Books: May-June 2003

Who's having the baby? In the early Sixties when it came time for childbirth, the doctor was in charge, and the mother was simply present. Delivery was medically controlled, efficient, and "safe." As a student nurse during that time at "Mr. Duke's" hospital, Peggy Vincent cared for women who wanted to have their babies "their way," rather than the way medical rules dictated. Vincent listened to these women. In her view, mothers should have carte blanche to behave the way their bodies dictated during childbirth. Her career of rule-breaking-on-behalf-of-her-patients had begun.

In Baby Catcher, Vincent traces her personal journey to midwifery. After Duke, she moved to Berkeley, California, where, in the context of the Seventies revolution in women's health (the time of Our Bodies, Ourselves), she established a birthing center at Alta Bates Hospital. In the center, medical control decreased, and women had more control over birth in a natural and supportive environment. Doctors who opposed the birthing center believed that "no birth is normal until after the fact." Following this experience, Vincent entered nurse midwifery school, where the thinking was exactly the opposite: "Birth is normal until proven otherwise."

Vincent shares unforgettable stories of birth in homes, boats, and harrowing car rides, as she lovingly and expertly "catches" babies for Berkeley couples. Her descriptions are warm, funny, and inspiring, and her clinical judgment in delivering babies is astute. Whether the mother is noisy or quiet, stoic or dramatic, Vincent is comfortable. She answers calls in the middle of the night, travels to deliveries in her VW bug, welcomes each woman's way of birthing, and shares a celebratory meal with her families. Baby Catcher gives an insider's view of the magic of birth when the mother is in charge, and it is a delightful read.

Vincent was a leader in the revolution in maternity care. Her story is one of listening to women, breaking the rules, and helping them have babies in the way they desire, despite the predominant obstetrical medical paradigm. However, in 1988, she was unable to renew her practice insurance because of increasing reluctance by insurance companies to provide coverage for midwives; by 1991, no insurance agency would cover home births by midwives. Across the country, home births by midwives all but ceased.

Vincent's book chronicles the influence of liability insurance and its power to limit the practice of nurse midwives and the choices of families. She takes the reader into the politics of health care through a provocative and personal account of the difficulties midwives continue to face in the United States. Her story is one of independent thinking, expert care, courage, and the "labor of love." Today's health-care system needs more Peggy Vincents.

--Mary T. Champagne
Champagne is dean of the School of Nursing at Duke.

According to the National Center for Health Statistics, the United States spends more money on childbirth than any other nation in the world, yet it ranks twenty-second among nations in maternal and infant mortality and morbidity rates. Author Catherine Taylor acknowledges that international comparisons are tricky, but the presence of universal health-care access is one key factor in the success of every single country ahead of the U.S. on this list. The other notable factor is the prevalence of midwife-attended births.

In 1990, the World Health Organization declared that birth is safer for mothers and babies when using midwives for pregnancy and childbirth. The Netherlands provides a striking example. Dutch babies and mothers are the least likely to die or be injured in childbirth and the least likely to require medical intervention. Midwives attend 70 percent of Dutch deliveries, and, remarkably, a third of these are home births. By comparison, 93 percent of U.S. women have their babies with doctors, and 99 percent of births occur in hospitals.

Given these statistics, and her own less-than-satisfying experience with the birth of her first child, Taylor set out to learn more about alternative birthing options in the U.S. and to study the cultural influences that led to the marginalization of midwife-assisted births. Over the course of a year's research--most of it conducted in New Mexico--she documents more than a dozen births and interviews a range of private and hospital-based midwives and other experts about the relative merits and hazards of delivering a child in a private birthing center, a high-tech hospital, a rural health center, or at home. Taylor even trains to become a doula, a birthing assistant who works closely with midwives to help prepare mothers-to-be and their partners for the birthing process.

With an engaging style and a discerning eye for human behavior, Taylor carries us through the births she witnesses with a powerful sense of drama and a steady compassion for the families and health-care providers involved. Meanwhile, we learn of the author's own stress about the best means of delivery for her second child. Leaning toward home birth, she struggles between her culturally induced fears about having the child outside a physician's easy reach and her desire for personal control over a normal physiological process.

When her first son, Max, was born, Taylor's delivery was performed in an un-named North Carolina hospital. She was a graduate student in English at the time. Under the primary care of a nurse-midwife, Taylor was subject to what have become common medical interventions--labor-inducing drugs, preventive antibiotics, and, finally, a pain killer--all administered according to standardized, time-based hospital protocols aimed at ensuring a punctual march toward delivery. After a routine twelve-hour labor, the process left Taylor disappointed, groggy, and surprised by the midwife's only sporadic attentions and by her level of pain in delivery despite the drugs.

As Taylor later came to understand, midwives who work in high-tech hospitals must operate according to protocols that can turn the birth experience into something akin to a production line rather than a natural process in which each woman's physiological differences and needs are honored as the birthing unfolds. When things don't go according to schedule, "the cascade of interventions," as she calls it, begins. At worst, a mother may undergo an episiotomy or forceps- or vacuum-assisted delivery that can be difficult on the child, or at the extreme, a Caesarian section--a procedure that has quadrupled in use since the Seventies.

Helping women avoid these invasive techniques is generally a point of pride among midwives, though in U.S. hospitals, such procedures still happen at a much higher rate than in the twenty-one nations ahead of the U.S. in the statistics. Moreover, Taylor suggests, the common occurrence of these procedures only enhances the pervasive notion in this country that birth is a dangerous and even pathological event, dependent upon the medical establishment to render it "safe."

Hospital birth protocols may have grown stricter in recent years because of malpractice threats, but, as Taylor argues, the medicalization of childbirth was initiated at the end of the nineteenth century when physicians (mostly male) began taking over the birthing process from midwives. (She cites historian Judith Pence Rooks, whose research shows that between 1918 and 1925, deaths of babies from birth injuries rose by 44 percent.) U.S. physicians then began moving childbirth out of the home and into the hospital, discouraging attendance by midwives and other family members who had previously played a significant role. Today, only fourteen states allow nurse-midwives to perform home births; midwives who are not licensed are outlawed in ten states, and twenty-four states have no certification process for them.

Though American midwives have continued to practice over the years with and without certification, they mostly served indigent mothers until the onset of the natural childbirth movement in the Sixties. "With the rise of managed care in the 1980s," Taylor writes, "midwives' excellent outcomes combined with cost-effectiveness increased their availability and popularity." The Medicaid rate for midwives is 65 percent of the rate that doctors get for deliveries.

In the last decade, midwife-attended births have doubled in the U.S. Taylor sees this as a positive trend. Ultimately choosing to have her second child at home with a midwife, she describes the event as a happy rite of passage--a powerful contrast to the impersonal regimen she experienced the first time around. "We need to rethink the hospital as the main site for birth and doctors as the main attendants for normal pregnancies and births," she concludes. By her own story, Taylor makes a persuasive case.

--Georgann Eubanks
Eubanks '76 is a freelance writer who lives in Carrboro, North Carolina.