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Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. Birth in the United States is largely understood as a major medical procedure, best done in the hospital under the supervision of doctors, even though the use of midwives is on the rise. It's true that it's dangerous. Here in the United States, you've probably heard this, we've talked about it on the show, we have the highest maternal mortality rate among developed nations. It's 10 times more than some other high-income countries, including Australia, Austria, Israel, Japan, and Spain, according to NPR.

It bears repeating, Black women are three to four times more likely to die from childbirth than white women. This runs across income levels. Some researchers lay the blame at American women's poor heart health and levels of obesity, but a growing number of doctors and researchers are suggesting it's the system that's failing birthing people. The CDC estimates that 80% of pregnancy-related deaths are preventable.

Joining now to make the case that current medical practices around childbirth harm women and what can be done to change them is journalist Allison Yarrow. She has a new book called Birth Control: The Insidious Power of Men Over Motherhood. Allison, thanks for coming on for this. Welcome back to WNYC.

Allison Yarrow: Thanks, Brian. Thanks for having me.

Brian Lehrer: We'll get to the subtitle of your book in a bit about why you cite The Insidious Power of Men, but tell us, in general, why did you write a book about birthing now?

Allison Yarrow: It was curious to me when I went into the experience myself. I've had three births, that we don't really share our birth stories. I wanted to do so more formally, so I surveyed women and birthing people. I got about 1,300 people in my survey. My training as a journalist told me to talk to all the experts, so I did that, too. I talked to doctors and midwives, doulas, anesthesiologists, everyone who touches women and birthing people. I wanted to understand more about the system and more about individual experience.

What I found in doing all of this research is that it is in fact the system that is broken. It's not individual people giving birth. We have a system in which we are using tradition over the best evidence-based medicine. What that looks like is when you enter a hospital in labor, 99% of childbirth happens in the hospital. When you show up, you're administered a pelvic exam, perhaps you're coerced or asked to do it without the ability to consent to it. You're strapped to an electronic fetal monitor. Perhaps you're administered Pitocin, a synthetic oxytocin to speed up or start your contractions.

Then maybe if doctors are ready to leave, it's dinnertime, maybe you're given a C-section. All of these procedures that I just described are not really supported by the best evidence that we have. Their use is based on old studies, and what we know is that the managed care model of childbirth in the US where birth is an individual process and should be cared for by folks taking care of individuals. When it's managed care, few people taking care of many births at once, the financial incentives are great but the care is poor.

Brian Lehrer: Let me get one terminology question out of the way. What you just said and the way you use words in your book, you use the word mother and you use the term birthing people. Obviously, there's been a lot of discussions here and elsewhere about which term to use and what really respects women. How did you incorporate or think about using those terms?

Allison Yarrow: Most people who give birth identify as women and mothers, but not everyone does. I use the term birthing people to encompass the people who give birth, who don't identify as women and mothers.

Brian Lehrer: Listeners, we can take some phone calls with your birth stories, perhaps what you learned, and what you might like to pass on to our listener community. Call or text us at 212-433-WNYC, 212-433-9692 for Allison Yarrow, whose new book is called Birth Control: The Insidious Power of Men Over Motherhood. All right, let's get to the men part. I'll pick one fact, you write, "Men created due dates." Discuss.

Allison Yarrow: Yes. About 5% of people give birth on their due date, which is pretty low. It's probably better to talk about a due month or a due timeframe. There isn't a lot of evidence to support that babies must be born by a certain time. In fact, there was a study that supported inducing everyone at 39 weeks gestation. "Let's just get you in, let's get you into the system. We'll give you the medicine. We'll put labor under our control." That isn't better for women and for birthing people to do that.

Historically in this country, the way that birth was founded in this country was, it was attended by indigenous and Black midwives and they trained apprentices, and it was a tradition where women gathered to witness birth. This was stripped away as white men decided to go to Europe and attend medical school, come back to the US, set up practices, and they wanted to take care of childbirth because that was what was happening. They learned from midwives, they learned their techniques, and eventually, they stole birth away, promising procedures and tools, medical arts, and drugs. They said it's safer this way, come to the hospital and everything will be fine and better.

As you noted earlier when you introduced me, maternal mortality has never been higher in my lifetime. We have to question the procedures and the practices that are being done, and we have to tell stories. I mean, that's the other really important thing here is when we tell our birth stories, we alert others to what is possible in childbirth. There's a lot of evidence that midwifery-led care, the midwifery model of care, is the way to go.

Brian Lehrer: You cite a 2013 report titled, The Early Pregnancy Study, that found that a normal pregnancy length in healthy people can vary up to 37 days or more than 5 weeks. Do you think that part of the excess maternal mortality rate in the United States compared to other high-income countries has to do with inducing?

Allison Yarrow: The maternal mortality rate in this country is incredibly complicated. I think what's more responsible for what we're seeing is the care, is the foundational patriarchy and white supremacy in the care. What that looks like from the research is our C-section rate is about a third of all of the births that are happening in this country. That's over a million C-sections a year. The majority of them are not necessary. They are wonderful technology to have in rare instances when there is something like placenta previa, which is a condition where the placenta is blocking the baby's exit.

We need to get that baby out another way, and so C-section is wonderful for something like that. It's great that we have it, but C-sections are being overused. So many people are having them that the risk for-- C-sections creates a risk for hypertension, for sepsis, for hemorrhage, which are all related leading causes, in fact, of maternal mortality. C-section is not being examined as closely as it should be as a factor here in the maternal mortality rate.

It probably will not surprise you to know that the group with the highest C-section rate, the racial group, is Black women. Black women are receiving more C-sections than any other group in the country, and they're also the women more likely to have adverse outcomes for maternal and fetal health.

Brian Lehrer: Why do you think more Black women have C-sections?

Allison Yarrow: I think based on the research that I've done, that more Black women have C-sections because there's interesting research into this. Historically, if you look at old medical textbooks, which I had the opportunity to do in researching this book, there are ideas that come from anthropology and from early obstetrics that position the Black body as animalistic as not deserving of the same quality of care as the white body, the white body being more frail and more needing of care. This has evolved into, you can see in the texts and in the research, this has evolved into an idea that Black women's pain is not taken as seriously as white women's pain.

You can see that in the hospital now. I spent time with a woman named LaToya who told me in detail about her C-section and what it was like, and the dehumanizing way that it felt. This is actually the case for C-section for everyone. They're all of these elements of C-section that are done to people under the auspices of like, "This is going to make you safer," but we know that we don't have to do all of these things. For instance, when you-- I actually also heard of a story, Liz who had a-- what's called a gentle C-section.

Sometimes you do need to have a C-section, but there can be ways to make it a better procedure. You can visit the operating theater beforehand. Any woman could come do this, could meet the surgeon who's going to perform the procedure. Often people don't realize that when you have a C-section, you're restrained, your arms and legs are strapped down. That's not because they need to be. That's for the doctor. That's for the comfort of the doctor, not for you, but that's incredibly-- women have told me, LaToya and Liz both told me about this. They told me how dehumanizing that felt.

There are ways in which we can better these experiences, what's called a gentle C-section, what Liz had. She was able to visit the operating theater, to meet the surgeon, to have her baby handed to her immediately, to watch the birth through a clear screen. It was such an empowering experience, to breastfeed immediately, and everyone, no matter who they are giving birth. If you need a C-section, you should have the opportunity to have it.

Brian Lehrer: Let's take a couple of calls. One from a woman who's going to describe a good experience, someone else is going to describe a bad experience that relates to something you write about in your book. Let's go to Stacey in Rockville Center first. Hi, Stacey, you're on WNYC.

Stacey: Hi, thank you so much for taking my call. Yes, when I gave birth to my second son, when I came into the hospital, I had politely let the nurses know that my goal was to have an unmedicated birth, and they responded in a quite, what I interpreted to be adversarial manner that their goal was to have a healthy child as if that was not also my goal. Then I had a doula with me. I was induced because my water had broken and there were other reasons why they wanted me to be induced. I was hooked up to all the monitors, but I was moving around a lot because I wasn't having any pain medication, which was my choice and was fine.

Then when it was around 2:00 in the morning, they said that they weren't seeing any progression, and they were going to give me more Pitocin. My doula said, "She is progressing. The monitors just keep falling off because she's moving around to try to keep herself comfortable." I said, "Can I at least speak to my doctor first?" They said no, and they gave me the Pitocin. Then, shortly thereafter, it was time to push, which to me not being a doctor said like, "I was ready to push." It was they weren't hearing all the information, and I don't know if legally they needed to contact my doctor, but I felt like I had asked to speak to a doctor and was denied that option.

Everything turned out fine. My son was healthy, but it wasn't what I had. It certainly wasn't what I wrote in my birth plan if I had written one.

Brian Lehrer: Stacey, thank you for that story. Oh, I thought Stacey was going to tell a more positive story than that, but it really exemplifies some of the things in your book, Allison, and I think so will Judy and Katona. Judy, you're on WNYC. Hello.

Judy: Hi. Thank you for taking my call. Mine isn't just massive a story, but this is my first child's birth in 1990. I had actually switched OB practices because there was a male doctor at the practice I was at who had a very high percentage of C-sections compared to the other doctors there and I knew there was a chance he might end up being my delivery doctor. I switched to an all-woman practice about five months during the pregnancy.

At some point, a couple months later, I came in with a birth plan, and the doctor, a female, who saw me that day, said that I didn't want medication and that I did not want an episiotomy and all the things the birth plan might have had, and she took a red pen, sitting right in front of me across the desk and she marked out input as if she were grading a term paper and scratched things out on it. When the time came for my delivery, she was not the doctor, the doctor said, "I'm going to do a little nick of an episiotomy," and that was not my plan. I knew all about stretching exercises and all these things I had been doing and I wanted done at that time.

I'm not in a position to argue with my doctor while I'm delivering. She did a little nick of an episiotomy which thereupon tore into a much bigger tear, which likely would not have happened now that the integrity of the vagina was lost, or the vulva. That was my other story, is the routine use of episiotomy which actually can be avoided.

Brian Lehrer: Judy, thank you very much. You've got stats on that in your book, right, Allison?

Allison Yarrow: I do. Yes, Judy, I'm sorry. This is a story I have heard. I've heard a version of the story many times before. Episiotomy is a cut in the perineum, and generationally, it's been something that doctors used to do all the time. It's a surgical procedure, so you're supposed to report these numbers. It's very hard to get these numbers from hospitals. It's very important that we understand them because the higher the rate of episiotomy at a hospital or with an individual provider, the greater chance that you as a birthing person or woman will show up and get one, whether or not you need one.

The best research that we have about episiotomy actually shows that it really is hardly ever called for if ever. I think one of the researchers said, to move toward a more humane childbirth, we would need to eliminate the use of episiotomy. The Leapfrog group, which is a healthcare watchdog, found that at some hospitals, the rates can be as high today as 40%. This is a procedure that is very difficult to heal from, and it's very invasive. Even though I didn't ask specifically about episiotomy in my survey, those who shared with me that they had an episiotomy, more than half of them, were not able to consent to the procedure.

To have a surgical procedure without consenting to it is medical battery. There's just no other way to look at it. I interviewed medical battery lawyers for this book. We must be able to exercise informed consent and refusal in our medical care, and in our birth care because it is the law, and it means that when you go to see your provider, and they want to offer you a drug or a treatment, they have to explain what it is, and they have to equalize your ability to say yes or to say no. If they try to manipulate you into saying one or the other, then that's breaking the law.

Brian Lehrer: Yes. That stat in your book, 59% of women who had an episiotomy, that cut during labor, according to a 2013 Listening to Mothers Survey, 59% who had the episiotomy said they did not consent to being cut. In addition to some mentioning that healing from their episiotomy was a grisly process. Let me read you a couple of texts that have come in. Let's see. Listener writes that she supports both C-section and having a midwife and apparently doesn't want to see them posed as opposite. She writes, "I'm all for the general thesis, but as an older mom whose son's life was saved by C birth, attended by a midwife, I have to offer gratitude for the procedure." What do you say?

Allison Yarrow: It's complicated. I think what we would need to have happen, and it's a simple idea to better birth for everyone, is to center the person doing it. The woman is the expert in her body and the expert in her care. I think with everything that I've shared so far, and what I report in this book, we need to understand that when a doctor is saying to you that your life is in danger, or your baby's life is in danger, we have to understand and trust that our care providers are really telling us the truth, because what I've seen in my research and from anecdotes that I've heard, that's not always the case. Often doctors will say things like that to coerce care, to do C-section, to do episiotomy.

There's a story in my book. A very brave nurse told me a story of witnessing a manually done episiotomy in a hospital. She was attending a birth, and the birth was not apparently going fast enough for this doctor, and he was trying to lower his episiotomy rate. Instead of cutting episiotomy, he used his hands, and another nurse in the room felt-- she thought that that was just a normal procedure because she's seen him do it so many times, but that's also medical battery.

When we have a birth system in which "this kind of care", I put that in quotes, is happening, we have to question when our providers are telling us that our lives are in danger because it cannot always be the case. I'm not questioning or doubting what this woman is sharing, because it is her story and her experience, and I hear her, and I want to validate what she's saying. I just think it's incredibly important that when we are giving birth, we are centered as the experts, and the people who are caring for us and for our bodies are in partnership with us and are letting us lead, and that's not what's happening today.

Brian Lehrer: Last question coming from a listener. This is a text message that says, "What strikes me as a mother of two is the lack of personalized postpartum care, including mental health support in this country." Other people are writing about how birth is such a traumatic experience and they don't think it needs to be, so that's a number of people writing about that. I know that's in your book too, but this listener continues. "My friends and I have spoken about this at length, and as I and quite a few of my peers experienced postpartum complications that were preventable or could have been minimized if our symptoms were taken seriously earlier on."

We do end on that because I've also read elsewhere, I'm not sure if this is in your book, too, that so much of what we call maternal mortality actually happens after birth, in the first year after birth.

Allison Yarrow: Yes, that's right. I'm so glad that this person brought up postpartum care. In this country, it is almost completely absent. There's very little. Some 95% of people say that they have some unidentified risk or need in the postpartum period. About a quarter of people who give birth go back to work within two weeks of doing that. Birth is a major body event. It's something that we need care, we need recovery. There are the postpartum mental health conditions that go undiagnosed or misdiagnosed. I write about in the book, postpartum post-traumatic stress disorder, which is something that happens. People experience PTSD from birth.

When 45% of people describe their birth as traumatic, there is PTSD that comes with that. It's incredibly important that we honor the person giving birth. Too often, I think part of the reason that the postpartum care is so poor is that we're so focused on the baby. Just get the baby out, the baby needs to be healthy, the baby needs to be safe. We say those things and think those things, we want to go over and hold the baby, to the exclusion of the well-being of the mother. It's just so important that we give the mother respect and screening for postpartum mental health. Paid leave and subsidized childcare would do a tremendous amount to support families, to support breastfeeding initiation and continuation.

I think it would result in what we need, which is having a birth experience that is transcendent. I had three birth experiences, two in the hospital, and one planned at home. My planned home birth was the most just sacred, transcendent, empowering experience under midwifery care with a doula. No matter what kind of birth you have, you deserve to have that experience. Everyone deserves to walk away from their childbirth feeling empowered, safe, healthy, and just entering back into the world with these feelings, and with the state of being. That would just change the world.

Brian Lehrer: You mentioned paid family leave. Anything else you'd put on the table as we run out of time at the policy level to try to address all these problems? I could tell you, we could keep taking phone calls that back up some of the horror stories in your book and some of these statistics that are really shocking when people learn them for the first time. We could take calls all day. There are so many people wanting to get in. At the policy level, okay, paid family leave, what else is at the top of the list?

Allison Yarrow: Subsidized childcare, the Momnibus bill which has been introduced would do so many things to support Black maternal health and to end Black maternal mortality as we have come to know it. We need all of these things. We need to be with our families during this time. At the policy level, there are so many good people doing incredible work on this topic. The New York City Doula Program is another fantastic piece of this. You can access free or low-cost doula support in New York City if you meet a certain income threshold, and doula support is so important because it reduces C-sections. It encourages breastfeeding initiation.

People who have doulas appraise their births better, there's less birth trauma, and it's something that the city is providing, and there are also public-private partnerships that are doing this. The Mama Glow Doula Foundation is another partner in this, and I think we need to see policy that supports birth or getting the support that they need and not care that is based on tradition and not evidence.

Brian Lehrer: Allison Yarrow, her new book is Birth Control: The Insidious Power of Men Over Motherhood. Thanks so much for coming on.

Allison Yarrow: Thanks, Brian.

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