Directed by Abby Epstein
Produced by Ricki Lake, Abby Epstein, Paulo Netto, Amy Slotnick
Ample Films, Barranca Productions
In a 2007 episode of ABC's drama "Private Practice," an elite obstetrician asked whether "midwifery" was even a word. The Business of Being Born responds with a compelling argument that the United States return to a midwifery-driven home birth model. The film presents our OB care as a dysfunctional business that has consigned midwives to the periphery, so that physicians who don't understand natural birth can perform dangerous, unnecessary interventions. Meanwhile, the film contends, the rest of the developed world achieves better outcomes for less money using midwives for most births. Abby Epstein's documentary is not the explanation of nursing expertise and obstetric care that it might have been. The film largely ignores the work of nurse midwives and obstetric nurses in hospitals, and it never explains how nurse midwives differ from other midwives. The movie also could have been more balanced and focused. The momentum flags in some scenes focusing on Epstein's own pregnancy and the thoughts of executive producer Ricki Lake. But the film is a powerful call for women to reclaim what we might call their "ancient properties" (following Toni Morrison's idea of black womanhood)--in this case, women's ability to birth their own children, to embrace fully the transformative experience of giving life.
The film mixes comment from health experts and patients with scenes of midwives delivering pre-natal and birthing care, including some explicit birth scenes. The experts, mainly midwifery advocates and pro-midwife physicians, deliver the policy arguments. One key theme is that the U.S. stands alone in the developed world in its physician-driven birth system, since midwives attend over 70% of the births in Europe and Japan, but less than 10% in the U.S. At the same time, the film's experts argue, the U.S. spends twice as much money per birth as any other nation, yet it has the second worst newborn death rate and one of the highest maternal mortality rates in the developed world. No one appears to challenge this data or try to explain it as the result of anything but our misguided focus on hospital-based, physician-driven OB care.
The film argues that this sad state of affairs has developed because the medical profession has convinced the vast majority of U.S. women that they "don't know how to birth." Instead, an increasing number of women choose to have Caesarian sections--major surgery. The movie says that even those who do not have C-sections often submit to an array of interventions that disrupt the mother-child bond, and that can lead to serious complications for mother and child. The film contends that because OBs are basically surgeons, they know nothing about natural births, and they have no business even being involved with most births. It shows that OB/GYNs rarely even witness a fully natural birth, much less a home birth. However, because of the training they do get, they are socialized to see pathology even if it is not there, which, of course, also gives them more to do and be paid for. The film includes clips from the classic Monty Python film The Meaning of Life showing idiot physicians doing procedures just for fun. At the same time, we hear, litigation fears may drive many OBs to do unnecessary procedures--even ones that present greater health risks--so that they can say they did all they could.
The film explains the harm associated with the most common physician-directed interventions in some detail. It argues that these interventions often occur for the convenience and profit of physicians and hospitals rather than the health needs of patients. The film is critical of the lithotomy (supine) position in which women are still encouraged to give birth. It explains that while this approach is easier for the physician, it restricts the mother's movement when she wants to move around, and makes it harder for her to push (a practice the film also questions). All this in turn makes more likely interventions like episiotomies and the use of forceps, which present serious risks.
Another physician notes that the brain chemicals released in the mother at birth (the "complex cocktail of love hormones"), which have evolved to keep mom focused closely on protection of the helpless infant, may be disrupted by these interventions. He asks whether we are inhibiting this critical mom/baby attachment: "Can we survive without love?" The suggestion that women who have C-sections don't love their children is a bit off the deep end (is that also true of adoptive mothers, or for that matter, all fathers?).
Of these OB interventions, the film focuses most closely on C-sections and the drugs that may lead to them. The film stresses that the U.S. C-section rate has risen 46% since 1996, and that in 2005 it accounted for one in three births. It suggests that C-sections are attractive to physicians (and some misguided mothers) because they are quick, they seem to be painless, and they can be scheduled. Even when a C-section is not planned, the institutional interest in speeding up the birth process in order to turn over hospital beds (and increase reimbursement in the managed care era) contributes to a pitocin or "pit" culture. Birthing mothers are commonly given pitocin to increase contractions; the strong contractions increase pain and may lead to an epidural anesthetic; but that slows labor, leading to a perceived need for more pitocin; and so on. The cycle may well continue until the baby's blood and oxygen flow is compromised, leading to an emergency C-section. The physicians are then credited with saving the patients (or not), when the domino effect of interventions may have actually contributed to or caused the emergency.
The movie argues that women are often cowed or deceived into having these interventions, such that there is not true consent. Its experts assert that physicians resist giving women all the information about what they might undergo in a hospital birth and the risks the procedures might entail. Even the OBs who appear in the film agree that C-sections are "major surgery" with much greater risks than vaginal delivery. But the midwifery advocates argue that the procedure is presented to patients as no big deal. Others point to the undue influence women may experience during labor from physicians and other caregivers with far more power. In addition to another bit on this from The Meaning of Life, we actually see a physician, in a friendly voice of authority, inform a laboring woman that "it's time" for the baby to come out. This is not a judgment that most people would question, particularly in a culture that holds physicians in such esteem and in which women have been persuaded (in part by the media, as one nurse midwife notes) that birth is a scary emergency process and they don't know how to do it.
Unfortunately, in the midst of all this detail, non-midwife obstetric nurses are virtually non-existent, and the film has literally nothing to say about them. One appears for a few seconds to helpfully explain pitocin use. Even if the filmmakers felt these nurses were not a significant force in the overall trends they were discussing, it would have been better if the film had said something like, "Of course, obstetric RNs play a far greater hands-on role in the care of birthing mothers than physicians do, and patient advocacy is ostensibly a key part of the nursing profession, but these nurses appear to lack the power to make any significant change in the intervention-happy 'pit culture' that dominates U.S. birthing." However, the film fails to convey that non-midwife nurses are of any consequence in hospital birthing.
The film also cites some historic reasons that the nation seems to have gone so far off the rails. A century ago, most births occurred at home, but today less than 1% do, as hospitals were presented as the only safe, modern place to have children. Legendary "professional" midwife Ina May Gaskin says that unlike in other nations, midwives here did not follow births into the hospital. Indeed, the film shows that traditional midwives were the subject of an organized physician "smear campaign" to portray them as backwards, ignorant, and dangerous--though in many cases they would have been safer than the physician-driven hospital environments. The film refers to a long history of dangerous interventions, including the use of drugs like thalidomide that caused birth defects, strapping women down and restraining them, the regular use of x-rays that gave babies cancer. The movie suggests that the surge of physician-attended births was a result of physicians needing something to do and of a "business" culture. The film suggests that midwifery experienced something of a rebirth in the counter-cultural era, when many became less trusting of traditional authorities, and women began to seek more choices and a return to more natural practices.
However, the film is not optimistic about where midwives are today. One midwife argues that physicians fear competition from midwives, noting that the AMA opposes allowing anyone to do things over which physicians have traditionally had a monopoly, and that physicians get rid of midwives when they start attracting too much business in hospitals. Advocates contend that insurance companies are reluctant to reimburse midwife home births, or even birthing center births, because OBs have convinced the companies that those births are unsafe--despite the evidence to the contrary, and the evidence that those births are far cheaper. One midwife says she sees plenty of OB/GYN "refugees," but that's "not enough to turn this around for us;" we later see her closing her practice because of insurance costs.
The film's other main narrative technique is to show us how home birth midwives work, and to have midwives and patients explain why midwife care is so valuable. Near the start, Epstein asks a few women if they would ever consider using a midwife. Predictably, the answers suggest the common conception of midwives as crones in a barn. The smear campaign worked. The film also offers glimpses of what we assume is the perspective of most OBs. One OB suggests that promoting home births is like telling someone they don't need to wear a seatbelt because you're a good driver. This OB suggests that the avoidance of birthing drugs amounts to "feminist machoism"--being able to say later that a mom did it naturally. Another OB wonders if home births include fetal monitoring. One smilingly refers to all the great technology now available--why not use it?
The film's answer starts with Ricki Lake, who explains that she felt that she had unnecessary interventions in her first birth, and was determined to explore the issues that ultimately became the film. We actually see her second birth, a home birth with a midwife, which she describes as painful but an essential, transformative experience.
The movie shows that trained home birth midwives are highly skilled, and that they actually have available many of the standard interventions should those actually become necessary, including pitocin. One expert notes that one third of births in the Netherlands are planned home births, and that nation achieves better outcomes than the U.S. does. Gaskin cites the very low C-section rate of the deliveries in her early years of care.
The film relies heavily on nurse midwives, but it never really explains the differences between nurse midwives and other midwives. Of course the groups share a great deal, but it might have been helpful to explain how much training nurse midwives have, and perhaps to provide a bit more historical background on nurse midwifery, such as through discussion of pioneers like Frontier Nursing Service founder Mary Breckinridge. The film never really links the midwives' holistic approach to the holistic approach of nurses generally, which would have had the added benefit of drawing non-midwife OB nurses into the discussion. And the film largely fails to communicate the extent to which nurse midwives operate effectively in hospitals, or to ask whether midwifery births in or near hospitals could offer the best of both worlds--the benefits of midwifery along with ready access to the full range of medical interventions if needed.
The closest the film comes to defining nurse midwives is in its portrayal of New York City nurse midwife Cara Muhlhahn. We follow Muhlhahn to her appointments, see her deliver babies, and hear her explain the merits of home birth. Muhlhahn explains that she attended nursing school at Columbia, worked as an OB nurse for five years, attended midwifery school, spent a year working at a hospital, then four years at a non-hospital birthing center, and has had a solo home birth practice for 10 years. This is a good example of an expert midwife's background. Unfortunately, the film does not explain that nursing school at Columbia meant a bachelor of science degree, or that "midwifery school" meant a rigorous graduate degree program.
Muhlhahn does come off as expert. We see her packing up her equipment, giving pre-natal care, and delivering babies. These scenes may shock some because of their lack of medical drama. There is clearly pain, but her patients give birth as if it was, you know, a natural process, rather than a medical emergency. We see a pro-midwife physician marvel at how simple and low-stress birth can be with an experienced midwife. Then the movie shows Muhlhahn attending just such a birth. Muhlhahn is articulate and passionate in explaining her role as "guardian of safety" and "witness to [the mother's] process":
A woman really doesn't need to be rescued. It's not the place for the knight in shining armor. It's the place for her to face her darkest moment, and lay claim to her victory.
Muhlhahn also responds to OB concerns about midwife home births by explaining that studies show home birth is safe, and that she follows guidelines as to who is a good candidate, based on the mother's health and history. We see some of Muhlhahn's own, very painful birth process, which she says was good for her midwifery practice, ensuring she understood how hard it can get.
We see other low-stress midwife births (sample moment-of-birth line: "Hey, Jen, reach down and take your baby"). One midwife talks about how women, before birth, often say they know they can't do it -- then they do. Another talks about the amazing "oxytocin rush" women experience, but stresses that you can't have that bliss without the pain.
The film's final focus is the story of director Epstein's own pregnancy, which occurred during filming. She planned to have Muhlhahn attend (Epstein's OB agrees that midwives do a better job with normal births). But we see Muhlhahn come to Epstein's home one night and find her dilated pretty far, with her baby in breech position. So they rush to the hospital. Epstein has a C-section, and her 3 lbs. 5 oz. son apparently spends 3-4 weeks in the NICU. Months later, Epstein seems to regret missing the ultimate moment of other births they filmed. But, she notes, the interventions were what her son needed to survive.
Epstein more or less ends the film with this. Her very technological and interventionist C-section / NICU experience may seem to contradict the film's main theme--does it suggest that everything that came before is misguided, since even the film's own director needed these interventions urgently? But it shows that planning to use a midwife does not foreclose those interventions if they are needed. Epstein and her experts recognize that OBs will have an important role in some births. The final scenes enhance the balance of the film, which does not give the interventionist OB perspective equal time, to say the least. At the same time, Epstein's regret underlines what women who need to do it this way are missing. Of course, ending with Epstein's experience may strike some as a curious way to make the film's argument.
On the whole, The Business of Being Born makes a compelling case for increasing the use of midwives for normal births, and highlights what seem to be the tragic flaws of the interventionist OB approach in the United States. The film places virtually no emphasis on the nursing element in midwifery, glosses over midwives' hospital care, and ignores obstetric nurses. But it is a great showcase for home birth nurse midwives, presenting them as skilled, articulate health experts who could help return birthing in the U.S. to the transformative and empowering experience the film suggests it was meant to be.
Reviewed by Harry Jacobs Summers
Nursing Editor: Sandy Summers, MSN, MPH, RN
Reviewed January 14, 2008
The views expressed herein do not necessarily reflect those of the Board Members or Advisory Panel of The Truth About Nursing.
We will put more dates up as we get them, you can also check for more up-to-date information at TheBusinessOfBeingBorn.com
January 9th - 22nd
BYOB - Bring Your Own Baby for the 11AM shows on Thursday and Tuesday.
Bring Your Own Baby shows on 1/19, 1/20 at 11AM, and on 1/24 at 12:45PM.
**Filmmakers Ricki Lake and Abby Epstein will hold a Q&A session after the
Wednesday, January 16th at 7:30pm screenings.
* *Special screening with Ricki & Abby on opening night January 16 to benefit the Doula Association of Southern CA. Go to dascdoulas.org for tickets!
Group sales available
Opens January 18th
The Roxie Film Center
3117 16th Street
San Francisco, CA 94103 map
Group sales available
Bring Your Own Baby shows on 1/19, 1/20, 1/23 at 2:30PM.
ATTEND A Q&A WITH RICKI AND ABBY
Friday, January 18th at 7pm
Saturday, January 19th at 7pm (director only)
February 29 - March 6, 2008
Seattle International Film Cinema (SIFF Cinema)
9AM PST KTLA Los Angeles TV -- Ricki to be interviewed on Morning News
11AM PST KALW San Francisco interview with Ricki & Abby
2-3PM PST Live Interview with Ricki on Celesta Rannisi’s "Timely Topics in Childbirth" internet radio show on VoiceAmerica's Women's Channel
3PM PST KPIX TV San Francisco View From the Bay interviews Ricki & Abby
7AM PST San Francisco 92.7 FM Radio interview with Ricki & Abby
8:30AM PST KTVU San Francisco -- Morning News interview w/ Ricki & Abby
11AM PST KGO San Francisco - Live Radio Interview w/ Ricki & Abby
12:40PM PST KCBS San Francisco - Live Radio Interview w/ Ricki & Abby