Cuts You Up
A ceramic ape bares his teeth from his perch on a bookshelf in the Kendall townhouse where Cher Durham is preparing to deliver her first child. A quizzical little monkey in a framed print stares at midwife Corina Fitch from the dining room wall as she settles herself under a blanket at one end of a couch in the Durhams' living room. Having delivered more than 150 babies and witnessed 300 more births, the midwife knows from the serene expression on her client's face that delivery is a far way off. Still Fitch, a registered nurse as well as a licensed midwife, measures the expecting mother's progress: The usually thick tissue of the cervix is now paper-thin and is beginning to part ever so slightly for the baby -- a process that could take a first-time mother ten hours or more. The Durhams are in for a long wait.
Johnnie Durham has been up half the night already. The head primate keeper at Monkey Jungle met his wife at the attraction while she was studying primate biology at Florida International University. Soon the pair were dating and Cher was working at the park too, preparing the animals' diet. They married at Monkey Jungle in May 2003. Nine months later, at 5:30 in the morning of February 18, the father-to-be distracts himself by bouncing on an enormous plastic ball that the couple learned in childbirth class could help relieve back pain during labor. Johnnie flashes his wife a chimp's grin when she walks past, his extra-long sideburns almost touching the strained outer corners of his lips. Cher is too uncomfortable to be amused.
The enormous stomach and breasts protruding from her petite frame make 32-year-old Durham almost as round as her exercise ball. Her tawny hair is pulled back into a severe bun, revealing a freckled Irish face and light-blue eyes set in a determined squint. She pads into the kitchen, peels a pair of athletic socks filled with rice off her shoulders, and places the fuzzy tubes in the microwave. When Durham lies down again in the couple's bedroom -- the air thick with incense, candlelight, and birdsong twittering from a battered boom box -- her husband gently presses the warm rice socks against the lower curve of her aching belly. All night long Durham watched the couple's pet sugar gliders chase each other around the wooden cages stacked outside the patio door while her mind replayed the objections to home birth raised by her friends and family: What if something goes wrong? Now as the tiny marsupials nestle down to sleep for the day, she tells herself: If I can do this, I can do anything.
Durham had not expected to wait until so late in her pregnancy before going into labor. She had been sure the baby would come on her due date, February 7, the night of the full moon. Had she followed the example of her sister-in-law and gone to Baptist Hospital to give birth, as she originally planned, she almost certainly would have delivered by Valentine's Day; her doctor, following the guidelines of the American College of Obstetricians and Gynecologists (ACOG), most likely would have induced labor by her 41st week of pregnancy. Instead at 1:00 p.m. on February 14, a still-pregnant Durham hauls her bulging belly to a rally outside South Miami Hospital, where her midwife has organized one of the twenty anti-ACOG demonstrations taking place that day across the nation. Representing more than 40,000 doctors in the United States, ACOG sets guidelines for obstetric practice. Because ACOG is the primary professional organization of ob/gyns in the country, those guidelines help establish the standard of care by which doctors are judged in malpractice suits. The protesters believe that ACOG promotes a level of medical intervention in birth that is at best unnecessary and at worst deadly.
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Durham joins a group of 30 or so natural childbirth advocates handing out flyers that decry the nation's rising cesarean section rate. In 1990 the U.S. Department of Health and Human Services set a target c-section rate for the country by the year 2000 at fifteen percent, the same number recommended by the World Health Organization. But the National Bureau of Health Statistics reveals that in 2002, the most recent official count, the national cesarean rate hit an all-time high of 26.1 percent. The statewide rate in Florida is currently 32.4 percent, and in South Florida the rate at most hospitals is higher still. At 50 percent in 2002, South Miami Hospital had the highest rate in the area, but the latest figures from the Florida State Center for Health Statistics show that at Baptist Hospital, Durham's initial choice, the c-section rate is 41 percent.
Activists link the rising rate to a series of ACOG positions that they believe promote cesarean section over vaginal birth. Critics are especially concerned about 1999 ACOG guidelines that warn that the scars left from the surgical incision during a c-section place mothers at a slightly higher risk of rupturing the uterus when delivering subsequent babies vaginally. Although the risk is statistically low, the organization recommends that hospitals have an emergency surgical staff on hand throughout labor whenever a woman is attempting a VBAC (vaginal birth after cesarean), a requirement too costly for most hospitals to meet. Eager to follow ACOG recommendations, a growing number of doctors and hospitals refuse to do VBACs at all. Critics fear that the rate of cesareans will soar even higher since ACOG released a document in October 2003 that they believe promotes "elective cesareans" -- surgery not prompted by any medical necessity, but by a woman's "choice." Concerned that expectant mothers tend to "choose" whatever their obstetricians recommend, the women stalking the sidewalk outside South Miami Hospital on this windy Valentine's Day hold purple balloons emblazoned with the words: Cesarean is dangerous, risky, and major surgery. Durham dons a sign that says: Women of Earth/Take Back Birth.
When a group of medical personnel in scrubs emerges from the hospital, Fitch, the militant midwife calls to them: "One out of every two women that come to this hospital [to give birth] will be cut open by cesarean." Seeing the group pause, Fitch presses on: "Women are twice as likely to die from a c-section as from a natural birth."
By temperament and birthright, it seems, Fitch was destined to be a midwife. She was born in 1974 in the converted school bus where her parents lived on the Farm, the famous commune established south of Nashville in the Seventies that also happens to be known as the birthplace of modern midwifery. She was delivered under the watchful eyes of Ina May Gaskin, a leader in the natural childbirth movement and author of the influential book Spiritual Midwifery. Ten years later, the Fitch family moved to South Florida along with two of the Farm's most capable midwives. Mother Claire Fitch, a biologist and lab technician who assisted the midwives in Miami, would come home with vivid stories about each delivery. Her daughter would listen spellbound.
As an adult, Fitch returned to the Farm to apprentice with Gaskin, whose practice currently boasts a two percent cesarean rate. That experience inspired Fitch to enroll in the midwifery program at Miami Dade College, where her mother taught the section on prenatal and postpartum lab tests. She graduated in 1999, then completed her studies to become a registered nurse a year and a half later. This year Fitch opened her own practice in Miami, called Birthright. When she learned of the national day of action against ACOG, she took it upon herself to mobilize her clients, fellow midwives, and friends.
The 300 pamphlets that Fitch had printed up for the protest run out quickly, and a second batch copied on the fly disappears within the first hour. Fitch drew much of the material for her pamphlets from the writings of Henci Goer, author of The Thinking Woman's Guide to a Better Birth and one of ACOG's most outspoken critics. "No objective person can believe that one in four women needs major surgery to be a healthy mother having a healthy baby," the medical writer tells New Times over the phone from her office in California. Not content to let the numbers speak for themselves, Goer reviews childbirth research and claims to have analyzed more than 3000 studies. In publications widely circulated among natural childbirth advocates, Goer debunks ACOG's positions and essentially lays out the party line. She contends that scheduling c-sections, rather than waiting out the unpredictable and often prolonged course of vaginal delivery, allows hospitals to charge more for the surgery while reducing the cost of maintaining a round-the-clock obstetrics staff. Doctors also save time and, by conforming to ACOG-mandated standards of care, ward off potential malpractice suits. The patients' well-being is not a factor because, Goer argues, "The people who benefit by the [ACOG] guidelines are writing the [ACOG] guidelines."
Dr. Laura Riley, chair of the ACOG committee on obstetric practice, points out that the organization's positions do not directly dictate medical procedures. "ACOG can only provide guidelines; how people actually use the guidelines is not something we can control," she says. "We're trying to provide education so that doctors can provide the best care."
Riley stands by ACOG's position on VBACs. "In general [VBAC] is a safe procedure, but sometimes things go wrong," she explains. "There's a whole long list of situations where we need to think that maybe we shouldn't be doing a VBAC." But if the ACOG recommendation discourages some doctors and hospitals from doing VBACs at all, Riley insists that is only a minor factor behind the rising cesarean rate. She lists what she sees as more pressing reasons: "We don't do breech [births] vaginally anymore. Women are heavier during pregnancies. They have bigger babies; the babies don't fit. Women are older."
Riley believes that critics have misunderstood the organization's position on elective cesarean. The October 2003 document, she says, "was not about cesarean delivery." Rather it was a discussion of the ethics of talking to patients about elective surgery and "used elective cesarean as an example." As an obstetric practice, she clarifies: "At this point we don't agree with elective cesarean delivery." Riley directed New Times to the ACOG press office for what she called a "restatement" of this position, but she could not specify when the restatement was released. ACOG press liaison Amanda Hill speculates that Riley must be referring to the February 19 response by deputy executive vice president Stanley Zinberg to a Washington Post op-ed piece objecting to the college's position. Far from stating any disagreement with the practice, Zinberg writes: "The jury is still out on whether elective cesarean will become a standard of care or commonplace within the delivery room." In the meantime, he concludes, ACOG is simply responding to what women want: "Women themselves are raising the elective cesarean issue with their doctors -- not the other way around."
Had the Valentine's protest been on any other day of the week, Janessa Wasserman would have been there, holding one of the purple balloons that read "Bring Back VBAC." Adhering to her Orthodox Jewish faith, Wasserman keeps the Sabbath on Saturday, so she sat out the protest at home with her husband and three children -- the youngest delivered by Fitch less than two months before. The 30-year-old attorney/homemaker first heard about the rally when she called the midwife in a panic; her obstetrician had attempted to dissuade her from having a VBAC, suggesting she schedule a c-section instead. She had delivered her first son by cesarean and never wanted to have that experience again. "I was so naive," she remembers. "You grow up and you trust doctors: They know you better than you know yourself."
When Wasserman gave birth to her son at Mount Sinai Hospital on Miami Beach in 1998, she had a fairly typical hospital delivery. She was given Stadol for pain relief and Pitocin to speed up labor. She was hooked up to an internal monitor to keep track of the baby's heartbeat. Drugged up and plugged in, she felt detached from her body. It didn't help that her family began to ignore her, watching the monitor instead. "I could be screaming, but they would say, It's not that bad, because that's what the machine says," Wasserman recalls.
After fourteen hours, Wasserman was informed that her labor was "failing to progress" and that she required surgery. "They said they were concerned about the baby," she remembers. "They were concerned about me." The operation went well. "The surgeon had a lot of experience," Wasserman observes wryly. (Six years ago, Mount Sinai's cesarean rate, now 38.8 percent, had already topped 30 percent.) Yet she remembers feeling "devastated." She was depressed about the delivery and says she did not fully recover physically for a year afterward; she is still numb where her nerves were cut to make the incision.
So when Wasserman discovered she was pregnant again two years later, she sought out Devorah Stein, a friend who had graduated midwifery school with Fitch. The two Orthodox women live within a mile of each other in North Miami Beach; their families worship together at the Young Israel of Greater Miami synagogue. Wasserman paid attention whenever Stein, who had survived her own unpleasant c-section, talked about alternatives to hospital birth. The attorney began to research her delivery options the way she'd studied for the bar. "There wasn't a philosophical reason why I didn't want to have an epidural or an induction," she explains. "I did not want to repeat what had happened to me. I was going to do the exact opposite of what I did with [my first son] with [my second]."
Wary of depending exclusively on a midwife to deliver her second child, Wasserman hired Stein as a doula, an advocate for a woman during labor. She found a doctor, Wayne Di Giacomo, willing to give her a VBAC. Though one of the few doctors willing to perform such deliveries in South Florida, Di Giacomo is no renegade. He blames doctors' fears of malpractice suits, not ACOG, for the rising cesarean rate. "It makes no sense [for doctors not to do VBACs]. None whatsoever," he insists. "If you take away [the threat of] liability, you can practice medicine the way it should be practiced." Following ACOG guidelines, Di Giacomo advised Wasserman on a Thursday, as she approached 41 weeks of pregnancy, that if she didn't go into labor by the weekend he would induce her. "I was afraid the whole thing was being set up again," Wasserman remembers. So she took extract of blue cohosh, an herb midwives believe naturally induces labor, and drank a root beer float laced with castor oil, another homeopathic remedy. On Friday afternoon she turned to her husband, a professional acupuncturist with an office in Aventura, for treatment. Two hours later she began the early stages of labor.
On Saturday afternoon Wasserman went to Stein's North Miami Beach birthing center, where she labored for 25 hours, going to Aventura Hospital only when she was on the verge of pushing out her son. Because she labored so long, she remembers Di Giacomo telling her over the phone -- again following ACOG guidelines -- that if she did not deliver by 10:00 p.m., I'm going to cut you. Wasserman delivered her son Efrem at 9:59 p.m. When the baby weighed in at seven pounds and fifteen ounces, Wasserman recalls that the doctor observed: If he had been any bigger, I would have had to cut you.
Three years later Di Giacomo, who delivers twenty or more babies a month, no longer remembers Janessa Wasserman or anything he might have said or done during her delivery. Yet he has had enough clients like her, who do not like the level of medical intervention typical of hospital births, that he opened A Birth Center last summer near the Memorial Regional Hospital in Hollywood. If more women demand more control over their care, Di Giacomo says, obstetricians will have to accommodate them. "Consumer demand drives the market," the doctor observes.
After delivering her son without surgery, Wasserman remembers feeling as if she didn't need a wheelchair to carry her to the recovery room. "I wanted to run a marathon," she says. "I had so much energy." To this day Wasserman considers natural delivery "the single most empowering moment of my life."
On May 16, 2003, not long after Cher and Johnnie Durham returned from their honeymoon, the newlyweds realized that the night would bring a lunar eclipse. An avid student of nature, Cher has a moon tattooed on her right shoulder and a sun on the left. The moon seemed to follow the couple everywhere: They first met at Monkey Jungle outside the cage of the Diana monkeys, primates named for the crescent marking on their foreheads that connects them to the Greek goddess of the moon and of motherhood. Although they had not planned on starting a family quite so soon after the wedding, Cher felt the universe was giving them a sign. At that moment the sun, moon, and Earth aligned, she says, the couple conceived.
The Durhams had an inkling that they might like to try natural childbirth, but once the pregnancy was confirmed, Cher sought the Obstetrics and Gynecology Associates of Kendall, the practice that successfully delivered Johnnie's sister's twins at Baptist Hospital. "It's not like there's a lot of information out there," she notes. Then the Durhams signed up for a five-week session on Wednesday evenings at a Baptist Hospital outreach center near their home. Durham sat with her husband, taking in every word uttered by Judy Resuzenko, a licensed nurse and certified doula. The teacher went around the room, asking everyone to share with the class their greatest fear about childbirth. Johnnie joked that he was afraid of "the hospital bill." Cher was serious: "I was more afraid of the epidural than the birthing process." She was terrified of having a needle filled with painkiller jabbed into her spine. "People say, Why would you want to feel the pain if you don't have to?," Durham recounts of the reaction when she told her friends and family that she had changed her mind about a hospital birth. She rehearses her reply: Why would you want to be medicated if you don't have to? Why would you want a needle in your spine?
What resounded most with the Durhams, though, was when Resuzenko told the class: Your body is naturally capable of giving birth. The message appealed to biology majors Cher and Johnnie. Cher felt a spiritual connection to the natural process. Johnnie felt a Darwinian security, inspired in part by the many mornings he arrived at work to find primate babies born in the night without any medical assistance.
Cher shared her doubts about going through with a hospital birth. "What if we did something alternative?" she asked her husband. "Whatever you feel comfortable with," Johnnie reassured her. Looking for a midwife in the yellow pages, the couple didn't go too far into the alphabet before an ad caught their eye: Birthright, free consultation, Corina Fitch.
The mother-to-be kept her next appointment with the obstetricians in Kendall as a courtesy, to relay in person that she would no longer require their care. But Dr. Manal Saad Antoun, her physician that day, was not supportive. "Why not?" Durham remembers her asking sarcastically. "Women gave birth alone in the woods for years before there were doctors." She warned her errant patient not to expect to be treated by the practice if there were any complications. Her office charged the Durhams to release Cher's medical records. (Dr. Antoun could not be reached for comment.) "If I had doubts about those doctors before," Durham says, "they were confirmed that day."
By the time Janessa Wasserman found herself pregnant with her third child in the spring of 2003, her friend Devorah Stein was also pregnant, with her sixth, and no longer practicing midwifery. Determined to deliver her third child naturally, Wasserman hired Stein's friend Fitch and sought out another doctor who would perform a VBAC. She called a number of practices before finding William Shure, the head of obstetrics at Memorial Regional Hospital in Hollywood. Wasserman used her lawyer's skills to do a thorough background check on Shure: Trained in New York, he has been in practice since 1979 and has no outstanding malpractice suits. Here was a physician she could trust.
By the time she was 30 weeks pregnant, though, Wasserman got the feeling that her doctor was developing amnesia. "I couldn't fault him, because he sees so many women," Wasserman grants. Yet she could not help feeling distressed every time Shure would glance at her chart and say, "Cesarean, right?" She would answer: "No, VBAC." They would go through the same routine every visit until two weeks before her due date. "This is really upsetting me," she says she told the doctor. "We met with you specifically to see that there's no problem doing a VBAC." The distressed mother claims the doctor hedged: "Well, Memorial has only had one VBAC in the last month." As she sat on the examining table, it dawned on Wasserman that the doctor had no intention of doing a VBAC. Still she could hardly believe what she heard next.
"I believe all babies should be born by cesarean," she recalls him saying.
"Do you mean all VBACs or all babies?" she asked, incredulous.
"All babies should be born by cesarean," the doctor clarified. "Better for mom. Better for baby."
Shure, who delivers roughly ten to twelve babies each month, tells New Times over the phone that he does not remember a patient named Janessa Wasserman. In any case, Shure insists that he never made any of the statements Wasserman attributes to him. "I do VBACs all the time," he maintains, before asking himself aloud: "I wonder why a VBAC would be a problem in this case?"
Whatever transpired in Shure's examining room, Wasserman found herself looking for another doctor two weeks before her due date. Fitch recommended Mark Spence, an obstetrician based in North Miami. Born in Jamaica and raised in New York City, Spence did his residency at Bronx-Lebanon Hospital Center, where he says the staff kept cesarean sections down to twelve percent of all births.
Like Di Giacomo, Spence believes the rising cesarean rate is driven by perceived liability rather than real health benefits and risks. "A lot of info we're using now is more protective to the physician," he points out. "Everybody is so worried about being sued, we're not paying attention to the experience." For Spence, what the expectant mother and her family want carries as much weight as any controversy over obstetric practice. "Forget what ACOG says; forget what the midwives say. Anybody can manipulate the data to say whatever they want," he suggests. "At the end of the day, I'm going home and you're the one with the baby. Even if you take two million dollars out of me. How you want it is how it should be. What can we do to make you comfortable? Comfortable and safe."
Wasserman says she felt comfortable and safe in Fitch's hands. "It was so peaceful and calm at home," she remembers. Yet after eleven hours of labor her lingering fears prompted her to go to the hospital as planned: "I still had in the back of my head: You have a scar. Something could go wrong. You have to go to the hospital."
Although his practice delivers 25 to 30 babies a month, Spence remembers Wasserman well. "Since her [previous] doctor said, I'm going to cut you, that took away a lot of her confidence," Spence surmises. He remembers the fear he read in her face: Was my doctor right? Is this person going to treat me the same way? Is he going to see a blip on the monitor and cut me?
Wasserman was so panicked about potential intervention that she locked herself in the hospital room's tiny bathroom rather than allow herself to be hooked to the fetal monitor. The exasperated nurses noted Wasserman's lack of cooperation on a chart, then left to attend to other patients. Fitch waited patiently outside. She did not call the nurses or the doctor back into the room until the baby's head had crowned.
By that point, Wasserman had placed herself on her hands and knees on the floor, a stance Fitch recognized as the Gaskin position helpful in dislodging babies whose shoulders get stuck in the birth canal. Not schooled in midwifery, Spence told Wasserman that as a VBAC, according to hospital protocol, she would have to get on the bed where she could be better monitored. "They're the deep pockets," the doctor deferred to hospital administrators. Shortly afterward Wasserman pushed out the head and -- despite a short delay because, sure enough, the shoulders were stuck -- she pushed out her daughter's body. At eight pounds, four ounces, Talia was her biggest baby yet.
Cher Durham reclines naked on her bed. Her enormous breasts rise and fall as her stomach heaves with every push. Her husband Johnnie sits beside her, holding her hand and caressing her leg. He murmurs encouragement in her ear: "Good! Oh, beautiful!"
"As the head comes closer, you're going to feel burning," Fitch warns. "It's your tissue stretching."
"Oh, God," Durham moans.
With a slender gloved hand, Fitch massages olive oil into Durham's straining vagina. A few drops fall onto the midnight blue shower curtain covered with constellations that protects the mattress. The crown of the head appears, framed by Durham's legs.
Durham whimpers. A tiny head covered with slick black hair bursts out. Durham's vagina is like a red flower ringing the baby's neck.
"Oh, God, I can't believe it," she moans.
"When you get the next contraction," Fitch promises, "you're going to push out the baby."
"Whooooooooaaaaaa," Durham wails in a rising tone.
The body does not come out with the next push. For a moment the baby is stuck, snagging her mother's insides with her left hand. Durham feels the strange sensation of the little body wiggling inside her.
"Push, sweetie, push," the midwife coaxes.
Durham responds with a guttural moan.
"Push. One more. Push."
All at once the body slides out. The baby stuffs her left hand in her mouth. It is 3:07 p.m. Fitch puts the infant on her mother's chest, and swaddles the girl in a purple towel. A white translucent cord connects mother and child.
"Hi, baby," Durham murmurs through tears. She stares into her daughter's dark eyes, strokes her hair. The baby girl reaches for her mother's face with her left hand.
Suddenly Durham looks up and announces: "I'm so proud of myself."
She is not moaning anymore; the pain and discomfort washed away in a flood of adrenaline and endorphins. "I can't believe I did it naturally," Durham says, resuming a conversational tone. The new mother is already imagining how she will pass on this story to her daughter. "I can't wait to tell her when she grows up that she was born at home. I feel like I can do anything now."
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