Book Review: ‘Birth,’ by Rebecca Grant

BIRTH: Three Mothers, Nine Months, and Pregnancy in America, by Rebecca Grant

The French existentialist philosopher Simone de Beauvoir provides an epigraph for “Birth,” Rebecca Grant’s exploration of pregnancy and childbirth in the United States. “Pregnancy is above all a drama playing itself out inside the woman between her and herself,” Beauvoir wrote in “The Second Sex” (1949). “She experiences it both as an enrichment and a mutilation.”

The words are jarring, in both their violence and their certitude. But coming as they do from a person who never actually was pregnant, they embody perfectly one of the major themes of this often compelling new book, which repeatedly drives home the degree to which childbearing has inspired philosophizing, moralizing, catastrophizing and politicizing — more often than not, from high-minded and influential parties with no firsthand knowledge of the experience.

There were, for example, the male doctors who displaced female midwives as bedside facilitators of birth, denigrating the women’s expertise and burnishing their own mystique — not to mention their fees — through sometimes questionable actions. There were the lawyers, insurers and hospital executives who helped turn the practice of delivering babies into emergency medicine. And, of course, there are the politicians and sometimes all-male panels of judges who continue to define the limits of women’s reproductive possibilities today.

T’Nika, Alison and Jillian, the three mothers-to-be whose pregnancies give form to Grant’s book, want nothing to do with the culture, beliefs and practices that stem from that history. Above all, they reject the idea that doctors know best, and that the safest, surest place to give birth is in a hospital. That’s why they’re all clients — and in Jillian’s case, an employee as well — of the Andaluz Waterbirth Center in southwest Portland, Ore.

Andaluz is a stand-alone clinic where parents with low-risk pregnancies are followed exclusively by midwives and can experience birth in a homey environment: on a queen-size bed, in a warm tub or on a birth stool, with friends, family, music and snacks nearby. It’s a place where T’Nika, an aspiring labor and delivery nurse, can have a water birth, receive nitrous oxide (laughing gas) for pain and be “seen and heard” — in sharp contrast with the belittling treatment she has received as a young Black woman facing a white, male medical establishment in the past. It’s a place where Jillian, a former doula who watched powerlessly as doctors steamrolled frightened laboring patients into a “cascade of interventions” they neither wanted nor, in her judgment, needed, can find support for a home birth. And where Alison, a teacher and “overachiever” who doesn’t like to feel out of control, can design a “natural” birth experience consistent with her composting, chicken-owning, vegetarian values.

The three women are willing to forgo the hospital-based comforts — or, critics might say, safeguards — that Andaluz doesn’t provide: epidurals and narcotic painkillers, blood transfusions and inductions, doctors who can surgically intervene, should serious complications arise during birth. That’s no light decision, and the horrendous levels of pain all three experience during their long days and nights of labor and childbirth will demonstrate the high cost of that choice. Yet they make it for weighty and worthy reasons.

Mainstream birth in America, for all its seemingly reassuring medical advancements, technological enhancements and exceptional levels of expense, is a shamefully risky business. Our maternal mortality rate is more than three times that of most other high-income nations. At nearly one in three births, our rate of cesarean section deliveries is considerably above the 10 to 20 percent level that public health experts consider an acceptable benchmark. Bad as those numbers are, they’re considerably worse for Black women, who are nearly three times more likely than white women to die or suffer serious complications from pregnancy and childbirth and have a higher C-section rate.

And then there are the many and varied permutations of personal insult in our profit-driven, racialized and unequal medical settings.

Jillian and Alison have each had a miscarriage, and both suffered the added injuries of cold treatment by the hospital staff. (Alison, who required a D&C procedure, informed both her obstetrician and her anesthesiologist that she didn’t want general anesthesia — only to be told that, since she seemed “kind of high maintenance,” she’d probably need even more of it. She only realized she’d been put under when she woke up.) And for T’Nika, personal and collective history combine to make the powerlessness that a partially paralyzing epidural would bring a terrifying prospect. A key reason she wants to give birth at Andaluz is that, for once, “she didn’t want to have her guard up.”

“Birth” is an important book. Yet it’s a frustrating one as well. Grant is a good storyteller, subtle and compassionate, but she can be inaccurate with numbers, language and the odd historical detail.

The social context she deftly weaves into her protagonists’ stories lends her work national scope. And yet her choice to focus on three women giving birth outside of hospitals — where 98 percent of deliveries currently take place — gravely undercuts the book’s ability to tell its promised story of “pregnancy in America.”

Ironically, Grant’s narrow scope does Andaluz, which she clearly admires, a disservice: Since both T’Nika and Alison end up in hospitals, where they opt for pain medication, the birthing center ends up losing two-thirds of the book’s sample to doctors, nurses and the midwives who work alongside them in a mainstream setting. That’s a rate that’s way out of line with the best numbers available for free-standing birth centers in the United States. (While high-quality statistics on transfer rates to hospitals are few, the most frequently cited and largest study to date puts it at less than 20 percent.)

And Grant would have done better by her subjects if, at the end of the book, she’d done more to contextualize the difficulties they face in their first weeks of postpartum life. The exhaustion, isolation, pain and anxiety — not to mention the logistical difficulties of running back and forth to medical appointments with new babies — are all heightened by the do-it-yourself exceptionalism of early motherhood in the United States. In other wealthy nations, longer hospital (and birth clinic) stays, and at-home midwife, nursing and lactation consultant visits are standard parts of postnatal care — regardless of new parents’ ability to pay. In Grant’s account, going it alone after childbirth seems inevitable. But it doesn’t have to be.

Judith Warner’s most recent book is “And Then They Stopped Talking to Me: Making Sense of Middle School.”

BIRTH: Three Mothers, Nine Months, and Pregnancy in America | By Rebecca Grant | 384 pp. | Avid Reader Press | $28.99