Care
Pregnancy makes me angry. I don’t mean the hormones or whatever. Learning about pregnancy and childbirth in our supposedly rich progressive country, and in one of its leading cities, has been an altogether shocking and depressing ride. While maternal mortality has dropped almost everywhere in the world over the past two decades, it’s risen in the U.S. to double the rates of other developed countries. Most deaths here divide along racial lines (in NYC, Black people are 12 times more likely to die than white). The country’s Caesarean rate has been growing since 2000, and at 34.4%, New York is particularly high. Only 8% of births in the US are attended by midwives, versus 75% in Europe, which is related to our high rate of interventions and probably why we spend twice as much per birth.
Even in unexceptional births, the experience can be grim. Studies have shown that what makes childbirth a traumatic experience is not the length or difficulty of labor but how the person giving birth felt they were cared for during it. You’re going through intense pain and you’re so vulnerable — mostly naked and deep within yourself in a noisy overwhelming space — and on top of that you’ve got to do a thing that at times you don’t believe you can. Feeling supported and taken care of during this time can be especially meaningful; I’ve had friends who said that childbirth brought them closer to their partners. Conversely, feeling neglected or steamrolled into decisions you didn’t want to make can be traumatic enough to lead to PTSD, which about 3-9% of people develop. Almost everyone is put on continuous fetal monitoring during labor, which has not been shown to improve outcomes but is linked to higher C-section rates, 43% of new moms have labor artificially induced, 76% are restricted to bed during labor, and 92% give birth lying on their backs.
To understand our expensive medicalized model of birth, it’s helpful to go back in history. Initially, the newly forming United States was welcoming to midwives and female healers, more so than Europe, which had begun the process of professionalization of male doctors. Women — many of them poor immigrants who had acquired their knowledge from passed-down wisdom combined with practical experience — worked at small family practices with their husbands or established their own. When middle/upper class physicians attempted to outlaw them in 1800, they rose up with the Popular Health Movement in the 1830s and established new “irregular” medical schools that emphasized herbalism and preventative care. This was both a class and feminist struggle, since they were the people’s doctors and focused on patient education and empowerment in contrast to the elite professionalism of the “regular” doctors. It might have been successful, but the turn of the century brought on a shift in power. Germ theory, a new science being developed and taught in Germany, gave expensively-trained male doctors a monopoly on technical knowledge. Suddenly, money poured in to back them from the newly established Rockefeller and Carnegie foundations. In 1910, a Carnegie representative was sent to survey all the country’s medical schools to decide who would receive funding. After his report was published, 6 of the 8 black medical schools and most of the irregular schools with female students were shut down.
In 1900, 95% of all babies were delivered at home, but that number had dwindled to half by 1938 and less than 1% by 1955. The 20th century saw the feminist movement coalesce around upper-class Victorian women, who focused on suffrage to the exclusion of full equality and invented the profession of nursing, which created a subservient position of care in hospitals that was non-threatening to the doctors and further deepened the divide between curing and caring in healthcare. For the first half of the century, feminist healthcare advocates de-emphasized individual empowerment and focused instead on pain medication that rendered women even more passive through labor. Professionally, women had been stripped of their power as healers, and as patients they were treated more and more as objects in a system whose professionalism barred them from participating.
Most of this history comes from the influential pamphlet Witches, Midwives, and Nurses: A History of Women Healers which was published by Barbara Ehrenreich and Deirdre English in 1972. “I might have said I was a feminist before 1970,” said Ehrenreich, who went on to become a prominent author and activist (she wrote Nickel and Dimed). “But six months of prenatal ‘care,’ capped off with a hair-raising labor (induced at 11 p.m. by a doctor who wanted to go home), cured all that. When the whole experience was over, there were two more feminists in the world — the other one being my daughter.” The pamphlet became popular in the natural childbirth movement, which for awhile looked like it would radically change maternity care in the U.S. Like the previous century’s Popular Health Movement, Ehrenreich and other activists set up workshops in NYC to educate women about reproductive health. Ina May Gaskin arose as a spokesperson for midwifery and out of hospital births. Educators and pregnant people spread information about birthing positions and non-medicated pain management techniques like Lamaze, massage, and hydrotherapy.
Birthing centers began to open across the country as an alternative to hospitals. The first urban birth center was established in downtown Manhattan in 1975 and more followed in the 80s and 90s. But something happened after that, which can be partly but not fully explained by rising insurance costs and expensive real estate. Five birth centers in NYC shut down between 2003 and 2011, including the Bellevue Birth Center, which was the only one in the city’s public hospital system and served mostly low-income clients. Today, of the 350 birth centers across the country (California has 55 and Texas has 70) only three are in New York: two in Brooklyn and one in Buffalo, none of which are midwife-led (and also none of which are covered by my insurance). The Jazz Birth Center that opened during Covid closed in the fall while we were scheduling our orientation. It’s unclear to me why New York is particularly hostile to non-hospital births. A law was passed in 2016 to allow midwives to open birth centers, but the process is so complex and onerous (the financing requirements are akin to building a new hospital) that not a single center has finished the application.
I only learned about all this because I wanted to have an easier birth. I did a little research on water births, widely practiced in Europe, and concluded that they were safe, less painful and shortened labor and recovery, only to learn that no hospital in the state offered it as an option (I’ve been told by doctors that water births are “illegal” in New York hospitals though I don’t know which law states that). As I searched the web for childbirth classes and doulas in the city, I noticed that pretty much all the organizations were involved with activism. They’ve been out there for decades petitioning against the closure of birth centers (like the Birthing Center at Mt. Sinai West, which was converted in 2018 into a NICU facility and suite of private postpartum rooms that cost $900 a night). In the last few months, most of their efforts were around a bill to change birth center requirements so that they only had to meet national accreditation, rather than all the additional stuff piled on by the state. Though the bill passed the state legislature unanimously, it sat on the desk of Governor Hochul until New Year’s Eve, when she finally signed it with so many amendments that it’s unclear if it makes the process any better. The organizations seem to be regrouping politically after this, while they continue their efforts around education and making doulas accessible to more New Yorkers.
I’m not completely satisfied with my birth plan, but I think we’ve made the best of our options. Traveling an hour and a half (not only for the birth, but weekly prenatal visits) to a birth center in New Jersey wasn’t practical and a home birth, not covered by insurance, could have cost us $10k. I’m planning to deliver with a midwife from an organization that’s among the only ones allowed to work in the hospital system and we’re paying out of pocket for a doula whom we found through the NYC Doula Collective. I’ll be showing up to the hospital armed with printouts of my birth plan and a team of midwife, doula, and well-prepared partner (our childbirth teacher had Anthony role play how to say no when doctors push for interventions). I know that no amount of research can prepare me for all the possible ways it could turn out, but I trust the people I’ll have with me and I think that’s what will matter the most.
Unlike most identities with turbulent political histories, pregnancy is one that you pick up and put down in less than a year. I won’t continue to be personally affected by the laws and cultural standards that regulate pregnancy and childbirth, but like Ehrenreich, I believe I’ll be able to say that my experience with it will change my relationship with reproductive justice. Never have I felt more strongly than in pregnancy that it should be a choice. No one should be forced to carry a pregnancy to term and no one should be prohibited from it because of costs or the fear of mistreatment or death. Maternity care is just the tip of the iceberg in the United States’ sexist, racist, and anti-queer healthcare practices. It’s stupefying to contemplate the full scope of loss and trauma across a system that could be so much better.
What I’m cooking
Lemon potatoes with tuna & herbs
I’ve been eating fish every now and then during pregnancy and threw together an exceptionally easy and delicious meal with some leftover Greek lemon potatoes and tuna the other day. You can also just make the potatoes (this technique works quite well). Or replace the fish with white beans or chickpeas, which would also work well with everything else and provide the protein to make this a complete meal.