. Instead of explaining the rationale behind vaccinating an hours-old baby for a sexually transmitted disease my husband and I had both tested negative for, the nurse slit her eyes in anger.
Two weeks later a pediatrician applauded our decision and told us that a fax on her desk warned that hepatitis B should not be given to newborns. I would find out ten years after that what happened: Since vaccines are tested individually and not in com...
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