Pushed: The Painful Truth about Childbirth and Modern Maternity Care

  • Jennifer Block
Da Capo Press, 2007 316 pp., hardcover, $26.00 0738210730 | ISBN: 0-738-21073-0

As an MD/PhD high-risk obstetrician, I was sure after reading just the title of this book that I was going to hate it. But I didn't. In Pushed: The Painful Truth about Childbirth and Modern Maternity Care, Jennifer Block focuses on the role of patient autonomy in the decisions surrounding antenatal care and birth. She reviews the history of midwifery and the 'medicalization' of childbirth, including the introduction of male obstetricians, the discovery of drugs that induce labor and the evolution of operative vaginal (forceps) and cesarean deliveries. The section dealing with the advantages of having a female support person (doula) present during labor is particularly insightful. The book is easy to read, well researched, and extensively, albeit somewhat selectively, referenced.

The author starts off by pointing out that many practices introduced by obstetricians (including multiple vaginal examinations during labor and induction of labor for a large baby) have since been shown to be unhelpful in improving maternal and perinatal outcome, and that some (such as episiotomy) have even been shown to be harmful. If 'excessive' medicalization of childbirth is the problem, Jennifer Block suggests returning to midwifery as the solution. But she is not proposing a system in which care is provided by certified nurse midwives in a birthing center with ready access to a hospital should the health of the mother or baby be at risk. Instead, she is proposing the use of community-based lay-midwives, whose only 'training' consists of an unofficial apprenticeship of variable length. Although I sympathize with her agenda of reinstating female autonomy and psychosocial support into the childbirth process, I find her solution alarmingly simplistic and her one-dimensional and glossy portrayal of home births arguably dangerous. The heroines of her story are a handful of lay-midwives who — despite their lack of formal training, certification and standardization of care, and despite the existence of legislation in many states banning their activity — continue to encourage and support home births of both low- and high-risk women. Their successes are celebrated in a series of carefully selected case histories that, not surprisingly, all end happily. The only exception, which could hardly have been left out given the impact it had on Virginia law, is the case of Cynthia Caillagh, whose client, Julia Peters, died in childbirth in 1997 from “excessive hemorrhage.”

What is clear from the book is that lay-midwives do offer something different from the hospital birth experience. They are more attentive and patient during labor, willing to sit alongside their clients and work with them through every contraction. They are more supportive in the postpartum period, helping with household chores to ease the mother's burden for a few days after delivery. Although these services are important, my major concern with this book is the lack of balance in the evidence provided and the selective use of case histories. For every anecdote of a good home birth experience, there is one of a bad outcome. Although every effort should be made to make the birthing experience a positive one, it should not be done at the expense of the safety of both mother and child.

One particularly memorable case reviewed in the book is that of a 48-year-old woman with seven prior cesarean deliveries who had a successful vaginal birth at home. This case and others like it, the author argues, demonstrate that home births are safe. An alternative and more likely interpretation is that women and fetuses are extremely resilient, so much so that care providers can often get away with bad management. Did this care provider put her client's life at risk? Was the mother gambling with the life of her unborn child? No, says Jennifer Block. She argues — despite extensive scientific evidence to the contrary — that home births are safer than hospital births, and that women are “in a far better position to make evidence-based decisions than their doctors.” Though the author's central tenet that women should be in control of the decisions relating to their pregnancy and labor is admirable, her assertion that “mothers never make decisions without thinking about that healthy baby” needs to be examined more closely. What about pregnant women who abuse alcohol or cocaine? The truth is that, although most women do have their infant's best interest at heart, they may not be aware of which of their decisions place their baby at risk. And nowhere is this statement more true than with home births.

Although I find myself on the opposite side of this controversial issue, I have to admire Jennifer Block's courage in writing this book. Women should not have to choose between a good birth experience and medical safety, between social support and hospital resources, or between a sense of autonomy and access to life-saving interventions. Hospital-based providers would do well to incorporate some of Ms. Block's recommendations, such as focusing more intently on supporting women during labor.

But let's not throw the baby out with the bathwater. Maternity care has come a long way since the seventeenth century, when a woman had a one in six chance of dying in childbirth. Abandoning modern maternity care will not solve the problem. Let's instead work together to identify medical and psychosocial strategies that will improve outcomes for both mother and child.