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An excerpt from Nathanael Johnson's book, 'All Natural'

There is, in fact, a vigorous debate over medical intervention in birth, and not just between the fringe and the medical establishment, but within the establishment. No one is suggesting that we revert to the practices of the 1900s, but many clinicians and scientists are warning that the medicalization of birth has gone too far. When I took a closer look at the data, I found one seemingly impossible statistic after another. Progress in reducing the infant mortality rate had advanced through the 20th century, but had stalled in the 21st century. This plateau, "has generated concern among researchers and policy makers," according to a 2008 brief from the National Center for Health Statistics. "The U.S. infant mortality rate is higher than those in most other developed countries," wrote the statisticians, "and the gap between the U.S. infant mortality rate and the rates for the countries with the lowest infant mortality [Japan, Sweden, Spain, and others] appears to be widening." In addition, the numbers of preterm and low birth-weight infants had actually risen (a part of this increase was due to a higher number of twins and multiples, perhaps from the rise of fertility treatments, but the increase remained when researchers only looked at singleton births).

When it came to the health of mothers, the trends were even more troubling. A paper published in the Journal of Obstetrics and Gynecology noted a marked increase in severe injuries to women during birth: kidney failure, pulmonary embolisms, respiratory failure that required patients to be put on a breathing machine, and more. This increase had occurred between 1998 and 2005, including a 92 percent rise in the percentage of women who needed blood transfusions. Mothers hadn't become less healthy in that period. The study had adjusted for the effects of hypertension, diabetes, age, and multiple births, but weeding out these problems hadn't made much of a difference. What did make a difference was controlling for the mode of delivery: "For many of these complications," the authors wrote, "these increases were associated with the increasing rate of cesarean delivery." Most disturbing of all, national vital statistics showed that the maternal mortality rate was climbing. This, in particular, seemed too bizarre to be true, and most researchers initially chalked it up to "statistical noise" – the result, they said, of several states adding a checkbox to death certificates to note if a woman had been pregnant a year prior to her demise. But then the state of California made an inquiry that adjusted for these changes and revealed that there was still a consistent upward trend in maternal deaths. "After several decades of declining rates of maternal mortality in California, rates began to rise in 1999 and proceeded to double in the next seven years," the researchers reported. Part of this rise was due to the fact that mothers had become older, sicker, poorer, and more obese – but not all of it.

The total number of women dying was still minuscule compared to the turn of the century: Maternal mortality had gone from 6 deaths per 100,000 births in 1999, to 14 per 100,000 births in 2006. But more troubling than the total number of deaths was the implication that the best efforts of obstetrical medicine to improve health had perhaps done just the opposite. When the California researchers, speaking at a conference, got to the slide showing a graph of this increase, there were gasps from the audience of obstetricians.

These numbers hit home when I did the math and found that it had been safer to give birth in 1978 (when I was born), than it would be for Beth to deliver in 2011, if the upward trend continued. The popularization of supposedly safe and reliable techniques like the Caesarean were meant to improve outcomes. In just the last decade, the Caesarean rate had increased from 22 percent to 32 percent, which amounted to half a million additional surgeries each year – an extraordinary investment of money and medical resources. And yet, when I asked experts what that investment had bought us, they said that there had been no corresponding improvement in the health of mothers or babies. The conventional wisdom has held that, while C-sections may hurt mothers, they reduce the number of babies who might develop cerebral palsy or die due to lack of oxygen. But cerebral palsy rates, like infant mortality rates, have been flat.

"If you look at the statistics, we don't see much improvement in the last ten years," said Debra Bingham, the executive director of the California Maternal Quality Care Collaborative, a partner in the state's ongoing inquiry on maternal deaths. "What we do see is more women dying, and more women suffering birth-related injuries than we have in decades."

I met with Bingham in her office on the Stanford University campus. She had worked for years as a nurse, and then as an administrator of a labor and delivery unit in New York City, before earning her doctorate in public health. Her short, neatly coiffed white hair framed an unlined face that radiated grandmotherly warmth. When I asked why our efforts weren't improving health, she cleared her throat delicately. Administrators and clinicians were allowing their faith in progress to guide them toward presumptively beneficial technology, Bingham said. What they were not doing – for the most part – was allowing the numbers to change their minds when the evidence suggested the technology didn't help. For example, she said, "Clinicians adopted electronic fetal monitoring with the hope that it would improve outcomes. Even after it became known that continuous fetal monitoring does not improve outcomes clinicians continue to use the technology."

Bingham herself had been an early advocate of fetal heart monitors. The rationale for these machines made sense: Watch babies closely enough and you should catch a certain number whose hearts are slowing because they are desperately low on oxygen. She became an expert interpreter of fetal heart rhythms and spent much of her career teaching these skills to nurses. But when the actual data from randomized controlled trials came out, the comparisons among thousands of births showed that the babies who had received continuous heart monitoring were no more likely to survive (nor have less risk for cerebral palsy) than those who had not. The birth industry in the United States basically ignored this evidence, continuing to buy machines for hospitals and routinely using them in every labor (while other countries heeded the science). Years later, after looking at the evidence anew, Bingham began to suspect that in most cases these machines had done more harm than good: They tethered women down (a problem because the inability to move freely can make labor more uncomfortable), they provided fodder for frivolous lawsuits, and they prompted unwarranted surgeries with frequent false alarms of fetal distress.

Despite the lack of evidence to support them, some traditions in obstetrics perpetuate obstinately, Bingham said. She first began to question these traditions in 1981 after she herself gave birth in the hospital where she worked as a maternity nurse. Another nurse had taken her son away to the nursery shortly after he was born, as was routine. Bingham had done the same thing hundreds of times herself, but this time it felt unmistakably wrong. For months she'd been waiting eagerly to see and hold her newborn baby and, lying there without him, she felt a suffocating loneliness. She still gets emotional thinking about it. She waited anxiously, wondering if her son was crying, trying to hold the contours of his face in her memory until, after two hours, she'd had enough. She walked into the nursery and, despite the entreaties of her coworkers, refused to go back to her room until they agreed that she could take her son with her.

Reprinted from "All Natural" by Nathanael Johnson. Copyright (c) 2013 by Nathanael Johnson. By permission of Rodale Inc. Available wherever books are sold. 


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