Wednesday, November 12, 2008

Book Review: Pushed

When I happened to see Pushed: The Painful Truth about Childbirth and Modern Maternity Care on a featured shelf at the library, I admit that my first thought was something like, "what, again? Haven't we been there already? What could Pushed possibly have to say that hasn't already been said in books like Birth, Misconceptions, Giving Birth, etc. etc. etc.?"

The answer is: quite a bit, as a matter of fact. I'm glad I decided to take the book home and give it a chance. I won't go so far as to say that this is a book about childbirth that men could actually get into (does any such book exist?), but it's probably about as close as you're going to get. In large part, that's because Pushed, unlike any of those other books, does not appear to have been motivated by the author's own negative birth experience. In fact, the author, Jennifer Block, mostly keeps her feelings to herself and lets statistics, and to a lesser degree, anecdotes and interviews, tell the story for her. It's not until the final chapter, a treatise on mother/fetus rights (or sometimes mother vs. fetus rights) that we really get the full force of her personal opinion on some of the major issues affecting women's choices in childbirth.

This book holds particular interest for me at this time for a few reasons. First, as you know, I recently gave birth to my second child and had a birth experience as different from my first one as day is from night. So the choices and procedures involved in maternity care are still very fresh in my mind. Second, I have a sister-in-law who is pregnant right now and who (as far as I know) is hoping for a VBAC (Vaginal Birth After Cesarean). And wow, does this book ever have lots to say about that issue.

Out of respect for my sister-in-law, I'll keep my analysis of what Pushed has to say about VBAC very general.

I knew VBAC was "controversial" in the sense that not every woman was interested in trying it, or that not all physicians were willing to take on such cases. But I had no idea that it is probably the most divisive issue confronting the obstetric community (and, thus, pregnant women) at this time. Perhaps this is because the concept of VBAC touches just about every nerve possible: was the first cesarean necessary or not? If not, was it elective? If necessary, has that assessment changed in either direction in hindsight? Are the circumstances that led to the cesarean likely to present themselves in a future birth? Most of all, VBAC starts a firestorm when you start comparing the risks of a VBAC versus a second (or third, or fourth) C-section. Essentially, and I am leaving out chapters and chapters of analysis and commentary, Block makes a very convincing case for the side that contends that VBAC is at best safer than, and at worse, as safe as, a second C-section. In doing so, she goes against the current position of the American College of Obstetricians and Gynocologists, which is that VBAC is not a recommended course of action. However, that has not always been the case. For several years during the 1990s, VBAC was sanctioned by ACOG.

You can see how navigating the arguments on both sides of the medical community spectrum is like walking through a minefield. Unfortunately, it is pregnant women who are caught in the crossfire. I didn't realize this until I read it in this book, but it is by no means guaranteed that a woman who wishes to try a VBAC will be allowed to do so. Depending on where she lives, she will face opposition from hospitals, doctors, and insurance companies. The book describes women who have been denied a trial of labor so desperate for a VBAC that they labor clandestinely in the parking lot of the hospital and go inside only when it's "too late" for a C-section. However, apparently it's almost never too late, since one woman who tried that was told she could start pushing as soon as she took in some oxygen. Except that the mask they gave her wasn't supplying oxygen, it was general anesthesia, and she woke up having given birth by C-section, without her consent.

This, of course, brings up the issue of reproductive rights. When that term is mentioned, most people think of abortion, but birth is a reproductive right, too. One interviewee in the book describes maternity care as the last great frontier of feminism, and one that has not yet been taken on in full force. Somehow, the debate keeps getting re-directed to abortion, and meanwhile, women everywhere are being denied choice in the manner in which they birth their babies. The stark incongruity in the way these two closely related issues are addressed is shocking.

Lesser issues than VBAC are also addressed in the book, such as why the C-section rate in general is so high (almost one-third of births these days) and getting higher, and why birth has become so rife with interventions.

That latter issue is one I took particular interest in, having given birth so recently. According to the author's research, only 2% of mothers have had an "optimal" birth experience. Obviously, some women have risk factors or other complications that will keep them from being able to avoid some interventions. But Block cites lots of research that calls into question the increasingly entrenched methods of intervention such as routine IVs, continuous blood pressure readings, electronic fetal monitoring, epidurals, Pitocin, forceps, episiotomies, and flat-on-your-back pushing.

The 2% statistic is slightly misleading, of course, because honestly, some women don't care if they're hooked up to an IV, or receive an epidural, or are induced, or are confined to a bed during labor. "Optimal" should of course be defined by each individual woman. Who is Ms. Block, or Ricki Lake, or anyone to tell a woman that she shouldn't be satisfied with what she thought was an OK birth experience?

The good news is, Ms. Block seems to realize that. And that's what separates Pushed from other books in this genre. The anger and indignation just aren't there. Or they are, but they just sort of simmer below the surface, manifesting themselves largely in anecdotal interviews or statistics, instead of being in your face, demanding that you feel disenfranchised.

That being said, the book's thesis, as indicated by one of its closing paragraphs, is (p. 271):

"What's best for women is best for babies. And what's best for women and babies is minimally invasive births that are physically, emotionally, and socially supported. This is not the experience that most women have. In the age of evidence-based medicine, women need to know that standard American maternity care is not primarily driven by their health and well-being or by the health and well-being of their babies. Care is constrained and determined by liability and financial concerns, by a provider's licensing regulations and malpractice insurer. The evidence often has nothing to do with it.

"Today women have unprecedented access to the information they need to make the best decisions for themselves - and therefore the best decisions for their babies. They are in fact in a far better position to make evidence-based decisions than their doctors. They have a right to make those decisions, and they should make those decisions."

I completely agree. However, I would add the caveat that if a woman, having accessed the pertinent information, makes the decision to be induced or send her baby to the nursery or not breastfeed or, heaven forbid, elect for a C-section, then they're allowed to create their own "optimal."

As long as they allow me the same and let me have my ginger ale and Gladiator music.


Liz Johnson said...

So do you think this is "unbiased enough" that I could get a certain spouse of mine to read this without throwing it out the window after the first paragraph?

I'm convinced. This will be the next book I check out of the library.

Liz Johnson said...

Also... does she touch on home birth at all?

Bridget said...

Liz, I think your husband could handle this book. There's not really much you can disagree with because it reads like a statistical analysis report. It's only the last chapter (or maybe two) that get a little bit dicey, but then again, he's in law school so he might enjoy that part the most.

It does talk about home birth - again, not in a touchy-feely way but in terms of statistics. It also goes into breech and twin births (I didn't realize twin births were so often "forced" C-sections - Mikael, you should be SO proud of yourself!).

However, if he's going to read it, he had better be able to stomach copious use of the word "vaginal."

Teresa said...

My sister-in-law had a C-Section with her first daughter, but had her second vaginally. She is pregnant right now and planning on another vaginal birth. She never had any problems bringing this about. Idaho must be a great state! Also, Jared is a twin and his mom had them both regular style, but she didn't know they were twins until after Jared came out and the doctor said "wait, one more!"
Would this book be interesting to me?

Teresa said...

PS- Although I mentioned that Idaho is a great state, the library here in Shelley didn't even have the book Constance. Do you remember that book? I have been wanting to read it so bad lately. Therefore I doubt they would have this book you mention... and I can't check out books from the library in IF since I have no proof of residence there. Shucks.

Jeanerbee said...

I think I want to read this! That's interesting about the VBAC issue... I have a friend out here who is having a home birth specifically because she could not find an OB to work with her for her vbac. It's just interesting that a hospital with all their safety equipment would refuse, and yet a couple of midwives and this girl are confident she can do it safely at home.

I recently had a home birth (4 days ago!) and had an awesome experience... and had another good friend comment to me about how our ideal birth experiences are polar opposites (she gets induced/epidurals and has had 2 great birth experiences) and it got me thinking about the very issue you've brought up... that we all have our own idea of optimal, and should have the right and support and services available to be able to have our babies the way we each want! It is a life changing rite of passage, not just some procedure to go through and I think deserves lots of thought and ultimately choice on the mom's part... and I like the idea you mentioned from the book that it is an are of feminism that has been forgotten and NEGLECTED in my opinion! I could go on and on...

mle said...

I think I might have to read this book, and get my good friend, who is also a OBGYN to read it too. I am sure she would get a kick out of it. Bottom line for me, since I have had three very different birthing experiences, is I dont care what you have to do to me, just make sure my baby is okay. Baby always comes first in my book. Oh wait, I dont have a book-gonna have to work on that. Cant wait to see you:)

Crys said...

So my mother had me vaginally, four c-sections, and then fourteen years after her first vaginal birth had my brother vaginally. When I tell OBs that, including my own midwives they about fall out of their chairs. Of course her uterus promptly fell out after that and had to be removed. I guess after being pregnant ten times, delivering six kids, and having four c-sections the thing just gave up the ghost. Still though quite a feat :) Here is the problem with all of these books as far as I can see, they ignore the cost to physicians on the times that things do go wrong. In our house we read a lot of policy and law books and here is what you learn about reproductive rights. It pretty much doesn't matter what the doctor tells you are the risk, if something goes wrong in your birthing experience they are responsible. Even though lets face it things do go wrong. I think we are lucky to live in a time when things going wrong for us are usually just having to have an emergency c-section versus losing our babies or losing our selves. A physician can explain the risk of a VBAC, he can tell you the percentages are low of a burst uterus, but if a uterus does burst and has to be removed guess who gets left holding the bill. It might be a small chance but it is a costly one as far as their insurance companies are concerned.

Sharalea said...

(Shara here. Sis-in-law of Jen Rose Jackson. Also fellow FLSR-er)

I am really interested in this book, thanks for the review! (I always love your thorough book reviews!) I read several of the birthing books you have reviewed in the past, plus several others to prepare me for the 'natural birth experience' that I wanted for my first baby. I hired the only doula in a 30 mile radius, I asked all of the 'natural birth' questions that put all the OBs on high alert, and I had a very specific birth plan that I handed out to everyone.

At about 22 hours after my water broke (and about 8 hours after a nurse mentioned the word 'epidural' which was totally contrary to my requests in my birth plan and totally shattered my concentration, leading to my final request FOR an epidural) I was only at a '5' and the drs. decided a c-section was the best option as 'preventative care' in fear of an infection (the whole 24-hrs-after-water-breaks scenario).

Exhausted & emotional, my husband and I were pursuaded (by fear) into doing the C-section. (I don't know if it would have mattered if we resisted, they were set on it). So my darling son was born via c-section & I didn't get to hold him for 5 hours later.

Obviously this was far less than ideal for me and my husband. We had both prepped ourselves for a 'natural birth' experience and were excited about what that meant for us.

During my hospital stay I talked to several of the OB's about the situation & about future births.

One OB said "oh, honey, you should NEVER put your birth plan in WRITING...that's when it all goes out the window!"

Another said "you won't find an OB that will do a VBAC, it's too dangerous"

And the one that bugged me the most "Do you know what uterine rupture MEANS? Are you really willing to put yourself and your future baby in danger?"

Yes, actually, I DO know what uterine rupture means (My Mom's uterus broke during labor w/my youngest brother=very dangerous, we almost lost both of them & my brother was left with some damage that caused his cerebral palsy) and I also know that VBACs are done all over the country very successfully!

I realized that if I have our next child here (Western Kentucky) then I will not be able to find an OB who will do a VBAC. Also, midwives are 'illegal' here (unless they are working at the OB office) so if you have one it has to be all hush-hush.

I have a friend who has a midwife & she can't even tell me her NAME.


Katie, Scotty and Cora said...

Thanks for this review, Bridget. I'll have to get this book and see if I can convince my stubborn husband to read it! :) It's amazing how shocked people are when they find out that my OB is letting me have a VBAC when my C-section was only 14 months ago. Not only are VBACs uncommon, but they are especially frowned upon if it's been less than 18 months since the C-section. My midwife (who works with the doctor practice I go to) told me no way, but when I asked the OB who actually performed the C-section last time, she said yes! She was very up front with me and honest about the stats. She told me that I was completely healed and had a 2% chance of my uterus rupturing, compared to a 70% chance of a completely normal delivery if I did VBAC! How sad that for a small 2% chance, they won't let most women have VBACs.

After reading these other comments, I realize how lucky I am to have a doctor who is willing to do this. In fact, the midwife wants her there when I deliver as a back-up, just in case another doctor comes in and won't let me do a VBAC when he finds that it's been less than 18 months. (It's sad that the midwife has to be "scared" of other doctors. Because she's in a doctor's practice, I feel like she really has no choice but to play by their rules and doesn't have much authority to make these decisions herself.)

So, with only a week left until my due date, I'm hoping for that natural birth that I so wanted with Cora! So far, things are looking good! Of course, I really want the birth experience that you had, but Scott wouldn't even consider letting me give birth anywhere but at a hospital...especially after what happened last time. I probably wouldn't be a candidate anyway.

Thanks for the book review. I'll have to check this book out.

Bridget said...

Teresa, there are other books you should read before this one. Milk before meat, because this one is meaty - full of statistics.

Shara, your story makes me sad. I think anyone in your situation would have done the same thing - like MLE said, we all just want our babies to be OK. I'm not necessarily sad that you had to have a C-section, but sad that YOU feel sad. Do you see the difference? I'm glad everything turned out OK, regardless, though I suppose you could have done without the fear-mongering.

If I'm not mistaken, Katie went into labor just a few hours after making that comment. What good timing! Since it was her husband who sent out the email I have no idea of the details but I think he would have said if it was a cesarean. So it sounds like Katie now has personal experience with a successful VBAC. I hope I'm not jumping to conclusions...

Kristen said...

Great review. Makes me wish I had more time to read, but I'm grateful I have you to give me the Cliff Notes, if you will. :)

I just want to say that I believe my husband would love a book like this. He read 'Birthing from Within' while we were expecting. After reading a lot about birth choices and intervention statistics, he was thrilled that I wanted to give birth naturally, at home, and was very supportive throughout the process. Of course many husbands would be as supportive, but maybe not as many would want to read all about it. Having a shared knowledge on the subject gives a couple much to discuss.

JackJen said...

Yeah, so it's over a year after you've posted, but I finally finished _Pushed_ and wanted to read your review.

Side note: Did you know Jennifer Block (at the time of publishing) had not given birth?

Upon learning we were home birthing, my OB/Gyn promptly informed me that I was no longer with his practice, that I could not call upon him were I do need a hospital transfer, and that he could no longer legally treat me because I was no longer his patient. (His decision, not mine).

What's SAD, is that I FIRMLY believe that he was compelled by the terms of his malpractice insurance to inform me of this change, rather than because of his personal feelings on home birth.

If I need a hospital transfer, I'm no longer able to call upon the doctor who had provided me with months of prenatal care, who knows my health history, and who also knows my birth plan.

And that, Bridget, is a problem.

I recommend _Pushed_ all the time, because (like you said) it's not a screaming, angry book with nothing to back it up. (Did you read the appendices?)


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