Our first appointment was in a tiny room on the third floor of an annex to the Illinois Masonic hospital, just a few steps away from the northernmost exit of the Brown Line’s Wellington stop (since this is where Sam was born, everytime we go by there on the train I get a shiver and tear up). It was one of those medical rooms that is too small for all the purposes it’s trying to serve. It contained a desk, an extra chair, an examination table, several drawers of supplies, all labeled, a sink, sanitizers, a computer, that blood pressure/thermometer thing, and more I’m probably forgetting. There was not enough space for two people to sit down if a third was trying to come in or out of the room. There was an intermittently flickering fluorescent light, and a buzzing from the air-conditioning system, and a period rumbling from passing El trains.
This appointment was with Mary, one of the midwives in the practice She was a severe woman in her late 50’s with salt-and-pepper hair in a bob, and carried herself just a bit like my mother. For a while I was confused: would she be delivering our baby? The answer: perhaps. It depends. The practice involves 10-12 midwives, all equally competent to deliver babies, and it would just depend who was on call the night our baby arrived. That was initially discomforting. I had always envisioned a doctor, someone who would definitely be there. But of course that’s impossible, as babies come when they come. Our first couple of appointments were with Mary, and so I found myself hoping it would be her when the time came, naturally placing my trust in her, as she seemed to know what she was doing.
The appointment itself was underwhelming. Mary asked us a few questions, and they were very perfunctory. When did Brooke last have her period? Had she ever been pregnant before? Were we sure I was the father? There was also an awkward moment where Mary became even more severe and asked me to leave the room (it was, I later learned, so she could ask Brooke whether I had ever abused her, a question DCFS required her to ask). Mary explained a few of the relevant logistics, like how often we would have appointments, and how there actually was a doctor they could call in if it became necessary through the course of our appointments, etc. After this, she looked at us and asked if we had any questions. I got the impression we were done.
I had one question, an inchoate one, but I knew it was there, so I started to speak: “Don’t you like, isn’t there…” What I wanted to say was self-evidently ridiculous, something like “isn’t there some huge expensive high-tech device you need to hook her up to? You know, like a pregnancy-detection technology that could incontrovertibly tell us a child was on the way?” I didn’t say that, but Mary I think sensed what I wanted to ask, and went in to describing a bit more about their philosophy: they generally just would talk with us, do some measurements, check Brooke’s vital signs, listen for the baby’s heartbeat, feel around to check its positioning later on, and on a FEW occasions do more involved things like ordering an ultrasound, but generally, this WAS it.
In just a moment I realized many, many things about myself and our country. That might sound overblown but it is very much how I felt. I realized just how conditioned I had been to expect certain things wherever hospitals, doctors and medicine were concerned. And I also realized in a flash something I’ve heard many people say, but haven’t seen many of them actually act on the truth of: women have been having babies for two million years. This is often deployed by already overly medicalized people who have for some reason ruled out going to any sort of birth classes. The idea is ‘what would I need to learn about this? It’s been this way for such a long time and it usually works out.” What this ignores is that for most of those two million years, we did not have anything like a modern hospital, or modern ob-gyn procedures. So if you don’t take those classes, that knowledge those women had acquired over those millions of years was essentially set aside, checked at the door, rendered useless in the face of medicalization and the passivity it encourages. Leave it to the experts – such people seem to think – after all this going to cost you an arm and a leg.
I remembered a passage from “The Apology of Socrates,” where Socrates likens himself to a midwife, and explains that he is no teacher. His analogy all of a sudden made so much sense: I’m not someone who lectures at people, he says, I am someone who helps develop inborn capacities. The medical-industrial complex, it does that: it says “this is how big your baby should be at this many weeks, this is what we do if this happens, this is what we do if that happens, you just leave it to us.” The midwife idea is – you do this, we’re here to help. It’s a subtle shift, but it’s a massive one at the same time. As I said before, it’s a shift that would be regarded as common sense in most of the rest of the world, but not here. Another quote, from Thoreau, comes to mind: “the people must have some complicated machinery or other, and hear its din, to satisfy that idea of government which they have.” And so we need the literal complicated machinery of labs, blood and urine extraction, ultrasounds, x-rays, and professional anesthesia, to satisfy our idea of what a medical procedure ought to look like. And after we’ve seen all that, well, we’re more than willing to fork over all that money. Or let our insurance company do so. It’s the least they could do – we’re accustomed to thinking – considering all the premiums, copayments, and denied services I’ve dealt with over the years. We’re having a god-damned baby and you’re going to pay for it. I’m going to have every test in the book, I’m going to get my money’s worth.
I’m not saying there are not times and places for the advances in medicine we’ve made over the past hundred years. Yes, women have been having babies for two million years, but also, women have been dying in childbirth at high numbers over much of that time. Medicine is at its best when it is intervening to deal with pathology and illness.
My mother gave birth to me at a hospital, with the full regimen of painkillers and other interventions. It was 1977, a few years past the high tide of medicalized birth in this country (though, to be sure, the tide is still pretty high), and since my family was well off I’m pretty sure that the default setting for the birth of their first child (i.e., me) was something I’ve come to think of as “the best birth money could buy.” It was at Highland Park hospital. My mother has told me different versions of this story for as long as I can remember, but all the retellings come to the same end: it was a horrible experience for her, from start to finish. My three younger siblings were all born at home over the next 10 years, with the help of a doctor (who was also for some time our pediatrician) and attending nurse-midwives.
When I started writing this essay, I was committed to trying to avoid being “political” but the fact of the matter, is, this is impossible. One of the biggest conclusions I came to through the birth of my child was that the birth process is political in perhaps the deepest sense of the term, since it sets the terms for the beginning of the lives of our children.
Before I delve more deeply into this, I think it’s important to repeat what I’m not saying: I’m not saying that there is no legitimate reason why many high-risk pregnancies are best dealt with through ob-gyn practices. Of course there is. What I’m talking about, though, are the 90% of pregnancies that don’t have major complications associated with them, and the social, political and economic, and yes, health cost this levies upon all of us.
The simple (political) fact is that what we’d signed on for at Illinois Masonic is something that fewer than 10% of American women and families do – have their babies monitored as they develop and delivered by nurses, in the relative absence of doctors and the various interventions that many of us associate with “normal” or even “natural” birth. In the rest of the world – “developed” and otherwise, this is not true. Something like 90% of women in Europe, for example, give birth to their children through midwife practices, delivering their children either in home or in hospitals.
Now I think to many Americans, this sounds sort of like when you hear someone insist that David Haselhoff is “huge in Germany” or that some pop star you barely remember is “famous in Japan.” There’s always this sense that that can’t really be true. Surely, when it comes down to it, there’s a doctor, probably the administration of an epidural, the lingering possibility of a C-section, and so on. But this simply isn’t true. Yes, Europeans use those things, but in such drastically lower numbers that it is astounding. What they do 90% of the time – give birth with the aid of midwives, we do less than 10% of the time. In the developing and lesser-developed world, things are much the same. Women give birth to children in their homes, with the assistance of midwives and elder family members. Doctors, when they are there, are there for emergencies, not as a matter of course.
There are many complicated reasons for this difference, but the core of it seems to be that most Americans think that what we do is somehow the civilized and technologically advanced way to do things – get “the best baby money can buy.” If you go to Northwestern hospital in downtown Chicago, like most of its wealthiest residents do, unless you ask otherwise, you will be directed towards the Department of Obstetrics and Gynecology, and if your insurance covers it, you will receive access to each and every device, computer, service, and test possible. Again, this is widely seen (among most Americans anyway) as a sign of process, even enlightenment. There are no barbaric deliveries in huts here in America, the thinking seems to go, we leave it to the experts.
Never mind that it probably costs well over $50,000 per child to do it this way. In fact, even the money is seen as some sort of sign that we’re doing this right. If that much money is spent, it makes us feel better. Never mind that there are still probably more than 40 million people in the United States who lack regular access to health insurance, and therefore the system that makes it cost $50,000 is the same system that makes it much more difficult for poor people to have children in general (even setting aside all the problems that come from raising a child in a poor community). That, essentially, it is not possible or sustainable for everyone to have their child born under these conditions, that babies born at Northwestern mean also babies born at Medicaid-subsidized hospitals under terrible conditions, or that – and this is the really tough pill to swallow for many otherwise thoughtful human beings – spending all that money may in fact make the birth LESS safe, more prone to complication, over-intervention, so on and so forth. For whatever reason, many people have no interest in thinking through any of this. People quite literally put more thought into shopping for a car than they do in learning about the process by which their child will be delivered.
Setting aside all these neverthelesses, the overall consensus among Americans seems to be that if you care about the health of your child (and who wouldn’t?) then you’ll use every resource at your disposal the entire way through, from the earliest prenatal appointments, through labor and delivery, into neonatal appointments and early childhood health care.
In the months since I first learned we were having a child, I’ve been astounded at what I’ve learned about that consensus. As I said before, having a child seems to be one of the most politically charged acts my wife and I have ever engaged in. Not politically charged in the sense that we were aggressively self-promoting about our decision-making – I’m saying it’s political for everyone whether they see it that way or not. The decisions we make about childbirth affect the decisions we make about the rest of our children’s lives while they are under our care, and then the decisions they themselves later make, as well as the decisions that everyone else in our society makes about both of those things, given the effect those decisions have on resource consumption and resource allocation. Choosing to have a baby one way or the other is political much like choosing to live in one town, which requires the consumption of scads of oil- and coal-base resources to drive cars, go to the mall, etc., vs. choosing to live somewhere else, where you can use subway trains and buses, and live in a smaller square-footage situation. Or choosing to live in a community that supports de facto segregation, or wealth inequality, or both.
We’re accustomed to seeing those sorts of “lifestyle” decisions as not political, just “what we want for our family.” But “what we want for our family” and what we take for our family, affects what others’ families can want and get, and the whole enterprise is one huge act of collective decisionmaking – in other words, politics.
It’s no coincidence that where the most important decisions are made – which services should be considered normal, how much money should be spent on which children, etc. – almost none of this happens publicly. It is almost entirely depoliticized, aggressively so. Try asking a doctor how much a given procedure will cost, what effect this will have if everyone does it, or whether they think it is a fair use of resources. You will be met with a blank stare, might even find yourself accused of not having your or your child’s best interest in mind. And since, of course, “everyone else,” we are led to think, is doing the same thing, you would be a fool not also to take advantage. And if you buck that trend, you are told YOU are the one who’s “making it political.” Because we never call something a political statement if everyone else is doing it. We are really bad at seeing that “going with the flow” and doing what everyone else is doing can have immense political consequences, acknowledged or not.
The “natural birth” movement comes in for a lot of scorn from otherwise liberal sources. The Onion, for example, recently ran a story making fun of breastfeeding and the self-righteousness it allegedly engenders. Another common way this stuff is discussed is to act like “natural” childbirth is an aesthetic conceit, one that is oriented around “the birth experience,” thus making women and families who opt for natural childbirth sound like the kind of people who insist on eating free-range chicken because it tastes better. Again, the Onion, ordinarily a dependable left-leaning source of humor, ran a story more or less suggesting that of course we all understand that none of this has anything to do with the baby’s life or wellbeing, because it won’t remember anyway.
What all of that misses – though of course childbirth, like any other experience, does have aesthetic aspects, but the political ones get predictably and perhaps intentionally drowned out by casting them as aesthetic or trivial concerns And there’s not a little bit of sexism implied there too. The (mostly male) medical establishment becomes the “serious,” “adult” and “scientific” authority; those silly women who think having a midwife etc. is better, well, they’re not engaged in the same sorts of dalliances as people who go to Yoga classes and insist upon using paper bags – but here a child’s life may hang in the balance!
I digress. But I cannot entirely set aside this theme. Because as much as I consider myself a liberal, reflective and thoughtful member of our society, I was also substantially weighed down by all the assumptions I’ve just named, and it took the better part of 9 months to get past them. I didn’t realize I was so weighed down, but I was. Fortunately Brooke had done enough reading and thinking about this for both of us, and we have a great group of friends for whom the nurse-midwife route is in fact the default setting. I’m surrounded, in other words, by that “less than 10%.”
[Next – Birth Classes]