(++) GETTING PUSHY

Pushed: The Painful Truth about Childbirth and Modern Maternity Care. By Jennifer Block. Da Capo. $26.

      Beware the committed do-gooder. He – or, in this case, she – believes so totally in her point of view that she argues with as much emotion as reason, and conveniently ignores matters that may undercut an argument that she just knows is correct. In the case of Pushed, that argument is that U.S. doctors do too many C-sections and give pregnant women too many drugs at labor, while midwives and birthing centers are scarce and in some areas illegal.

      Block, a former editor of Ms. Magazine and an editor of the revised version of Our Bodies, Ourselves, is a feminist of a rather quaint kind. Giving birth – specifically, giving birth the correct way, as Block defines it – is a woman’s absolute right, and anything that interferes with it is to be swept away.

      Unfortunately for this belief, some things don’t sweep so neatly. Block writes of the “casual resignation in the air” at one hospital where C-sections are routine and vaginal births unusual. That is, of course, Block’s interpretation of the atmosphere. Why is this hospital doing all those C-sections? Largely, it turns out, because the pregnant women are insisting on them; Block herself cites one poll in which 88% of respondents feared rectal damage from vaginal birth, and 58% feared sexual dysfunction. These fears, it is true, are vastly overblown. But what is a doctor to do when someone with these fears, or others, insists that she needs a C-section – perhaps after consulting a perinatologist, who may have administered sophisticated ultrasounds to determine a baby’s size and may then have told the mother that the size may be an issue? Notice all the “may” elements: this or that may happen, which of course means it may not. But if women control their bodies, themselves, and they want C-sections, should it be up to their doctors – or to Block – to discourage them?

      What’s in it for a doctor to argue strenuously in favor of vaginal birth? If the woman’s fears themselves lead her to have – or to believe she has – complications after giving birth vaginally, what happens to the doctor? A malpractice lawsuit – a possibility than hangs over doctors’ heads today like the sword of Damocles, but to which Block gives short shrift. As it happens, doctors’ fears of losing malpractice suits are overblown – they usually win – but the suits take time, effort and emotional strength to fight, and doctors are understandably more interested in practicing medicine than in practicing law.

      And what about insurers? Insurance coverage for some of the approaches that Block advocates, such as birthing centers and use of midwives, is spotty at best. But Block barely touches on insurance issues in her rush to advocate what she deems more-natural approaches to birth. She also has little patience with drugs to induce or speed up labor – but, again, are doctors to withhold drugs that patients want, or to let labor proceed at a drawn-out pace that may lead new mothers (correctly or incorrectly) to believe that the doctor caused whatever postpartum problems they have, and (again) to resort to legal action?

      The most irritating thing about Pushed is that it makes so many good points, but in such an annoying way. There are too many C-sections done in the United States – many doctors themselves say so. There are too many doctors willing to give in when women’s fears of the pain of childbirth (partly justified, partly irrational) lead them to demand more drugs than are necessary. There are too many doctors whose fear of malpractice suits leads them to overly cautious approaches in women for whom vaginal birth would be just fine. And there are too many areas where alternative birthing methods – for those who want them – are difficult or impossible to find. Block’s problem is not that she is wrong, but that she is dismissive. For example, “One could argue that the ‘liability crisis’ is to blame for the unique attitude [against vaginal birth after a woman has had a C-section] in the United States, but it seems to me that suspended in the chasm between evidence and practice is a profound cultural denial that goes beyond malpractice anxiety or convenience.” It seems to her, so it must be correct – and “liability crisis” is placed in quotation marks, indicating skepticism that there is one, and “profound cultural denial” is firmly asserted without backup. This is Block’s style: strong assertion of her positions coupled with skimming over of anything that does not fit them. This may be good advocacy – demean or ignore anything that might counter your argument – but it is not good science or good medicine. Block is right in much of what she says, but wrong, far too much of the time, in the way she says it.