Brave New World of Evidence-based Maternity Care ~ Chapter 3

by faithgibson on September 8, 2013

Chapter 3

~Turning the Page ~
Benign Neglect Benefits Black Mothers

Faith Gibson, LM (2005)

A better analogy for this section might be turning a telescope or binoculars around because everything about this next section is upside down and backwards as judged by the previous one.

Odd as it seems, the maternity care for black mothers was remarkably simple, straightforward, non-interventive. It was psychologically sound, made right use of gravity and was satisfying to me as a maternity nurse. As judged by the number of newborns who did not need resuscitation at birth, it was vastly more successful than the highly medicalized care visited on their Caucasian counterparts upstairs on 5 North.

The secret – there were no labor rooms, no labor room nursing and no medical management of labor for black women in our segregated hospital. The only really obstetrical service they received was to be wheeled into the 5 North delivery room for the actual birth and then immediately returned to the segregated part of the hospital. That eliminated a lot of unnecessary, painful, humiliating and harmful interventions. This started right off by doing away with too-early hospitalization.

Black mother-to-be who were not in good active labor were sent back home and told not to return to the hospital until the pains were 3 minutes apart and had been that way for at least an hour. This was because there was no specially assigned staff to provide care during the latent phase of labor. Higher parity mothers, perhaps having a 6th , 9th or even 13th baby, often gave birth precipitously upon admission – another sure-fire way to eliminate all manner of medical meddling.

Black women who arrived at the hospital at the ‘right’ time — early active labor — were admitted to their postpartum bed in a 4-bed ward in the basement of the hospital, a segregated medical-surgical unit known as One South that was stuck between the hospital laundry and the hospital kitchen. The other women occupants of the ward were not necessarily OB patients – they might have diabetes or be recovering from gallbladder surgery or some other non-contagious condition. For the newly admitted labor patient, the absence of labor room protocols (including isolation from any social support structure) combined with the presence of other, often older more experienced women, was beneficial. These women offered company, encouragement and tips for dealing with labor to the mother-to-be. This kept up her courage and helped her to feel safe and relax enough to make timely progress.

As for the hospital staff, they treated these laboring women with masterful inactivity – that is to say, these patients were functionally ‘ignored’. Because they were left to their own devices, laboring women walked up and down the hall of One South, stood around their bed, paced the floor of their large room, gossiped with the other women between contractions, passing the time in a beneficial manner. The one thing they did not do was lay in their bed – they said the ‘pains’ hurt too much when they laid down. And of course, narcotic medications for pain were not offered or available as we did not have the staff to protect them from falling out of bed. Also there was a strong prejudice that black women were fundamentally different and unlike white women, did not need or deserve drugs during labor. Unlike white women whose childbearing abilities had been bred out of them or damaged by the effects of civilization, the notion was that black women were more primitive, closer to an animal state for whom parturition was natural.

So unmedicated, unmessed with Black mothers labored on One South in the presence of other supportive female patients, making right use of gravity (upright and mobile mother), until it was time to be taken to the delivery room upstairs and give birth. Nurses occasionally checked on them but no one actually stayed in the room. The nursing staff only knew a mother was approaching delivery when the unmistakable sounds of pushing were heard down the hall at the nurses’ station. Then a nurse would grab one of the gurneys lining the hall and aim it hurriedly into the room, ask the mother to hop over on the stretcher and throw a sheet over her. Usually with a second nurse appeared to help steer the stretcher. Then this little threesome would race off to the elevator at the end of the unit, which would take them up the five floors to the delivery room on 5 North to give birth. At least that was the theory. However, with a high parity population (the majority of women were expecting a 3rd, 4th, 5th or even 13th baby), in combination with this liaise-faire method of labor monitoring, it was almost inevitably too later to actually reach the 5th floor delivery room by the time audible signs of second stage labor became apparent to the nurses who were way down the hall.

Instead we regularly had moms deliver on the stretcher in the elevator between floors. We would just turn the switch off so the elevator door would not open at the next floor (to a crowd of very surprised people) during the actual delivery. The ease and simplicity of the nurse-managed, non-medicalized births was remarkably similar to the very first spontaneous birth I had seen the first morning of my obstetrical rotation. These babies just slipped out with little fuss as we talked the mom through the last couple of pushes. Yes, they made guttural pushing noises and an occasional yelp as they did the hard work of squeezing that baby out but this seemed natural and did not shock or distress us or detract from the miracle of a simple and spontaneous birth. And wonder of wonder, these spontaneously born breathed on their own, since their mothers had not been medicated or anesthetized. There was no painful episiotomy performed, no river of blood issuing forth from a gapping perineal wound, no forceps, no potentially fatal fundal pressure, not ever a bulb syringe repeatedly jammed down the baby’s throat and importantly for premies or fragile babies, no precipitously clamping of the umbilical cord that would cut the baby off from 20% of its entire blood volume and the potential benefit of its own stem cells. Clearly Mother Nature, when respected and unmeddled with, did a damn fine job.

The irony of this situation was not lost on me, even as a 19-year-old student. By today’s legal standards these black mothers were actually receiving “substandard” care. Racial prejudice and discrimination had institutionalized the negligent treatment of black women and their unborn or newborn babies. Yet, they clearly were getting the best of the bargain and in a sense, they had the last laugh – their babies breathed and did not need to be resuscitated, thus contributing to increased IQ points and decreasing the exposure of the fetus to intrauterine narcotics and risk of addiction as an adolescent.  Not only that, but these mothers were not made to suffer the routine indignities and painful interventions in their labor that were the inevitable lot of while women. Black moms were not subjected to the labor-retarding effects of social isolation, immobilization on their backs with four-point psychiatric restraints, the maternal effects of being profoundly narcotized, the slowly healing episiotomy that made it hard to sit and difficult to care for a new baby.

It turned out that the ‘holies of holies’ for the miracle of birth was not actually the sacrosanct sterile delivery room on 5 North as I had first imagined but the elevator that ran between One South and the 5th floor. The altar upon which the sacred act of birth occurred was not a forbidding operative table with stirrups and wrist restraints but a simple stretcher. The obstetrical high priest had been replaced by the lowly and faithful servant of the system –  staff nurses or even me, a student nurse who only knew that above all, her first duty and her professional obligation was to “do no harm” and so “when in doubt, don’t”. This stands in sharp contrast to our contemporary situation in which this vow to ‘primum non nocere’ taken by doctors as a part of their Hippocratic Oath has been functionally obliterated by obstetrical medicine’s romance with operative delivery. The new version is “when it doubt, cut it out” referring to a perceived obligation to perform a cesarean for virtually every minor or temporary difficulty, including just the vague possibility that a problem might arise in the future and therefore the lie that “maternal-choice” cesareans are safest and best.

A compassionate obstetrician-gynecologist,
infertility surgery and success beyond my wildest dreams

This last topic is the final act of the big four influences on my professional life as a labor room nurse, a community midwife and now, an activist seeking to introduce long over-due changes into a maternity care system that fails in its mission to consistently make a positive contribution (and often inadvertently introduces harm) into the pregnancies and births of healthy women. This period of my life was after graduation from nursing school and involved two extremely personal experiences  – infertility surgery and the spontaneous birth of my first baby – a daughter named Shawn whose head emerged at exactly 11:02 pm, on January18, 1964 in the back seat of our family’s Renault at the corner of Orange Avenue and Gore, four blocks shy of Orange Memorial Hospital.

As a newly married woman who expected to have a “family” (I wanted 7 children) I was seeing an gynecologist because I had extremely irregular menstrual periods and had not become pregnant even though we were trying. At this time my husband was overseas and I had very little money and no health insurance. In spite of this an Ob-gyn, Dr. Louis Pullman, an older physician on staff at Orange Memorial Hospital, was willing to provide care to me, often not charging me for office visits and giving me free drug samples anytime medication was indicated. While it is easy to conclude from previous episodes of this story that I was somehow “anti-obstetrician”, I must relate my intense loyalty to obstetrical medicine and my undying gratitude to many different doctors who have provided care to me or my family members through out the decades. However, Dr. Pullman was a particular “hero” to me for the compassion he extended to me.

On one of these occasions Dr. Pullman examined me and remarked that my two ovaries “weren’t worth a toot” and that I was, functionally speaking, infertile. He diagnosed me with Stein-Leventhal ovaries – a condition now renamed as “polycystic ovarian syndrome” or ‘PCOS’ for short. I remember the shock of the moment in which this grim diagnosis was the same in my mind as one of terminal cancer – I could not imagine living without a family and thoughts of suicide danced through my head for a brief moment. But bless him, Dr. Pullman immediately urged me not to loose heart, that it was a condition that could be remedied with surgery – a bilateral wedge resection of my ovaries. With his help this surgery was arranged a few months later and was performed by him at Orange Memorial Hospital. I once read the pathology report and sure enough, I did have Stein-Leventhal ovaries.

The next major insight of my life came to me as I was waking up from general anesthesia in the recovery room after a laparotomy (surgical incision from belly button to public bone). I felt pain so intense that it was as if someone had kicked me in the stomach while wearing a pair of ice skates. Unfortunately this was accompanied with violent retching and agonizing pain with every move, even a cough or trying to shift to a more comfortable position on the stretcher. The major thought in my mind was how distressing this situation would be if I were a new mother who had been delivered by Cesarean and now had to both recovery from the pain of major surgery while trying to get to know and breastfeed my newborn. My experience with abdominal surgery gave me a well-developed compassion for what surgical delivery did to the experience of motherhood, a lesson I have never forgotten.

The good news post-operatively was that I immediately got pregnant. By this time my husband and I had moved to Cape Canaveral (60 miles to the east, on the Atlantic ocean) but I choose to continue my prenatal care with Doctor Pullman, which also meant having my baby at Orange Memorial. The distance (about an hour’s drive) didn’t seem to be a problem as the length of labor for first babies was always long – on average 15 to 20 hours (according to textbooks of the period). What did bother me however was the knowledge that I, as a white woman, would be subjected to a form of invasive obstetrical care that I neither wanted nor believed was safe. Worse yet, women at that time (still true to some extent) had no recognized “right” to refuse these procedures. I had been present when labor patients had been restrained so that procedures they did not want (or feared) could be performed on them against their will. As an L&D nurse, the mere thought of having a baby in that environment was frightening. I was more afraid of hospital labor care than of the labor itself.

During one prenatal visit I told my doctor that I didn’t want any pain medication or anesthesia, didn’t think an episiotomy would be necessary, didn’t want “outlet” forceps used and frankly, wanted to be permitted to labor like the black women admitted on One South. By this time I had worked with Dr Pullman as graduate nurse in the L&D unit and so expected to have more bargaining power than the usual maternity patient. He looked a bit bemused but genuinely engaged and patted my knee in a fatherly way. His gesture was not intended to be demeaning and I did not take it as sexist. In a calm and quiet voice he said “Well honey, why don’t you just have the baby before you get to the hospital because that is what hospitals are for –drugs and anesthesia.”

So of course, as a “good” nurse, I followed the “doctors’ orders” to the letter. Exactly how this came about was accidental though, as I never intended to give birth in the car – only to delay my arrival at the hospital until the birth process was too far advanced to provide the time or opportunity to do all those routine “procedures” – pubic preps, sleeping pills, narcotics, amnesic drugs, being subjected to four-point restraint forcing me to labor on my back and being anesthetized for delivery.  I just wanted to give birth on a stretcher in a stalled elevator, coached on by a nice nurse, just like those women from One South that I delivered as a nursing student. What actually happened was even better.

My water broke at 37 weeks of pregnancy and I labored at home for several hours while my husband was still at work. We already had plans to have dinner with a young couple who had a two month old baby. We had become friends with Loretta and her husband Bob after she gave birth at my hospital on my shift. Assuming it was still very early on in my labor, we went to their house as planned but within a few minutes my labor became to active to be sociable. Soon sitting on the toilet was the only place I felt comfortable.  The three of them concluded that it was time to drive to the hospital. Then my husband discovered he didn’t have enough gas in the car for a 60-mile trip and also didn’t have any cash. Loretta’s husband loaned him a few dollars and he left me laboring at their house while he filled up the tank.

Upon his return I climbed into the back seat of our little Renault, clearly in the deep fog of advancing labor. Loretta somehow convinced my husband that she should accompany us to the hospital. Just as we were about to back out of the driveway her husband Bob opened the back door of the car and thrust several bath towels in at me. I remember seeing the name of a popular hotel printed in white on a wide bland of green that went down the middle of each towel. He said “Here, you might need these” and I thought he was crazy – we were driving to the hospital, not the beach – why on earth would I need towels? Men just don’t understand labor was my foggy conclusion.

The three of us headed out for the long stretch of empty highway that connected the East Coast with Orlando, my husband at the wheel, Loretta riding shot-gun and me lying on my side in the back of the car, trying to ride the waves of uterine contractions that came again and again and just about sweep me away. I remember thinking that maybe drugs and anesthesia for childbirth were not such a bad idea after all. Then I fell asleep for a few minutes – a period of quiescence that sometimes occurs right at the edge between the conclusion of first stage (the dilatation phase) and before the second or pushing stage of labor begins. The well-known English birth activist, Shelia Kitzenger, named this the “Rest and Be Thankful” phase. I did rest for about 20 minutes and I was thankful for it. I felt refreshed and strangely calm upon waking.

What woke me was the first spontaneous urge to push. Without a great deal of thought I began taking the pink foam hair roller out of my hair and placed them on the ledge in the back window of the car – I did not want to give birth with my hair in curlers. Then I removed my undies and placed those Holiday Hotel towels with the green strip on the car seat underneath me. I do not recall having any actual sense that I was going to give birth in the car, I did not think about the baby coming or do this as an aspect of my professional ‘nurse’ persona – it was purely instinct.

Slowly it dawned on my husband that I was actually pushing. He’d listened to many stories about hospital births and heard me describe the need to keep women from pushing before their doctor had arrived – the magic phrase was “pant like a puppy dog”. He started urging me to pant, pant like a puppy, pant like a puppy. I remember emphatically telling him in the most churlish and cranky voice that “I’ll push if I darn well want to”. I had discovered that when I pushed, the pain did not seem sharp or unbearable – in fact, it was a vast improvement, almost pleasurable, down right satisfying.

By this time we were about half-way to Orlando – a desolate 30 miles from civilization in either direction, not even a gas station open in the middle of nowhere late on a Saturday night. Seeing a Florida Highway Patrol car on the road in front of him, he flashed his lights several times and finally both cars pulled off the road. The FHP officers asked my husband what the problem was and he replied “My wife’s having a baby in the car and she ought to know because she is a labor room nurse.” They said “so sorry, we’re carrying prisoners and legally can’t help you”. But they radioed ahead to alert the Orlando police. The plan was for OPD to pick up our car at the city limits and provide a police escort to the hospital.

I don’t remember hearing the police siren as we followed the squad car to the hospital – I do remember that they took us down South Street – a particularly unpleasantly bumpy brick road in the back of a compact car. As my baby’s head descended into the lower half of the birth canal I discovered why women instinctively place one hand on their crotch while pushing – the back-pressure of my fingers over the bulging caput of the baby’s head modulated its egress, slowing it down and helping to keep her head flexed (chin on chest). This presents the smallest diameter of the baby’s head to the opening of the birth canal and greatly reduces the likelihood of a perineal laceration. The immediate benefit was that pushing didn’t hurt as much and being able to help myself gave me a reassuring sense of control. And of course my pushing was self-directed – no one told me not to push, or when to push or how, no one shouted at me or counted to 10 again and again and again with every contraction. There was only the familiar comforting sound of the car traveling over the brick roads and me taking in a quick breath and then grunting, pushing and pressing my baby down in the slow ancient rhythm of second stage.

None-the-less, I was still afraid that if labor hurt like this, the birth would be many times worse – unimaginably, unbearably painful. I remember hoping that we’d make it in time for them to “knock me out”. But thankfully that did not happen either. Instead, my baby daughter slipped out on one of those self-modulated pushes and suddenly my fingers found themselves cradling the baby’s head. In the next fraction of time the L&D nurse in me came to the fore and I slid my fingers down around the baby’s head and into her mouth to clear her air way. As I did she sucked on my finger and suddenly I knew everything was OK. Once again I became just a normal childbearing woman, pleased and amazed as my half born baby nursed on my finger, comforting me perhaps more than herself. We were crossing the intersection of Orange Avenue and Gore. I remember a brief glimce of the liquor store, now long gone, that use to stand on the northeast corner.

In four more blocks our car made a right turn into the emergency driveway of the hospital and came to a stop behind the police cruiser. I was oblivious to the outward aspects of this drama as my husband and the two patrolmen — OPD police officers Richard Strange and Robert Noble (what wonderful names for the occasion!) jumped out and all three ran into the Emergency Room to alert the nurses. The next uterine contraction washed over me, I pushed again and the rest of the baby slipped out, my left hand firmly cradling a tiny wet shoulder and the other one between the baby’s legs. I didn’t have to ask that archetypical question of every new parent “boy or girl?” as I didn’t feel any of that outside plumbing and so instantly knew it was a girl. She peed on my hand and I thought: “well, at least we know that system works”. I pulled my new baby daughter up and laid her slippery warm body against the bare skin of my abdomen. She cooed more than cried, a soft sweet sound just enough for me to know she was breathing (a crying baby is a breathing a baby) and that everything was alright.

By clock time this all occurred in less than a minute but it was like a entire day passed as my mind wrapped itself around the amazing sensations of my wee newborn against my body. Why compared to the labor, the birth of the baby had been a vast improvement. In first stage one has to expend an enormous amount of energy trying to keep still and not get in one’s own way. But in second stage I could do something – I could push – and that was a big help to both my mind and my body. Pushing was soul satisfying. The moment of birth was easy and simple, a relief and not at all like my big secret fear – that the instant of delivery would be like the crescendo of a car crash. As a child I thought that having a baby must hurt so bad that if the mother wasn’t anesthetized, she would faint from the pain. Instead I was downright gleeful. The currently popular Yoplait yogurt television commercial comes to mind, the look of delight and the joy of a special appreciation communicated by the way the two actresses smile at each other and the sparkle in their eyes. It was “umm, ummm good!”

And I was so glad I hadn’t made it to the hospital and been given drugs or anesthetized, as I would have missed all this. I would have gone through life thinking that I couldn’t do it myself, that birth was agonizing and unendurable and that I as the childbearing woman need to be rescued from the cruel fate of female biology. Instead it was my delight to be the first person in the whole world after God to touch and welcome my baby. I treasured the few moments alone in the quiet car with my new baby hugged tight against me, lost in a deep ocean of awe for this astounding experience before the swirling mass of humanity bore down on us to “help” and brought me back out of my reverie.

An OB resident I knew but didn’t like walked by the car, and peaking through the back window announced that “if she already had the kid I don’t want to have anything to do with it” (in other words, if I had already delivered I didn’t need his obstetrical services and he was going home, thank you!). Then an emergency room clerk opened the back door of the car, letting in the cold January air, and covered the baby and I with a still-folded, crisply ironed, not very comfortable hospital sheet. Next I looked out the open door to see the OB resident I really liked – Dr. Ron Wilson. In an enthusiastic voice I chirped “Hi Dr. Wilson, look what I did!” For a split second he looked a puzzled at being addressed by name and then recognized me and asked what on earth I was doing there. Of course, no answer was necessary as my softly cooing baby said it all.

Dr Wilson left for what seemed like 10 minutes but probably was probably only 3 or 4 and returned pushing a stretcher. He stuck his head though the back door of the car, announcing that they were going to try to figure out how to get me out of the car. I immediately swung myself into an upright sitting position while cradling the baby against my body. With the other hand I reached down and put a sandal on each foot and then scooted forward out of the car, demurely pulling the skirt of my shirtwaist dress down as I exited the car. Holding my baby still tight against my tummy, I jumped up on the stretcher and laid down like a good patient. Now it was my turn to take one of those long gurney rides seen so frequently in TV shows, with overhead lights whizzing by my field of vision as I was pushed down the familiar halls of the hospital in which I had trained and worked. I was rolled into the elevator. Upon reaching the OB floor the elevator stopped and the door slid open  and there were the 3-11 nurses from the L&D  — all co-workers of mine –standing there ready to go home at the end of their shift. Like Dr Wilson, they were amazed to see me lying on a stretcher, holding my baby up, grinning from ear to ear and exclaiming proudly “Look what I did!”

Then the stretcher was pushed through the electronic door to our new delivery unit on the 4th floor of the hospital. For doctors and nurses and other hospital staff, hospitals become a surrogate “home” and so I felt that I had finally come “home” — the L&D that I had worked in, learn in, imagined giving birth in, had feared laboring in. Best of all, my baby was already born and I had prevailed in my desire for an unmedicated natural birth and a healthy baby. My stretcher was pushed into an empty labor room and a nurse I’d worked with on the 11-7 shift — Nancy Marsh – walked in to admit “the precip delivery in labor room #3”. After expressing surprise, she picked up my newborn daughter in order to take her to the nursery (protocol even for a former staff nurse!). Since the after-birth had not yet delivered and the umbilical cord had never been cut, I yelped as the cord tugged on the placenta deep inside. Of course, Nancy instantly stopped. The cord was properly clamped and cut, the placenta delivered, I was inspected for perineal tears (I had none). An hour later I was taken by stretcher to the postpartum floor and be put to bed. My husband was allowed to come in even though it was after midnight. I called my parents and tell them the good news. I was one happy camper.

At this point my baby daughter had begun her 24-hour quarantine in the isolation nursery, considered necessary because she had been born outside of the hospital and therefore was “contaminated”. However, in every other aspect, it was the perfect birth for me. Blessed by good childbearing genes, youth, good health and benefited by years of nurses’ training and the knowledge acquired by my employment as a labor room nurse, I had accidentally stumbled into a way to have a natural, unmedicated, unintervened with labor and delivery and yet to have the backup of medical care and the joy of sharing my special experience with my hospital “family” – the staff of our L&D. I had succeeded beyond my wildest dreams. The next morning Dr Pullman came in to see me along with the other partner in the ob practice. I heard them talking to each other in the hall just before they walked through my door. Dr Pullman said in an incredulous voice: “They couldn’t figure out how to get her and the baby out of the back seat of the car and she just walked out!”

In my next two pregnancies I again managed to labor physiologically (upright and mobile) and without medical interventions, narcotics or an episiotomy  – something I could only bring about my having unattended labors and dashing to the hospital at the last minute. For the birth of my son 16 months later I arrived at the ER in the back of our new station wagon – purchased with the possibility in mind that I might have yet another baby in the family car and the additional room would be nice. This time I was a “multip” (someone having a second or subsequent baby) and was already pushing. Again I hopped up on a stretcher and the orderly flew down the long hall and up in the elevator. I remember seeing the “Otis Elevator” nameplate and thinking I shouldn’t give birth in the elevator as I would have to name the baby “Otis”. I was taken straight away into the delivery room and gave birth about 4 minutes later. For the birth of my youngest daughter, I was only in the hospital a longish time (for me that is) almost ½ an hour before she was born.

Both of my hospital births were typical of the day and it should be noted, that not even I considered any other options other than giving birth flat on my back on a standard delivery room table in the standard OR-type delivery room with my legs in stirrups, surrounded by masked strangers. My arms were placed in the obligatory leather wrist restraints on each side of the delivery table despite my earnest begging each time, telling them I was an L&D nurse myself and promising not to “touch”. This request was refused each time because “you might contaminate the sterile field” or “sorry, its protocol”. The doctor stood expectantly between my stirruped legs with scissors in hand, awaiting the next contraction before he ‘snipped’. I argued, pushed and gave birth when I really did not have a contraction in a race to delivery before he cut an unnecessary (and must unwanted) episiotomy.

Pushing my last baby – bigger by a pound than my first – up hill while forced to be absolutely flat on my back was exhausting and difficult but I was enormously relieved when I succeeded. I had figured out how to have the unintervened with labor like the black mothers on our segregated wards of One South but not how to be supported by a caring staff during my labor or be ‘permitted’ to make right use of gravity, or avoid the unnecessary rituals of the delivery room and the loss of control. I was forced to give birth flat on my back, with my legs in stirrups and my hands in leather cuffs two out of three times. For all the contributions of monitoring mother and baby during labor (fetal heart tones and the like) I had 3 out of 3 unattended labors. I was obsessed with the thought “There’s got to be a better way”.

The Black and White Nature of ___________??_________

I am no fool – it is obvious that my personal strategy to have control over the manner and circumstance of normal childbirth was no answer for anyone but me. What about all the other healthy women who did not want or benefit from this massively medicalized process that for so many steals the birth experience away, making it something that belongs to the hospital staff. After being stolen from the mother it is then sold back to her at a great price, economically and in psychic trauma. And what was going to happen when my two daughters grew up and got pregnant, or my son married and my daughter -in law was expecting a baby? How could I make maternity care work for them too?

Miss Etta had trained me well as a student nurse and I took my professional role seriously, including the obligation to advocate for my patients, come what may. I was only twenty years old that cold Saturday night in January that I gave birth to my first baby in the backseat of car in a desperate effort to exercise one of the most fundamental rights of all, one that most women over the thousands of years of human history have experienced as a matter of course – the simple dignity, as an adult of sound mind, to have control over the manner and circumstances of normal childbearing. As an L&D nurse of various big & little hospitals I spent half a life time in this system trying to apply the lessons I learned as a student in our southern hospital and the insights gained as a mother who had given birth spontaneously. I did my best to be a “change agent” for the laboring women I continued to care for.

Unfortunately, the principles of physiological management, psychological support and non-intervention that I had seen be so successful to the black mothers on One South didn’t play well in Peoria, or any of the others places I lived and worked. As could be predicted, the obstetricians I worked with were not amused and I was fired on more than occasion (actually only twice) for taking Miss Etta’s advise about professional conduct to heart. I shall spare you the grimy details but suffice it to say that I failed in my mission to change ‘the system’ at any of hospitals where I worked. Eventually I left that system in despair.

The culprit here is the “usual suspects” – gender politics, money, power, ignorance, the ability of organized medicine to unduly influence and even set the agenda of the press and the broadcast media relative to maternity care. What should be a source of unbiased information in a public forum has become propaganda – we only get the self-serving side of the story that makes normal childbirth scary and dangerous while the increasing medicalization of normal birth is portrayed as a miracle of modern medicine that saves healthy women from a fate worse than death. Meanwhile the obstetrical profession continues to ignore the mountain of scientific evidence that confirms the wisdom on non-interventionist care for healthy women. They continue to insist that all the studies ever published and all the research ever done establishing the efficacy and benefit of physiological management is somehow flawed or outdated or doesn’t apply. Doctors insist they can’t “understand” what we women want or why we are upset about this most unsatisfactory situation, intimating that we must be crazy.

“Surprise! Midwifery IS the evidence-based model of maternity care!”

The bottom line for me is that what is considered by the lay public and most medical professionals to be “controversial” about appropriate for care healthy childbearing is the result of an institutionalized ignorance of the science of safe maternity care. This is not rocket science. The duel system that our segregated southern hospital represented, despite the discrimination that entailed (or more properly, because of it) was an incredible opportunity to contrast the two systems. You can’t ask for a better-designed study for comparing the medicalized management of normal childbirth versus the physiological model of care. Never will we have a more dramatic example of the success of the one and the serious faults of the other. The issue is how to build on that and turn this disgraceful era into a guiding light and a stairway that leads to a more humane and cost-effective system.