Portland author Rebecca Grant tackles challenges in the maternal health care system in ‘Birth’

What’s it like to experience pregnancy and birth in the U.S. for the first time? And how has that changed over time? Why are maternal death rates higher here than in other countries? Those are questions Portland journalist Rebecca Grant takes on in her new book, “Birth: Three Mothers, Nine Months and Pregnancy in America.” While the percentage of home births has risen recently to a 30 year high and the numbers of independent birth centers are rising, about 98% of births still occur in hospitals. She joins us to talk about her reporting and what these three women’s stories tell us about the state of maternal health in this country.

“Birth” publishes April 25, and Grant will appear at the book’s release event at Powell’s City of Books on May 1.

The following transcript was created by a computer and edited by a volunteer.

Allison Frost: This is Think Out Loud on OPB. I’m Allison Frost, in for Dave Miller. What’s it like for a woman in the US today to experience pregnancy and birth for the first time? And how has that changed over time? Why are maternal death rates higher here than in other countries? Those are questions Portland journalist Rebecca Grant takes on in her new book, “Birth: Three Mothers, Nine Months and Pregnancy in America.” While the percentage of home births has risen recently to a 30-year high and the number of independent birth centers are rising, about 98% of births still occur in hospitals.

Rebecca Grant joins me now to talk about birth. Rebecca Grant, welcome and thanks so much for being here.

Rebecca Grant: Hi, Allison, thanks for having me.

Frost: Now, you have been covering abortion and reproductive rights as a journalist for many years now. And it’s certainly an interesting time for this book to come out the year after the right to an abortion has been overturned by the US Supreme Court. And now access to the drug for mifepristone, used to treat miscarriages and of course induce abortions, is in jeopardy. Why is this a good time for an exploration of birth in America?

Grant: I have always thought of abortion and maternal health care, miscarriage and pregnancy loss as all part of the same spectrum. In my reporting, I started out as a full-time freelancer focused mostly on abortion rights, but over the course of those stories and talking to sources, I really came to understand the ways in which both the medical and clinical aspects of the care can be really related and really similar, but also the ways in which the same people who have abortions are also mothers or will go on to become mothers. I think 60% of people who have abortions already have at least one child.

So it really felt important to make sure in the book that we were not only talking about pregnancy and labor and delivery, but also looking at that as part of the broader spectrum in which these same people are also experiencing losses and having abortions.

Frost: So really the continuum of reproductive care?

Grant: Yes, absolutely.

Frost: Well, as mentioned, this book is about the personal experiences of three women, in part in addition to these larger trends, but let’s talk a little bit about their similarities. As you do at the beginning before you start to introduce us to them, they’re all cisgender women, they’re all middle class, they’re all married, English speaking, they all are juggling careers as well and there may be more similarities, but we’ll get into that. And why was it important for you to specify that these are the similarities and they’re not meant to be, and couldn’t be, reflective of the entirety of all patients having given birth?

Grant: Those sort of demographic characteristics or those similarities are really reflective of who seeks out birth centers and the midwifery care in the US. So it wasn’t so much that I started out thinking that I want to find people who check all of these boxes. It was more that in embedding at a birth center and choosing to set the book there that it was sort of the majority of the people who came through the birth center and sought care there just happened to have those characteristics. And in many ways, that is something that the book also addresses by looking at why the midwifery kind of workforce and the makeup of birth centers in the US and the clients who seek them out tend to tend to be middle class, they tend to have money to spend on a type of care that isn’t always covered by insurance.

There’s also all of these historical reasons that the book goes into in which midwifery, which had for a long time been a practice that was happening among African American communities and immigrant communities as well, then became stamped out and reemerged as this predominantly white phenomenon. I think that in choosing characters who were reflective of the kind of average birth center patient, I was able to explore all of those issues and consider why that was the case.

Frost: And so hold that thought. I want you to talk more about the history of midwifery, we’ll definitely get into that more. But first, I’d love for you to introduce us to the character as it were of the Andaluz Waterbirth Center in Portland and how that might differ from, say a maternity ward in a hospital, how birth centers are really different?

Grant: I think of birth centers as being a sort of midpoint between home birth and hospital birth. There are around 400 birth centers in the US. Most of the freestanding birth centers like Andaluz, that are not part of a hospital, tend to be staffed by midwives, usually direct entry midwives. But many also have nurse midwives on staff. Nurse midwives are nurses who have a midwifery credential and most practice in hospitals. But birth centers are the domain of midwives for the most part and they offer prenatal care, labor and delivery services, but they don’t offer or provide certain things that the hospital does routinely such as epidurals. Birth centers tend to rely more on what they call non pharmacological measures. So, things like a birth tub or some will offer nitrous oxide which can be pain relief, but it’s not as sort of medically intensive as something like an epidural, which an anesthesiologist would administer. Birth centers don’t do surgery so they’re not performing C-sections there. They don’t induce labor and so it’s a more sort of hands-off model for the most part.

Whereas at a home birth, you’re really bringing all of the supplies there–either the midwives and the client are–making sure that everything that they need is on hand. And at a hospital you really don’t have to bring anything. A birth center is kind of like that. You don’t have to bring anything with you and you don’t have to have your own supplies, but it’s also not going to be that sort of thing in that medical hospital environment where they’re also performing surgeries for other things.

Frost: And it feels very different, right? What kind of vibe would you describe it as?

Grant: I look at two birth centers in the book and spend some at each. Andaluz was sort of described as having a bed-and-breakfast vibe. You walk in, there’s rugs, there’s a fireplace, there’s plants, there’s artwork, the receptionist will usually offer tea and then there are rooms where they’re performing the appointments and also the birthing suites. The same rooms have beds in them with nice duvet covers. It really does kind of feel like a charming inn. And the other birth center where I spent some time had a different kind of aesthetic, but it was still the same idea and it really feels like kind of a home-like environment, but then all of the supplies, all of the equipment are still there.

Frost: And you actually met all three of the women that are in the book at Andaluz even though one of them ended up choosing a different birth center. Tell me how you first met Jillian and what is she like?

Grant: When I was first starting to do research about the birth centers in the Portland area, I tried to think through where it would make sense to set the book and where would even allow me to embed for an extended period of time and just sort of lurk around and shadow midwives, especially in the early days of the pandemic.

I reached out to Andaluz in part because it was the busiest birth center in the state at the time. And the birth center’s founder, Jennifer Gallardo, was very open and receptive to the idea. And one of the first things that she did was invite me to come take a tour after we had an initial phone call. And Jillian who was the office manager was the person who let me in and gave me the tour. And at the time, I didn’t know this, but it came out pretty quickly after that Jillian was pregnant with her first child and that she was planning to have a home birth and she was also an aspiring midwife. So she had completed midwifery school and she had done her apprenticeship at Andaluz and so she hadn’t yet taken the midwifery exam. So she wasn’t officially a midwife, but that was the track that she was on. When I met her, she just really checked all of these boxes for me in terms of the type of stories that I was hoping to tell and trying to tell and she was planning a home birth, which I thought was an interesting choice for her as someone who had really trained at a birth date.

Jillian is really committed and passionate about midwifery. She’s incredibly warm and open and inviting. She partly became a midwife because a friend said she would be a great midwife and that really just sort of emanates off of her. She really just seems like such a caretaker. She has a wonderful sense of humor really. All three of the characters did.

Frost: Yeah, they were also generous with you to share these details. Some of them allow you to be in the room a lot of times and some of them just tell you some of the most intimate details one can really imagine. How about T’Nika, can you describe the second one?

Grant: T’Nika was an Andaluz client. Once I decided that I was going to embed at Andaluz, and that’s really where I was going to spend the bulk of my time reporting the book and also trying to find characters who had engaged with the birth center in some way, then Jillian and Jennifer, the owner, helped to introduce me to clients who were going to Andaluz. So I was meeting clients both through sitting in on appointments and following midwives throughout the day as they did prenatal appointments or postpartum checkups. I was meeting clients that way and then I also was meeting clients that the birth center had kind of reached out to and said, would you potentially be interested in participating in this project? And T’Nika was one of those clients.

I think our first phone call was a couple of hours before we ever met in person. And I was immediately struck by the really interesting, creative ways that her mind engaged with pregnancy. She is extremely funny, but she also loves science fiction and fantasy novels. The way that she was thinking about her pregnancy was kind of unlike anyone I had ever heard before. She would make jokes about not wanting to get an epidural in case the zombie apocalypse happened and then she couldn’t run.

Frost: (laughter) She couldn’t run away.

Grant: And I just found that to be such a compelling voice to be able to tell. And T’Nika is also a nurse and part of what had drawn her to becoming a nurse and then also part of what interestingly drew her to birth center care was a recognition of the ways in which our healthcare system, and our maternal health care system specifically, don’t serve Women of Color, and Black women in particular, in the way that they should be treated. So T’Nika was really inspired to become a nurse so that she could be this person who could advocate for those types of clients and who could make sure that they were having all of, as she called it, the bells and whistles in their care and that they were being listened to. And so I was also really drawn to the fact that she was going through this pregnancy and birth experience for the first time and she also had one foot in that medical hospital world that she had tremendous respect for. But then I was also interested in trying to work for improvement and change.

Frost: And we’ll get into this her experience a little bit later in the interview that you get into in the book about her experience with medical racism. And we’ll, we’ll definitely talk more about that. And then finally, Alison.

Grant: Alison, she was sort of an outlier and that she didn’t become an Andaluz client. She was someone who said that she never thought of herself as a birth center or a midwife person. She never knew anyone who had really gone that route. Her friends, her family, everyone had gone to the hospital and plenty had really great experiences doing that. And Alison with her first pregnancy, which ended in miscarriage, she had sought out hospital-based care and had an experience where she felt like she was mistreated and emerged feeling somewhat traumatized by what she had been through.

When she became pregnant again, she really was approaching it in a completely different way and was thinking that maybe the hospital wasn’t the place that she wanted to go to give birth. And she did a ton of research. She had a friend who was a nurse midwife and reached out to her for information and really went on this quest to figure out where do I want to give birth and what are the pros and cons of the environment and what kind of matches what I’m looking for? And so that was part of what drew me to Alison’s story was just the fact that she kind of had this transition from being a kind of a “hospital person” to being interested in birth center care and the sort of rigor that she applied to the process.

She had toured Andaluz and liked it and thought that it was lovely, but didn’t think it was the best fit for her. She found that she wanted something that felt a little bit more clinical, a little bit more closely affiliated with a hospital. And so the location that she ended up going, which is another birth center in the Portland area, was a freestanding birth center, but it was affiliated with an obstetrics and gynecology practice and with a local hospital. And so I think that level of close connection made her feel a little bit more secure in taking this path and making this choice that felt a little bit unorthodox.

Frost: So Alison’s very negative experience of having been dealt with in the medical establishment for her previous miscarriage, wasn’t the only one of these three women that had had a miscarriage. Jillian, as you mentioned, also had a miscarriage and was not happy with it. I don’t know, do you think it’s a fair characterization for me to say that they were dealt with rather coldly and unemphatically by the medical establishment and that was one of the things that propelled them to seek a different kind of care?

Grant: I think that miscarriage can be an incredibly complicated emotional experience and different people feel differently or different people who have multiple miscarriages might feel differently about each one. And so I think that they each felt like the care and treatment that they received didn’t necessarily match what they were looking for or needing in the moment. I think to both of them, it felt like this really big scary complex sort of fraught thing that they were even still trying to figure out how they felt about it. And so then to be interacting with the system in which those health care providers probably see this all the time. Miscarriages are really common. So I think it was a challenge for both of them to be grappling with what was a complicated kind of emotional experience that they were still processing at the same time as interacting with these medical kinds of systems that they hadn’t had a huge amount of interaction with before. It felt like those things didn’t really match up. And I think for both of them, it was a little bit of an eye-opening experience and when they subsequently became pregnant, it certainly informed their questions about whether the hospital was the place that they wanted to go to give birth.

Frost: You say that miscarriages are very common and some people know that, but I think a lot of people don’t and certainly miscarriage is not something that you hear a lot about in general. So I think it’s maybe natural that people might not know how common it is. So how common is it? And one of the things that you seem to be trying to do is open that dialogue up?

Grant: Absolutely. I think the numbers differ a little bit because it is a hard thing to track. But it’s something like 10% to 20% of known pregnancies end in miscarriage. And that’s quite a lot. And I, even just personally, have so many friends who at some point have experienced some sort of loss and as did the characters in the book, both themselves. But then once they had this experience and were talking about it with family or friends, they then find out that these other people in their orbits had also had it, but they had never known. I think that’s really normal because it’s not something that’s widely talked about in the US.

It’s sort of the norm, the kind of cultural norm to wait until 12 weeks to share that you’re pregnant and part of the reason that people do that is because loss is much more common before 12 weeks. And so people don’t want to go and sort of share this news and then have to kind of unshare it and go through that really difficult process. It makes sense, I understand of course, why people wait until 12 weeks, but then the thing that also does is it means that people aren’t sharing news about miscarriages.

Frost: Right.

Grant: And I think there’s a lot of shame and stigma around it. I think that’s starting to change. Even certain celebrities have started to talk a little bit more openly about their experiences and I think things like that help. And I know with Alison’s story when she got pregnant the second time, she told people really early because she sort of thought, well, I know that if I have a miscarriage, I want my people, my support network, my family and friends to know, and I want them around me. So if I’m already going to tell them I might as well just share the news about the pregnancy early. But it really does create a new dynamic if you’re pregnant again because I think we’re sort of raised or at least maybe I had always just thought that it was relatively easy to get pregnant. We have always been taught to like not get in the hot tub (laughter) or something because you could get pregnant.

Frost: Don’t miss a pill if you’re on contraception.

Grant: Right. And it depends on the person. But I think for a lot of people who just assumed it would be easy for them to get pregnant when they find that it’s challenging either to conceive or that they are having or experiencing loss because that can be kind of surprising I think in some ways and something that a lot of people aren’t necessarily prepared for. So I think that being able to talk openly and honestly or for people who find that talking about it is helpful. I think that it’s really important to acknowledge that that is just a part of what it means to try to start a family.

Frost: Well, let’s get into some of the other numbers as far as how many births. I said approximately 98% of births in hospitals, but there has been a growing number of home births recently. And those freestanding birth centers not affiliated with hospitals, there have been more and more of those opening. That doesn’t mean that some of those births don’t end up in hospitals. I don’t want to have any spoilers for your book (laughter), but there may be some hospital scenes in the book and that’s not uncommon as I understand. But how different are our numbers from other industrialized countries as far as this overwhelming majority being in the hospital?

Grant: It really depends. Certainly midwifery care is much more common throughout Europe and those midwives might be practicing in hospitals. But it’s a very different model whereas here in the US, the sort of go to maternal health care provider is an OB/GYN. So I would say that the US is certainly an outlier in terms of the amount of medical management and sort of intensive hospital-based practices in the kind of standard maternal health care.

Frost: Well, let’s talk about how this has changed, too, because you do definitely devote a good chunk of the book to talking about some of these trends and how they’ve changed. A hundred years ago, this was not the case. So take us back a little bit and situate us in time. How did women used to give birth, sort of this transition between giving birth and having your baby delivered for?

Grant: Yeah, for a long time in the US midwives were the norm and that really started to change around the same time that medicine as a profession became formalized. It used to be that a midwife was someone who was usually a fairly respected member of the community, someone who had probably already had their own children so they were a bit of an elder and they very much learned through apprenticeship. It was kind of a tradition and a body of knowledge that was passed down.

Then at some point, I guess it was the 19th century, men started to realize that this was a great business opportunity because there’s babies being born all the time. So as medicine as a profession formalized around like 1850-ish, they started to make these arguments that having that male physician present at a birth was the best way to promote health and safety and they were the ‘men of science,’ they had these things that they could do in this body of knowledge that like lowly women didn’t have. And childbirth was incredibly dangerous at the time. So families were understandably really eager to do anything that they could that would seem to protect their chances of survival.

At first, male physicians were becoming more of a presence in home birth environments, in people’s homes, particularly among upper middle class women, upper and middle class women, but then as hospitals started to emerge as a sort of institution in the US, physicians kind of realized that there were benefits to having people give birth in a more clinical environment and some of that could have been convenience. Then the men don’t have to slop all over town to all of these different clients or patients, but also there were some sort of hygienic reasons as well. They could have more control over what the clinical environment looked like.

Over the course of the 20th century, the numbers completely flipped from where before, birth primarily happened outside of a hospital and then pretty quickly, especially around the inter-war period, birth really became almost entirely a hospital-based practice.

Frost: How did maternal outcomes change? Did it live up to the promise in terms of being a safer environment?

Grant: Certainly in the beginning of this transition, midwives had comparable if not better outcomes than a lot of physicians. So that transition to sort of the physician in the hospital was actually not particularly beneficial until there started to be certain discoveries around what caused infection, around how to create a sterile environment, the introduction later of things like blood banks. And so certainly there was a point in time in which all of these medical and scientific advances were able to make childbirth significantly safer. But until those things happened, in some ways, doctors had poor outcomes because they were intervening; they were doing things with tools like forceps, among others, that were actually causing problems and introducing infection and what they were doing in some cases was actively causing harm. So that idea of ‘more is more,’ I think has some pretty deep roots in the history of medicine and it’s one that we still are kind of grappling with today.

Frost: Well, another thing that has really changed is the cost, but how do those compare today, - just taking us back up to today - the cost of giving birth in a hospital versus the cost of giving birth at home or a birthing center?

Grant: In terms of absolute cost, giving birth in a hospital is wildly expensive in the US. I think that the cost of the average vaginal birth in the US is something like five times what it is in Spain.

Frost: Five times?

Grant: Yeah, I think the average cost of vaginal birth in the US is something like $23,000 and then for a Cesarean it’s closer to $50,000. And those numbers are just so expensive. That’s so much money. So birth centers and midwifery care is significantly cheaper. You’re looking at maybe $3,000-$9000 or something along those lines. But because of insurance coverage, the cost that the patient or the family incurs doesn’t necessarily match the overall cost. So most public and private, if not all insurers in the US, are going to cover hospital-based care and so the bill that the patient gets might be wholly covered or they might have to pay a certain amount out of pocket. And certainly, those costs can change depending on things like if there’s a Neonatal Intensive Care Unit stay for the baby.

For midwifery care, most clients have to pay out of pocket because insurance doesn’t cover it. And so that means that even if the whole thing was much cheaper, if you look at all of the cost itemized on the sheet, the amount that the person has to pay might be more. And so that was certainly something that all of my characters were considering when they were making their decision about where to give birth. That was something that I know T’Nika asked during her first appointment to make sure it was something that would be affordable. It was something that Jillian was facing when she was figuring out what kind of who her midwife would be. And it was something that Alison asked at every single birth center that she looked at to make sure that her insurance covered them. So I think for my characters as well as for most people, cost is absolutely a concern because nobody wants to go bankrupt from having a baby.

Frost: And in fact, people do go bankrupt because of medical bills and some proportion of those are from bills from having a baby.

Grant: Yeah.

Frost: Well, let’s talk a little bit about when you’ve been doing all this reporting, you actually started the reporting during the pandemic. Did your editor think you were crazy?

(Mutual laughter)

Grant: No, I think that we knew it was going to be even more challenging than it already was to gain access, both with the birth center itself and with the people that I was going to follow. When I was looking for a birth center, when I was looking [for] characters, obviously I’m looking for people who have interesting things to say, people who were going to enable me to tell a larger story or address some of these other themes that we’ve been talking about. But also an equal part of that is making sure that people have the time and the interest and the comfort and the willingness to speak with me and let me into their lives and let me sit in on their appointments, let me visit their homes. And so that was certainly something that I was contending with as I was figuring out who I was going to be following.

Frost: As hospitals were a very dangerous place, and sometimes still are, for COVID infections, what kind of effect, if any, do you think that the COVID-19 pandemic has been having on people’s choices? Is it having an effect on people choosing a different environment just because of that factor?

Grant: I think it is. I remember in the early days of the pandemic, there were all of these headlines about people who were sort of fleeing hospital, pregnant people who were trying to search for birth centers or search for midwives near them. They were trying to find an alternative because they were worried about going into a hospital and catching COVID or they were concerned about the rules that hospitals had in place to try to limit the spread of infection. But those rules might also be like having a mask on in labor or not letting you have any support people with you or separating newborns from their parents. So I think for a lot of people, the risk calculus that they had.

There’s, I think, this idea that hospitals are the safest place to give birth because hospitals are where the doctors are and it’s where the operating theater is. It’s where the medications are. And I think that with COVID, weighing the various pros and cons and the safety, it shifted for some people, where they actually thought this doesn’t feel like the safest place. And so I’m going to be looking at these alternative options.

Anecdotally, I know that midwives and birth centers were reporting upticks in the number of people at least who are reaching out for information about their services. And then, with some of the numbers that I saw from the increase in home birth for between 2019 and 2020, it was something like a 22% increase.

Frost: That’s huge.

Grant: …which was the biggest one in a long time. And so interest in midwives and out of hospital birth has kind of ebbed and flowed over the decades, but I think there are a variety of reasons to think that this uptick could be here to stay.

Frost: I’d like to talk now about the medical racism that T’Nika experienced and how that can play out in maternal outcomes writ large. She experienced a very, very difficult time getting a gastrointestinal condition prior to her getting pregnant. She had had this experience of just having a very difficult time with a rare condition - it should be said it’s a rare condition - but can you read a little bit of her story? What she went through before she was grappling with pregnancy and birth on page 107, just to give us a bit of a sense of what she was dealing with.

Grant: Sure.

[Reading]

‘No answers emerged. None of the doctors seemed to know what was going on. Floating Crohn’s disease or maybe ulcerative colitis as possible causes.

‘Finally, Daniel’s uncle, a GI doctor in California, referred Tanika to a well known specialist outside of Boston. She was hopeful that the specialist would be the game changer, but that doctor didn’t seem to have any more insight than the others. She prescribed Tanika additional medications including a drug that she had to stop taking because it gave her heart palpitations.

‘With every doctor she saw, Tanika left the appointment questioning whether she had been taken seriously. The providers she saw often made her feel like she was complaining, overreacting or annoying. They seemed to distrust her accounting of her symptoms as if she wasn’t a reliable reporter of what was going on in her body. One doctor had even asked her, are you sure you’re actually feeling these symptoms?’

Frost: What was her reaction to this?

Grant: She told me that she was pretty shocked by that question. She was a recent college graduate. She had been going through this extreme amount of pain and had been extremely proactive about trying to find answers. And so the idea that she would go to all of this trouble and rack up all of these medical bills for no reason, the idea that that was in her head, was just deeply shocking and offensive. And it really made her–when she later became pregnant–interested in midwife care at a birth center.

Frost: And you talk about how she really kind of internalized all of that and really made her sometimes question her own ability to even face the system itself.

Grant: Yeah. And I think that was also a part of why she was so committed to being a nurse and really loved the idea of working in labor and delivery and was so dedicated and committed to the patients that she works with at the hospital where she works because she didn’t want anyone who was under her care to ever have to feel that way.

Frost: Tell us a little bit about how medical racism factors into pregnancy and childbirth outcomes.

Grant: Well, the racial disparities in maternal health health outcomes in the US are deeply entrenched and really severe. Black women are something like three to four times more likely than white women to die as a result of pregnancy and childbirth and these numbers are appalling and awful and they’re also not new. This has been the case for a long time.

It’s an incredibly complicated issue and there are so many things that factor into it. But if you’re looking for the one word reason why that’s the case, that answer is racism and that manifests in a number of ways. It can manifest in that sort of medical racism that T’Nika encountered, where doctors weren’t taking her seriously. But then it’s also physiological. There’s this concept called weathering, which was developed by a researcher named Arline Geronimus, who basically found that the effect of chronic stress on the body can cause premature aging and it can cause all of these chronic conditions and it can lead to things that can cause complications during pregnancy. So the reality of living in America as a Person of Color and particularly in this case, as a Black woman, can have a real effect on people’s health in pregnancy.

And then they’re also encountering a system that isn’t necessarily treating them with the dignity and the compassion that they deserve. So I think that that was part of why T’Nika was committed to becoming a nurse, and working in a hospital environment, but also why she was interested in going to Andaluz and having her pregnancy care handled there.

Frost: And Black women are also much more likely to have a C-section than white women, as I understand it. Now this is not the only measure. C-sections are not the only measure of a medicalized birth, although about a third of all births are C-sections. How does that compare generally? Is that a much greater number than other countries?

Grant: It is. It depends on the country but yes, in terms of countries that have really good maternal health outcomes, it is a higher number. The World Health Organization has a recommendation, a window, that says that a C-section rate of around 15 to 20% is sort of what to aim for because below that can mean that people aren’t getting the care that they need. C-sections are a life saving procedure. There are a variety of reasons why people need access to surgical birth and it’s incredibly important that for those types of complications that they have access to that; however, that 15 to 20% benchmark can be a sign that people who don’t need them are having C-sections and that’s an issue because C-sections are major abdominal surgery. They’re a big deal and the recovery can be really difficult and they can lead to complications. And so it’s really something that should only be used when the patient needs it for their health and for their safety, not for some of the other reasons or some of the other factors that can lead to having a rate as high as one in three. And there’s a really interesting study about how the kind of number one factor that determines whether or not you’re going to have a C-section is actually the hospital that you go to because some hospitals have rates that are around like 7% and others have rates that are around 70%.

Frost: 70%?

Grant: Yeah. And so some of that might have something to do with the populations that those hospitals are serving, if they’re serving a population that tends to have a higher incidence of risk factors or that could lead to complications that could then merit a C-section. But some of it is culture, some of it is what are the norms in this hospital and what are the circumstances in which doctors are making this decision to perform surgery? And so yeah, it’s really pretty wild range and it’s something I don’t think people necessarily know to ask about when they’re choosing a hospital to give birth. What is the C-section right here?

Frost: Right.

Grant: If that’s something that they care about knowing.

Frost: The idea about practicing defensive medicine comes up, not just in pushing people sometimes to do a C-section when they might not be ready or maybe there’s still a choice like maybe that’s necessary but maybe not. Can you talk a little bit more about what is defensive medicine and why a lot of doctors might feel they need to practice defensive medicine?

Grant: The liability and concerns around malpractice are particularly pronounced, I think, with obstetrics. So for a lot of doctors and also for a lot of hospitals that they’re in, they want to make sure both because they care about the welfare of their patients, but also because they want to make sure that they have been seen or have done everything that they can to make sure that everything turns out ok. To that point I made earlier, that can lead to, well, ‘we’re going to do this and we’re going to do this and we’re going to perform surgery because then we’ve done everything that we can and so if anything goes wrong or if there’s some sort of an adverse outcome, it’s not because we didn’t do enough.’ It’s sort of like doing more ahead of time preparing for the worst case scenarios to try to heed them off. But the challenge is that that can kind of create problems of its own. And it’s sort of a dynamic that can happen to protect themselves from liability and from concerns about getting sued.

Frost: Because doing nothing is held up as something that you could potentially be liable for. You made a mistake by not doing something rather than by doing something?

Grant: Mhm. And it’s not to say that that’s a misplaced concern.

Frost: Right.

Grant: But I just think, based on the reporting and all of the research I’ve done, that medical interventions can be incredibly useful and valuable and life saving. But the key is really figuring out when and how to use them in the best possible way, in the right moments. And I think that’s something we’re still figuring out.

Frost: Well, we’ve talked about midwives but we haven’t yet talked about doulas. And for those who might not be familiar with the role or they’ve heard the word but don’t know exactly how it’s different from a midwife or a support person, what is their role? What can they provide that midwives, or even perhaps the patient’s partner, can’t?

Grant: Doulas are really there to provide continuous emotional support during labor. So that can mean lots of different things. It can mean being someone who can talk you through what the process is going to look like and what to expect. It could mean someone who is listening to all of your fears and anxieties and concerns. It can mean they teach you breathing exercises or they show up at the hospital and in some cases if there’s someone such as a doctor proposing something that you’re not sure whether you want, the doula can be someone who’s in the room who can say let’s take a minute and give this person the chance to think this over.

It’s an incredibly valuable role and there’s all of this research which shows that doulas have a really positive effect on outcomes. And there’s people who go to hospitals who use doulas, people who have birth centers who use doulas, people who do home birth who use doulas. They’re really a vital resource that I think people are starting to understand a little bit more about, but there’s definitely a lot of potential.

Frost: Alison in your book ends up choosing a doula after a lot of thought about it. And there’s just a very short passage that I would love for you to read just to kind of give us the sense of not only her personality, but what I think a lot of people who are pregnant feel in terms of being overwhelmed with choices.

Grant: Okay.

[Reading]

“She wanted to be prepared, but the pressure to be prepared was exhausting. Decision fatigue descended. But she didn’t know how to exist as a pregnant person without feeling compelled to vigilance. She wondered if hiring a doula would help her relax because there would be someone else with expertise to rely on.

She continued to go back and forth over the decision, pulling the people around her for their thoughts, including Gina.

‘A lot of people do,’ the midwife replied when Alison asked. ‘But a lot of people don’t. It can be worthwhile, but it’s up to you whether you want to incur that cost.’

That wasn’t particularly clarifying. Alison tried a more specific question. ‘Out of every 10 people at the birth center,’ she asked, ‘how many hired a doula?’

Gina estimated around eight. ‘Great,’ Alison thought, ‘I guess I need a doula.’”

Frost: And she ended up [with] a doula and she was pretty happy with those services. Right?

Grant: Yeah. She had an interesting, I don’t know if I’d call it an epiphany, but a realization where she was thinking partly of hiring a doula as someone who could help her stay outside of the hospital during birth, as someone who could kind of be an advocate, or as someone who could make sure that her preferences and boundaries were being respected, which was not something she had felt during her previous miscarriage experience. So she wondered, is it a waste of time and money to hire a doula if I’m just going to end up at the hospital? But then she realized that actually, maybe that would be the best reason to have a doula because if she did end up at the hospital, it would feel really good for her to have someone else in her corner, someone else who she trusted, who was there to support her.

I think once she realized that regardless of what happened, that a doula would have something that was valuable for her, that was kind of what really led her to decide, ok I’m gonna spend this money and do this research to find the right one because I think it’ll be worth it.

Frost: And it is an out of pocket cost for the most part. So it’s not a very big cost, right? But it is often out of pocket?

Grant: It is. And there are a few states actually, including Oregon, which are piloting or experimenting with Medicaid coverage of doulas. So I think that there are some really sustained efforts to make doula care more accessible. But plenty of doula practices also might operate on a sliding scale or kind of do something to make it more affordable. But for the most part, yeah, it’s something that people are going to have to pay for out of pocket.

Frost: Well, I want to leave a little bit of tension. All of these women do give birth. I hope that it’s not spoiling anything. And they all live healthy births, but they all look very different and that’s all I want to say because there’s definitely a lot of tension and they all go through very arduous processes.

But that’s not where the book ends, with everyone just having a baby and it’s over and smiling and gurgling. It ends with the postpartum section. Why did you want to include that and, and continue to follow each of these women after they actually gave birth to see how they were doing?

Grant: The postpartum period is sometimes referred to as the fourth trimester. And I think that that sort of captures why I felt like it was important to follow these characters in their journeys around six months after they had given birth. One reason in part is because complications can, and often do emerge after someone gives birth and so it’s not like the baby is out of the woods. There’s a lot of other stuff that can happen and it’s also just an incredibly emotional time. Your hormones are going crazy and your body doesn’t feel like it did before you got pregnant. It also doesn’t feel like it did when you were pregnant and you’re exhausted and you’re trying to figure out how to be a parent and all of a sudden you’re a mother and just felt like I was so interested and cared deeply about what their experiences were like and how their experiences figuring out new parenthood aligned or didn’t align with what their pregnancy experiences had been like.

And I also felt like, having invested so much time and spent so much time with them, thinking through and grappling with questions about how being a parent or becoming a parent would change their identity, how they thought of themselves, how they interacted with the world, the impact on their job, their relationship with their partner or friends. They all were really wondering about and asking all of those questions while they were pregnant. And so I wanted to make sure that there was some sense of resolution around those questions so that we were able to follow them as they had wondered what the impact was going to be. And now let’s actually see a little bit of a glimpse of what the impact actually is.

Frost: And none of these three women experience postpartum depression, but they definitely had stories to follow, as you mentioned, but how common is postpartum depression?

Grant: It’s very common. I don’t know the numbers off the top of my head right now, but it’s something that again, kind of like miscarriages, it’s not widely talked about. And I think people can feel a lot of stigma and shame around it. And the sort of “baby blues” are pretty normal because as I said, your hormones are going crazy. There’s a lot of new things you haven’t slept. And so postpartum depression is really when that is sustained and happens over a long period of time.

And I think sometimes there’s this idea of like, oh the bliss of new parenthood and you’re sort of so happy and it’s an incredibly challenging thing which I think almost everyone certainly that I’ve encountered in my reporting or just in my personal life will acknowledge. And so I felt like it was important to be honest about how hard it is while at the same time getting to experience these characters. There are moments of joy that they had in meeting their new baby and figuring out kind of what their parenting style was and if they were things that surprised them.

That was something I tried to do throughout the book was really balance these very real fears and anxieties and concerns and like this is awful. But then also being able to sort of have those moments of celebration and excitement and possibility kind of woven in because I think that just being able to hold those things together is so much of what the entire experience really seems to be about.

Frost: How did you know when it was time to let go and stop reporting, because you’re so invested in these three women’s lives?

Grant: It was definitely strange after I decided like I’m gonna stop recording, I’m going to stop taking notes and then I would still be in touch with them and it just, it felt a little weird, not in a bad way, but I was just sort of so used to like taking rigorous notes every time we spoke and so just casually chatting, it felt nice. And I think I just wanted there to be a sense of a phase completed. With each of them, wanting to end the book in a place where they had sort of figured some things out, gotten into a routine, checked some sort of milestone, maybe whether that was going back to work or in Jillian’s case getting a midwifery credential. And so, yeah, I think it was really time to stop when it felt like the sort of questions that they had asked throughout their pregnancy were somewhat resolved.

Frost: Well, Rebecca Grant, congratulations on this book and thanks so much for joining us.

Grant: Thank you for having me,

Frost: Journalist Rebecca Grant’s new book is “Birth: Three Mothers, Nine Months and Pregnancy in America.” It comes out next week and she’ll be speaking at Powell’s Books on May 1st.

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