the business of baby: what doctors don't tell you, what corporations try to sell you, and how to put...
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Tis publication contains the opinions and ideas o its author. It is intended to provide helpul
and inormative material on the subjects addressed in the publication. It is sold with the under-
standing that the author and publisher are not engaged in rendering medical, health, or any
other kind o personal proessional services in the book. Te reader should consult his or her
medical, health, or other competent proessional beore adopting any o the suggestions in this
book or drawing inerences rom it.
Te author and publisher specically disclaim all responsibility or any liability, loss, or risk,
personal or otherwise, which is incurred as a consequence, directly or indirectly, o the use and
application o any o the contents in this book.
Some o the material in chapters 4, 8, and 9 was previously published in a dierent orm in
Motheringmagazine.
SCRIBNER
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Copyright 2013 by Jennier Margulis
All rights reserved, including the right to reproduce this book or portions thereo in any orm
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First Scribner hardcover edition April 2013
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Book Design by Maura Fadden Rosenthal
Manuactured in the United States o America10 9 8 7 6 5 4 3 2 1
Library o Congress Control Number: 2012031245
ISBN 978-1-4516-3608-6
ISBN 978-1-4516-3610-9 (ebook)
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Contents
Introduction ix
Authors Note xix
c h a p t e r 1 GESTATION MATTERS: The Problem with PrenatalCare 1
c h a p t e r 2 SONIC BOOM: The Downside o Ultrasound 24
c h a p t e r 3 EMERGING EXPENSES: The Real Cost oChildbirth 45
c h a p t e r 4
CUTTING COSTS: The Business o CesareanBirth 75
c h a p t e r 5 PERINATAL PRICES: Proft-Mongering Ater the BabyIs Born 96
c h a p t e r 6 FORESKINS FOR SALE: The Business o
Circumcision 118
c h a p t e r 7 BOTTLED PROFITS: How Formula ManuacturersManipulate Moms 137
c h a p t e r 8 DIAPER DEALS: How Corporate Profts Shape the WayWe Potty 166
c h a p t e r 9 BOOST YOUR BOTTOM LINE: Vaccinating or Healthor Proft? 191
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CONTENTSviii
c h a p t e r 1 0 SICK IS THE NEW WELL: The Business o Well-BabyCare 226
c h a p t e r 1 1 So Where Do We Go rom Here? 246
Abbreviations 253
Glossary o Terms 254
Appendix 261
Resources 261
Recommended Reading 263
Vaccine Schedules in Norway and America 264
Photo Credits 265
Notes 266
Acknowledgments 329
Index 333
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c h a p t e r 1
GESTATION MATTERS:
The Problem with Prenatal Care
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Like many middle-class American women, Elizabeth Goodman-Logelin,at thirty, had put childbearing on hold to establish a career. In hertwenties she used her smarts, drive, and organizational skills to become a
high-powered management consultant. When she and her husband, Matt,decided it was time to get pregnant, the couple rom Minnesota elt as i
they had it all: a spacious new home in L.A., a happy marriage, and a baby
on the way.But pregnancy was harder than Liz expected. A petite woman, Liz
struggled to gain weight. As Matt details in his memoir, wo Kisses or
Maddy, Liz had debilitating morning sickness and vomited requently. Just
to be sae, when she was about twenty-eight weeks along, her obstetrician
reerred her to a high-risk specialist in Pasadena, Greggory DeVore, M.D.
DeVoreperormed an ultrasound and announced that Lizs amniotic fuidlevels were low, the baby was small or gestational age, and the cord was
wrapped around her neck.Ten he prescribed three weeks o bed rest.
When a subsequent ultrasound indicated no improvement, DeVoreinsistedthough the babys due date was still nine weeks awaythat
Liz spend the rest o her pregnancy in the hospital. erried rst-time
parents, Liz and her husband did not question this advice.
Aer two weeks in the hospital, the doctors told her and Matt that it
was time or the baby to come out, believing she would be saer outside the
womb. Madeline Logelin was born seven weeks premature via C-sectionon March 24, 2008. She was rushed to the neonatal intensive care unit
(NICU), placed in a plastic incubator, and given supplemental oxygen
as a precaution although her ather was told she was breathing just neon her own. It turned out that Maddy was a perectly healthy baby. At 3
pounds 13.5 ounces and 17.25 inches long, she was in the normal weight
and height range or her gestational age.Her only issue was that she wastoo young to swallowan iatrogenic problem caused by early delivery.
wenty-seven hours later, getting ready to nally hold her daughteror the rst time, Liz mumbled that she elt light-headed, ell backward
into the wheelchair waiting to take her to the NICU, and then slumped
orward onto the foor.
She was dead.
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GESTATION MATTERS: The Problem with Prenatal Care 3
Te doctors told Matt that Liz most likely died o a pulmonary
embolisma blood clot or other blockage that impedes blood fow to thelungs. Matt believed shitty luck killed the woman who had been the love
o his lie.Expectant parents such as Matt and Liz are rarely told that putting
a patient on bed rest dramatically increases the risk o pulmonary
embolism (one study showed that embolism is almost twenty times more
likely or pregnant women on bed rest). I was put on strict bed rest at
three dierent hospitals and never told there was a risk, says one mother
o our rom Pennsylvania.Most expectant parents are also unaware thatseveral studies have shown that it is dicult to access the amount o
amniotic fuid in utero accurately. When researchers at the University oMississippi Medical Center analyzed three techniques used or testing
amniotic fuid level, all three were ound to be moderately accurate,giving correct estimates only between 59 and 67 percent o the time.
In other words, at least one third o a doctors diagnoses rom ultrasound
that a womans body is generating too much or too little amniotic fuid
are wrong. Tese misdiagnoses lead to more pregnancy interventions,
including C-sections.As Sarah Buckley, an Australian amily physician
and obstetrician, birth advocate, mother o our, and author o GentleBirth, Gentle Mothering: A Doctors Guide to Natural Childbirth and Gentle
Early Parenting Choices, explains, using ultrasound to detect low amniotic
fuid levels has been shown to lead to overdiagnosis o problems resulting
in high rates o induction or healthy babies.Te science on this subjectis abundant: One double-blind randomized study o more than een
hundred pregnant women concluded that measuring amniotic fuid
levels or women who were at orty weeks gestation was not signicantlycorrelated with better etal outcomes. It was, however, a predictor or more
unnecessary intervention. Te study concludes: Routine use [o amniotic
fuid index, that is, an approximate estimate o amniotic fuid levels rom
ultrasound] is likely to lead to increased obstetric intervention without
improvement in perinatal outcomes.
According to her husbands account, the doctor spent only a ew minutes
looking at an ultrasound beore prescribing Liz bed rest. Yet more than
hal a dozen studies have determined that bed rest is either o no proven
benet or that there is simply not enough available evidence to support or
reute that it works.While there is not sucient evidence showing bed restis o benet, there is evidence that it causes harm. Researchers have ound
that it not only dramatically increases the likelihood o getting blood clots,but it can also lead to signicant bone loss in pregnant women.
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THE BUSINESS OF BABY4
I dont put pregnant women on bed rest anymore, asserts Reynir
mas Geirsson, M.D., the chair o the Department o Obstetrics andGynecology at the Landsptali University Hospital in Reykjavik, Iceland.
Reynir has been practicing obstetrics or thirty-six years and has attendedmore than three thousand deliveries. I sometimes ask women at risk or
preterm laborand occasionally those with high blood pressureto stop
work, to rest at home, or occasionally in the hospital, and I direct them
on what exertion to avoid, and when and how during the day to take rest
periods. But enorced strict bed rest has never been proven o use.
Since Baby Maddy turned out to be o normal height and weight or her
gestational age, its possible that nothingwas wrong with Lizs pregnancy
in the rst place. Lizs tragic story begs the question: Would this youngmom be alive today i the doctors had done less testing, paid attention to
the existing scientic literature instead o prescribing a course o action
that is o no proven benet, and taken into consideration that she was a
petite woman likely to have a smaller-than-average baby?
TESTING 1, 2, 3Te twenty-rst century has skewed every aspect o modern lie, argues
Michael Klaper, who has orty years o experience practicing medicine, and
has done postgraduate training in obstetrics at the University o CaliorniaSan Francisco. Dr. Klaper and I talk or more than an hour via Skypeteleconerence. Weve made pregnancywhich is normally this joyous,
wonderul processbecome a perilous and oen tragedy-lled event.
ake, or example, the astonishing number o routine prenatal tests that
almost every pregnant woman is subjected to in the United States today.
Tis dizzying array o testing can make prenatal care an unpleasant,
uncomortable, time-consuming, and expensive experience or women
and their partners. You go in and its like, Lets see what horrible new
problem you have today that youve never heard o beore, says one dad
rom Bualo, New York, who accompanied his wie to every appointment.Between the alse negatives and the alse positives, and the endless stream
o tests, when are you ever going to eel reassured?
As a mother o our, I know rsthand how stressul it can be to have
prenatal testing (or to reuse it and incur the wrath o a provider), but I
wanted to hear an obstetricians point o view. Which is how I nd mysel
on a bitterly cold December evening walking past a bicycle wrapped in
Christmas lights on the ront lawn o a home in Arlington, Massachusetts.
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GESTATION MATTERS: The Problem with Prenatal Care 5
Stephanie Koontz, an obstetrician at Mount Auburn Hospital in
Cambridge, grew up with me about eight miles rom here, in NewtonCentre. Tough we havent been in touch in years, she has graciously
agreed to gather colleagues to talk about prenatal care.Teres apple cider warming on the stove as Mary Baker, a certied
nurse midwie with a ready laugh and a thick Boston accent, tells me she
eels her practice overwhelms patients by having to oer so much testing
when they come in or a rst prenatal visit: serial sequential testing, AFP4,
CVS, nuchal translucency screening, glucose tolerance test, eighteen-
week ultrasound, amniocentesis, cystic brosis testing regardless o
genetic risk. Stephanie says she eels like she needs to give her patients a
crash course in statistics and risk assessment to help them understand thatmost o this early prenatal testing gives you only a percentage o risk, and
that a higher risk estimate on a test helps guide patients in considering
the option or urther (and usually more invasive) testing, not proo that
anything is wrong.
Te two obstetricians and two hospital midwives Im interviewing
dont hesitate to admit that we are overtesting moms. Teyre as rustrated
by it as some o their patients, but they also eel their hands are tied.
Hospital doctors and midwives are required to ollow state guidelines,answer to their colleagues, and be hypervigilant that they have oeredand perormed every test required in order to satisy both health and
malpractice insurance providers in the event o a bad outcome.
Mary and the other certied nurse midwie, Phyllis Gorman, both
agree they would rather spend their time talking, really talking, to
expectant moms: asking them what theyve been eating, how they are
eeling about having a baby, how they are preparing to welcome that baby
into the world, how they can work together to be a provider-parent team
and make shared decisions.
Stephanies colleague Brian Price, M.D., associate clinical directoro Harvard Vanguard Medical Associates, interrupts to interject that in
the current model o obstetric care in the United States, when youve got
dozens o items to cover and very little time per appointment, those kinds
o conversations are impossible.
Brian practiced or our years in Brooklyn, New York, in the late 1980s
and early 1990s at the Brooklyn Hospital Center, where there was virtually
no prenatal testing available. Tey did not do alpha-eto-protein testing,
routine etal surveys, or ultrasound scans to check etal growth. And yet
now that we are doing more prenatal testing, he points out, the outcomeshave not improved.
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THE BUSINESS OF BABY6
Brian is articulate, opinionated, and incisive. Bald and broad-eatured,
he sits up straighter to emphasize his point: We have not decreasedmorbidity or mortality, he says, talking loudly to be heard over his
colleagues, who are clamoring to agree. All weve done is increase thecost o care, and increase the anxiety.
GLUCOSE TOLERANCE TESTING
As any pregnant woman who has had it can attest: One o the most
unpleasant prenatal tests is the screening or diabetes. According to the
American Diabetes Association, about 7 percent o pregnancies becomecomplicated by gestational diabetes.Gestational diabetes arises when toomuch sugar builds up in the bloodstream, either because the body is not
producing enough insulin (the hormone that clears sugar rom the blood
and takes it into the cells to use as energy) or pregnancy hormones block
the eects o insulin. Many women have gestational diabetes that is not a
cause or concern. It is usually a mild condition that develops in the third
trimester, causes no symptoms, and clears up aer the pregnancy is over.
But pregnant women with elevated blood sugars can have larger-than-normal babies and be at more risk or high blood pressure. For this reason,care providers order a diagnostic gestational diabetes screening test. A
woman is told to drink an unnaturally sweet and horrible-tasting syrupy
beverage that has a high glucose content. One brand, GLUOLE, has 75
grams o glucose. Its ingredients: glucose syrup, maltodextrin (a creamy-
white slightly sweet starch derived rom processing corn or wheat),
puried water, acidity control compound E330 (a pH control agent),
preservative E211 (also called sodium benzoate, used as an antiungal
and antibacterial; one study ound that when paired with articial ood
additives it causes hyperactivity), cola aroma, oodstu color E150 (acaramel coloring made rom sucrose), and carbonic acid (a weak acid
with a tart taste ound in many sodas and also in champagne).
Te beverage made Angela Decker o San Mateo, Caliornia, when
she was thirty-our years old and pregnant or the rst time, so sick that
she vomited it up in the waiting room. But the real problem with thistestin addition to having an already queasy pregnant woman drink anunappealing nonood beverage laden with articial colors, preservatives,
and additivesis that there are no international standards or the amount
o glucose in the test or pregnant women (50 grams, 75 grams, or 100
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GESTATION MATTERS: The Problem with Prenatal Care 7
grams) and there is no clear consensus on what glucose response is
elevated enough to be cause or concern.A positive result leads to urtherscreening and, oen, aggressive intervention, including the use o insulin
during pregnancy, a scheduled early induction, or even C-section becauseo a ear the baby will grow too big.
I you are having a healthy pregnancy, your baby is measuring normally,
and you have no risk actors or diabetes, should you even have this test?
Although the American College o Obstetricians and Gynecologists
(ACOG) recommends that every woman be screened or gestational
diabetes regardless o risk actors,the U.S. Preventive Services ask Force,which does systematic reviews o all the available scientic evidence, has
concluded that the evidence is insucient to recommend or or againstroutine screening or gestational diabetes, and the American DiabetesAssociation concludes that low-risk status requires no glucose testing.
AvOIdING GESTATIONAL dIABETESTHROUGH LIFESTYLE CHANGES
Kristen Boyle o Denver, Colorado, was surprised to be diagnosed withgestational diabetes during her rst pregnancy seven years ago. Tirty
years old, slender, and t, Kristen had no diabetes in her personal or
amily history and she thought she ate well. But her diabetes got so badthat she had to take insulin during the last trimester. At every visit she
had etal monitoring and an ultrasound. At thirty-eight weeks her blood
pressure was high.
Your amniotic fuid is low, she was told aer an ultrasound. We need
to induce you today. She was given a Pitocin drip and then an epidural.
Hoping or a natural childbirth, Kristen ended up birthing her seven-
pound daughter Soa via C-section aer thirty hours o unproductive
labor.
My body wasnt ready to have her, Kristen remembers sadly when wetalk. Baby wasnt ready to come out.
For her second pregnancy, Kristen decided to do things dierently. She
went to a midwie instead o a doctor and she and her midwie devised
a proactive diet to keep her rom developing diabetes in the rst place.
It was then that she realized that what she had been eating during her
rst pregnancy had not been healthy. Instead o being advised to avoid
processed oods and eat whole resh vegetables and ruits, high-quality
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THE BUSINESS OF BABY8
protein and ats, and whole grains, Kristen had been told to eat granola
bars and take glucose tablets when her blood sugar was too low. Tis timeKristen added high-quality protein to her diet, eating hemp seeds, eggs,
chicken, and the occasional steak. She cut out all rened sugar (thoughshe still ate oods sweetened with agave or maple syrup). She made sure
to eat a lot o ber. Like in her rst pregnancy, she practiced yoga, took
prenatal swimming classes, and walked two and a hal miles around
Sloans Lake almost every day. Kristen monitored her own blood sugar
levels by pricking her nger. She had no problems and gave birth at home,
vaginally, to a healthy nine-pound baby boy.
In one survey rom August 2012, 62 percent o women who were
expectant or had given birth reported that their providers did not talk tothem about how to care or their health during pregnancy.Doctors oendont tell women that eating oods that are low in nutritional content but
high in sugar and starchlike white bread and bagels, white pasta, icecream, cake, candy, and so drinkscan induce or worsen gestational
diabetes. Tese oods also add to excessive weight gain during pregnancy,
which can lead to high blood pressure. Te best way or a pregnant
woman to avoid developing gestational diabetes is to eat a healthy diet that
contains high-quality protein and no added sugars and no rened grains.I elevated blood sugar becomes a problem, pregnant women can start
removing naturally occurring sugars rom their diet, like ripe bananas
and other ruits.
But even women who continue to eat a high-sugar diet can help theirbodies process the sugar by exercising. Tis is why most homebirth
midwives have women keep a ood log over three or our days to record
what they eat and spend a good deal o time during prenatal visits
strategizing about how to improve their diets and how to nd time to
walk, swim, run, bike, take yoga classes, or do other daily exercise.
When youre under the hospital model theyre just looking at numbers,
not the whole picture, Kristen says. She now suspects the anomalous high
blood pressure reading that led to an induction and then a C-section in her
rst pregnancy was because she was excited about having her rst baby.I my blood pressure had been high at thirty-eight weeks, my homebirth
midwie would have said, drink some water, relax, meditate, go or an easy
walk, and well check you again. First-time moms are very suggestible.
We look at doctors as being the experts. When they say something, we
say okay. I never questioned it. In hindsight, when they said induction, I
should have asked, Can I come back and you can monitor me? Do I really
need this? Is it really a medical emergency?
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GESTATION MATTERS: The Problem with Prenatal Care 9
NUTRITIONALLY dEFICIENTdOCTORING
What do you eat? What do you have or breakast, lunch, and dinner?When doctors start asking those questions o pregnant women, then well
see a change in prenatal care, says Dr. Klaper, who looks younger than his
sixty-our years and directs the nonprot Institute o Nutrition Education
and Research in Manhattan Beach, Caliornia. In the early days and
weeks o pregnancy, just aer conception, when a woman doesnt even
know shes pregnant, the embryo is the most vulnerablejust a cluster
o a ew cells. Tis is the time the mothers diet is key. Klaper, talking
rapidly and convincingly, continues, So she goes to a ast-ood restaurantor lunch, and shes ingesting a witches brew o chemicals, favorings,colorants, and stabilizers. All these molecules are inusing the baby in this
very vulnerable time. Who knows what this does to the etus?
When I ask Klaper why obstetricians dont emphasize the importance
o nutrition during pregnancy, he chuckles. No one tells us its important!
he exclaims, shaking his head. We go to medical school to learn how to
work in the body repair shopwhich is what hospitals are. I you break
your body, go to the hospital. Teyll x it. But then get out o there. Noone is going to mention nutrition to you beore, during, or aer, because
no one mentions it to us.Doctors actually denigrate nutrition, believing it is irrelevant and
unimportant, Klaper says. Tere is an inherent contempt or nutrition
built into Western medicine. Nutrition is a sissy sport among physicians.
One look in a doctors own rerigerator will show you that he is eating the
same junk ood that most Americans eat, Klaper points out. I think o a
riends husband, a doctor who eats vanilla cupcakes or breakast, and apediatrician I know who has been trying to eat more healthy ood but who
still eeds the amily sugar-laden processed cereals, bread ull o additives
like calcium peroxide (a bleaching agent), white pasta, granola bars, and
conventional milk (because organic is too expensive). Real doctors workin the operating room. Real doctors deliver babies, Klaper says. Te sad
irony is then they go back to their oces and see a waiting room ull o at,
unhealthy women who are sick because o what theyre eating.
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THE BUSINESS OF BABY10
dO PRENATAL vITAMINS MAkEPREGNANT WOMEN SICk?
At rst Jenna Nichols thought she was so sick because she was pregnantduring a heat wave in Philadelphia. A petite woman with air skin and
hazel eyes, Jenna, twenty-our, looked and elt green. But reaching the rst
trimester milestone, when morning sickness is supposed to abate, didnt
help. Every day, shortly aer Jenna took a one-a-day prenatal vitamin, her
hands would sweat, she would eel clammy all over, and get so nauseous
she could barely breathe. She lay as still as she could on the couch, air-
conditioning at ull blast, eeling more motion sick than she had on the
dragon ride at the carnival when she was six years old.One night about halway through her pregnancy, Jenna unscrewed the
cap on her vitamins to check i she needed more. Te smell triggered a resh
wave o nausea and Jenna realized it might be the vitamins themselves that
were making her sick. Because she was vegan beore she got pregnant,
Jenna was worried her baby might be malnourished. She kept a detailed
ood log o everything she ate and started trying dierent vitamin brands:
arget, rader Joes, Whole Foods. Nothing changed. Her symptoms only
went away when she stopped taking vitamins.Sarah Jane Nelson Millan, a mother o two in Los Angeles, broke out
into mouth sores every time she took her conventional prenatal vitamin.Every time Katherine Womack, a Las Vegasbased mom o a two-year-
old, took her vitamins she threw up twenty minutes later.Another youngwoman experienced unpleasant nausea in ve pregnancies. Because she
had undergone cancer treatment and been told by the doctors she would
stop menstruating, she did not know she was pregnant or the sixth time
until the second trimester. She took no prenatal vitamin and or the rsttime in six pregnancies had no morning sickness.
Tough some pregnant women are not aware o experiencing any
adverse reactions to prenatal vitamins, others report painul constipation,horrible stomach pains, and dizziness. Since bad reactions to prenatalvitamins are not unlike pregnancy symptoms, most women dont realize
when their body is reacting badly to the vitamins.
During pregnancy a womans body undergoes enormous changes: rst
the ertilized egg implants into the lining o the uterus and then, beore
a woman even knows she is pregnant, the egg (called a blastocyst) starts
separating into cells that will become the placenta and cells that will
become the baby. Just two weeks aer ertilization, the layers o the embryo
itsel actually start to dierentiate into specialized parts. Te outer layer
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GESTATION MATTERS: The Problem with Prenatal Care 11
will become the hair, skin, eyes, and nervous system; the middle layer will
become the heart, reproductive organs, bones, muscles, and kidneys; andthe inner layer the babys liver, lungs, and digestive system. As a pregnant
womans body grows an entirely new organ (the placenta) to sustain thebaby, her blood increases in volume and her heart enlarges. Because o
the demands o pregnancy, it is thought that women need more o certain
nutrients, especially iron, calcium, and olic acid. Women are told that
prenatal vitaminsbe they over-the-counter or prescriptionwill help
ensure they are getting what they need nutritionally to grow a healthy
baby. Tey are also told that olic acid around conception and in the rst
trimester is especially important. Tis has been the recommendation since
1999 aer a large study o pregnant women and inants in China oundthat taking 400 g o olic acid a day reduced the likelihood o neural
tube deects, which occur in early gestation when openings in the spinal
cord or the brain do not properly close.Prenatal vitamins are considereda nutritional insurance policyto protect a growing etus.
But what most pregnant women and their partners (and even doctors)
dont realize is that many prenatal vitamins contain extra nonvitamin
ingredients that are known to be harmul. Tere are no standard
guidelines or any clear consensus on what amount o which vitaminsshould be included in prenatal vitamins. For example, some doctors now
believe that to have a positive eect pregnant women need more than
twice as much olic acidas much as 1,000 gan amount available only
by prescription.
Women also dont realize that just because they are taking vitamins itdoes not mean the body is able to absorb and use them. In their promotion
o prenatal vitamins, the medical community overlooks this problem, as
well as that the studies o the importance o olic acid supplementation
have never included a group o pregnant women who receive olic acid
rom whole-ood sources (lentils, kidney beans, broccoli, spinach, kale,
and citrus ruits are high in olic acid).
Despite its name, there is nothing natural about Sundown Naturals, an
inexpensive over-the-counter prenatal vitamin. In addition to synthetic
vitamins, Sundown Naturals contain vegetable cellulose, vegetablestearic acid, calcium silicate (anticaking agent), vegetable magnesium
stearate, titanium dioxide color, FD&C Yellow No. 6 Aluminum Lake,
FD&C Red No. 40 Lake (CI 16035), FD&C Blue No. 1 Lake (CI 42090).Other brands, some o which are much higher in price, have identical
ingredients.
Tis natural vitamin contains our articial colorants. Tere is no
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THE BUSINESS OF BABY12
good reason or any articial colors to be added to prenatal vitamins,
but there are ample reasons to avoid them. itanium dioxide, also oundin paint and sunscreen, has been shown to cause neurological damage,
cell injury, mutation, and ultimately respiratory tract cancer in rodentexperiments, and is now believed to be carcinogenic in some ormsto humans. It has also been shown to harm marine animals and hasbeen linked to autoimmune disorders.Yellow 6, Red 40, and Blue 1 arepetroleum-based dyes that in industry-sponsored animal studies have
all been ound to provoke allergic reactions as well as nerve-cell damage
(Blue 1) and possibly tumors (Red 40 and Yellow 6). Red 40 and Yellow 6
have also been ound to be contaminated with carcinogens.
Stuart Prenatal Multivitamin/Multimineral supplement tablets cost$29.99,more thanour times as much as Sundown Naturals.Yet the list ounpronounceable ingredients you would never eed directly to an inant
and probably wouldnt want in contact with a developing embryois twiceas long. It includes sodium aluminosilicate, mixed glycerides, sodiumbenzoate, polysorbate 80, polyethylene glycol, as well as cornstarch and
sugar, to name just a ew.How can we assume that it is sae or benecialor a pregnant women to swallow a pill loaded with nonood substances
our bodies have not evolved to ingest?When Jenna nally realized her prenatal vitamins were making her
sick, she was told to switch to Flintstones childrens chewables. Tis is
common advice: Doctors and midwives tell women who cannot stomach
the prenatal vitamins to take a childrens multi. But it le Jenna perplexed.
She did not want to eat a sugary product (the children she used to nanny
thought their vitamins were candy), and she knew the amounts in vitaminsdesigned or children were not comparable with those or pregnant adults.
Indeed, it is impossible to know i the amounts listed on the label
o any vitamins are actually whats inside the vitamin. In 2004, testing
by ConsumerLab.com, a White Plains, New Yorkbased company that
independently evaluates health and nutrition products, revealed that one
prenatal brand tested could not ully disintegrate, suggesting it would not
deliver its nutrients to the body. It also contained twice the amount o olic
acid listed on the label. Tat same report ound that a childrens gummy
vitamin was contaminated with high amounts o lead.More recent testingo multivitamins showed thirteen out o thirty-eight brands did not
contain the amount o nutrients as listed in the ingredients.
Since 1994, when the Dietary Supplement Health and Education
Act was signed into law by President Bill Clinton, dietary supplements,
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GESTATION MATTERS: The Problem with Prenatal Care 13
including prenatal vitamins, all under a new regulatory ramework.
While the government plays a strong role in ensuring ood saety, it is thecompany that makes the vitamins that is responsible or determining i
they are sae. Manuacturers take ull responsibility that the representationsor claims made about vitamins are substantiated by adequate evidence
that is not alse or misleading. Prenatal vitamins do not need approval
rom the FDA beore they are marketed, their contents do not have to
be tested by the FDA, and the claims made about their health benets
are not independently veried. Te manuacturer does not even have to
provide the FDA with the evidence it relies on to substantiate saety or
eectiveness beore or aer it markets its products.
We nd problems all the time, says od Cooperman, M.D., presidento ConsumerLab.com. We have ound problems with prenatal vitamins in
the past. It wouldnt surprise me to nd a prenatal that was contaminated,
didnt disintegrate, or didnt have all its ingredients. I have three kids.
When my wie was pregnant, we only used products we had tested. Just to
cover our bases, I had her switch each day between two dierent products.
According to Consumer Reports, American consumers spent $26.7
billion on supplements in 2009.Te average prenatal vitamin costs about
30 cents a pill.I the more than our million pregnant women each yearin the United States take a prenatal vitamin every day or at least nine
months, they collectively spend at least $336 million a year. With so much
money at stake it is no wonder that pharmaceutical salesmen peddle
their brands directly to American obstetricians and amily practitioners,
bringing treats to their oces (like doughnuts or catered lunches) and
giving ree samples to the sta. When doctors distribute these samples totheir pregnant patients, they are openly endorsing the brand. Endorsement
by a trusted physician is an extremely eective marketing strategy. We get
salespeople in here all the time trying to promote their vitamins and saying
why they are better, says Dr. Lester Voutsos, section chie o obstetrics
at Providence Hospital in Novi, Michigan. I hear their presentation and
they give us ree samples, which I give out. But I dont prescribe them.
Voutsos doesnt think pregnant women should waste their money on
expensive prenatal vitamins when they can buy less expensive over-the-
counter or generic brands. Pregnancy is a proound experience, Voutsossays. When they are pregnant, women are so ocused on the pregnancy
they are willing to spend $30 or $40 a month on vitamins. Frankly, I dont
think its worth it.
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THE BUSINESS OF BABY14
FOOd RULES
When she was six months pregnant, a young woman walked into a bagel
shop and asked i they had bagels made with whole wheat four. Te youngclerk behind the counter looked perplexed.
No, she said in a low, almost conspiratorial tone, none o our
products are made with wheat.
Te clerk was mistaken. Tough there were no whole-grain bagels on
hand, all o the products in that bakery, even the pumpernickel (which
also contained rye four), were made with wheat four. Like the bagel clerk,
most Americans dont know the dierence between processed wheat and
whole wheat.A wheat kernel is made up o three components: the bran, the germ,
and the endosperm. Te bran, which contains most o the plants ber,
and the germ, which contains most o the nutrients, are both removed
in the process o converting whole four into white four. What is le is
the starchy endosperm. I your eyes are already glazing over, heres what
you need to know: Because so many vital nutrients are taken out during
processing, most ood companies add chemical nutrients back into white
four, which is why the four is called enriched. However, so manynutrients are lost in the rening process that enriched four, though it
sounds healthy, can never be as nutritious as whole-grain four.Most o the nutrients that were there to begin with are never
reinstated, Larry Lindner, ormer executive editor o the ufs University
Health & Nutrition Letterand an expert on nutrition, explained to me.
Tese include vitamin E, vitamin B6, pantothenic acid, magnesium,
manganese, zinc, potassium, and copper.
Phytochemicals are another vital component o the grain lost duringprocessing. Phytochemicals are substances ound in plants that are notvitamins or minerals but that play a part in promoting good health.
Unlike vitamins and minerals, phytochemicals are not put into prenatal
supplements, Linder explains, but they are in whole grains. In act,researchers are just beginning to isolate and identiy these compounds
there are literally thousands o them.
Whole grains (like brown rice, unpearled barley, whole millet, and
oats) are high in ber, which can help alleviate constipation. Since whole
grains take longer to digest, pregnant women suering rom low blood
sugar report ewer symptoms when they eat whole grains. Whole grains
metabolize more slowly in your body, explains a ormer obstetric nurse
rom Brattleboro Memorial Hospital in Vermont and an expert on
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THE BUSINESS OF BABY16
but emphatic way, Qualtere-Burcher explains that there is an enormousnancial imperative or obstetricians to see as many women as possible,
which is leading to an inadequate level o care. In order to pay or xed
overhead costs (including oce sta and medical liability insurance),obstetricians in private practice squeeze as many prenatal appointments
into a day as possible, keeping women waiting and then racing through
the visits.
Qualtere-Burcher recently chose to take a $150,000-a-year pay cut to
move rom a practice in Eugene, Oregon, to a medical school in Albany,
New York. In his new position he is doing more teaching and supervising.He tells me he can talk more honestly now because he doesnt have to
worry about jeopardizing his job or oending his colleagues. He patientlyruns through the numbers and the dierent work models, using words
like median productivity (the national standard across the country o
how many patients an obstetrician sees on average) and Relative Value
Units (RVUsthe more patients you see, the more income you generate).
Ten Qualtere-Burcher cuts to the chase: Whether in private practice
or employed with a steady salary by a health group or HMO, the more
women an obstetrician sees in a day, the more money he makes.
Human behavior responds to incentives, and the incentive or OBs isto spend less time with people, Qualtere-Burcher explains. Whether you
spend ve minutes or een, the ee is essentially the same. Te nancial
incentive is to run them through quickly. Tere is no nancial incentive
to take your time.
At Qualtere-Burchers last job or a nonprot medical group, moreincentives came quarterly. I you delivered enough women over medianproductivity, you could make as much as $48,000 more a year beyond
your base salary.
For OBs in private practice the nancial incentives are even more
pronounced: Once youve paid xed expenses, everything else you make
is yours. Even doctors who dont go into obstetrics or the money nd that
earning more becomes an irresistible motivator. Once youve covered
your expenses, its all gravy, Qualtere-Burcher says. Why take home
$200,000 when you can increase your patient volume and make $500,000
instead?o boost his bottom line even more, one o Qualtere-Burchers
colleagues reused to provide care or medically complicated pregnancies.
I a pregnant woman had any kind o problem, he sent her to another doctor.
Te doctor bragged to his colleagues that only seeing straightorward
pregnancies meant he could see more than orty women a day. Tat was
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GESTATION MATTERS: The Problem with Prenatal Care 17
his moneymaking conveyer belt, Qualtere-Burcher says, though he is
quick to add that this colleague was not typical. Most OBs like doing allaspects o their specialty, and do enjoy taking care o complicated patients.
It reminds us that we have some skills.But Dr. Edward Linn, chair o obstetrics and gynecology or the Cook
County Health and Hospitals System in Chicago, Illinois, who has made
time to talk to me in between seeing gynecology patients, says that he has
spent many years watching doctors punt complicated pregnancies and
cherry-pick their clients because they do not get higher reimbursement
or high-risk women who take up more time. We sit in his spacious h-
foor oce, which has a wide bankers desk piled with academic journals,
papers, and les. While many doctors reuse to give any care to women onpublic assistance, other doctors prey on them,Linn says, maximizing theirprots by ollowing a woman during pregnancy and collecting per-visit
reimbursement rom the state with no concern about the outcome. Tesedoctors see pregnant patients and carry them along with no intention
o ever delivering them, Linn tells me. Tey tell them that once they go
into labor, they should show up in the emergency room o the hospital o
their choice. Tese doctors increase their income margin by cramming
in as many oce visits as possible, collecting a per-visit ee or each visit,but reusing to be present during labor and at the birth (which takes time
away rom the oce). We see these patients coming into our emergency
room, Linn continues. People accept that. Tey dont understand why,
but they trust their doctor. Doctors who are practicing like that lackproessional integrity. Teyre looking or the billable opportunity.
Tis kind o unethical behavior leads to ragmented care and poor
outcomes, Linn says, especially or socioeconomically disadvantaged
women who have among the worst outcomes and who most need
ollow-up and continuity o care. Sharon Rising, a certied nurse
midwie with more than thirty years o experience, ormer aculty
member at Yale Universitys School o Nursing, and ounder and CEO
o a womans health care advocacy nonprot, agrees that the kind o
prenatal care we are delivering in America is not working, especiallyor Americas poor.
We have terrible premature birth rates, which i anything are getting
worse. We still have a high percentage o pregnant women who are
coming late to prenatal care, lots o women who arent breasteeding, and
the overuse o triage and emergency rooms. Tese outcomes are really
less than desirable, Rising says. Whats really happening? What kind
o a system do we have? We have a care system designed to support the
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THE BUSINESS OF BABY18
hospital and the clinicians, and is tailored to their convenience. When the
outcomes arent great you need to change the system.Tis is only xable at a systems level, agrees Qualtere-Burcher. You
want to say this is physician bad behavior, but it really isnt. . . . Nothing isgoing to change until you take the prot out o medicine. Te economics
o medicine keep distorting medical decision-making and the doctor-
patient relationship, even the relationships between physicians and
midwives, because you view a colleague as a potential competitor. It just
distorts everything. Until you remove that it is going to be impossible to
make substantive changes.
MIdWIFERY: PROACTIvE vERSUS REACTIvE CARE
When Alice Domurat Dreger, Ph.D., a proessor o clinical medical
humanities and bioethics at Northwestern University Feinberg School o
Medicine, asks her medical school students to describe the kind o woman
who would give birth with a midwie rather than an obstetrician, they
imagine someone who wears long hippie skirts, eats vegetarian ood, and
drives a VW minibus. Her students are always shocked to learn that whenDreger, a pants-wearing omnivore and sel-described science geekandher partneralso an academicbecame pregnant in 2000 they chose to
have their prenatal care and delivery overseen by midwives.Why? Dreger scoured the scientic literature to learn everything
she could about the saest way to have a baby. Her reading revealed she
should walk a lot during pregnancy, Dreger explains in an article in the
Atlantic; get regular checkups o her weight, urine, blood pressure, and
belly growth; and avoid vaginal exams. She also ound out that she should
not agree to any prenatal sonograms in her low-risk pregnancy because
doing so would be extremely unlikely to improve the babys health, but
could result in urther testing and intervention that increased risk to her
and her baby with no benet.But her obstetrician and his team were uncomortable with such an
old-ashioned approach. So Dreger and her partner quit the practice,
instead engaging a midwie who, she says, was committed to being much
more modern.
Te modern midwies approach is to be proactive during pregnancy
and childbirth. Instead o aggressively treating gestational problems with
the latest medications and the most advanced technologyaferthey arise,
good midwives (like the one who helped Kristen avoid gestational diabetes
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GESTATION MATTERS: The Problem with Prenatal Care 19
by changing her diet) work closely with their pregnant clients to ward o
problems beore they start.Te medical model o obstetrics is reactive, explains Stuart Fischbein,
an obstetrician who has spent much o his thirty-year career workingclosely with midwives, when I interview him via Skype teleconerencing at
his home in southern Caliornia aer hes spent a long day seeing patients.
When a woman develops diabetes, theyll x it. When a woman develops
preeclampsia theyll treat it. When a woman develops anemia, theyll deal
with it. Te midwiery model is preventive. Tey help build a womans
hemoglobin so she wont become anemic. Tey educate her about not
eating sugar and doing exercise so she doesnt get gestational diabetes. en
minutes o every hour visit is spent talking about nutrition so a womanwont develop preeclampsia.
Tough many hospital midwiery practices run their groups much
like obstetricians, racing through appointments and reacting only aer
problems arise, midwives usually oer a higher level o individualized
prenatal care than obstetricians. Qualtere-Burcher thinks one reason or
this is that midwives dont ace as many nancial pressures as doctors.
Tey make less money, pay a much lower rate o malpractice insurance,
and usually dont graduate rom school with the kind o education debtthat physicians do. When Qualtere-Burcher worked at Olean GeneralHospital in an academic position or SUNYBualo rom 1995 to 2002, his
medical malpractice insurance cost about $65,000 a year. Te midwives,
who supervised just as many pregnancies and delivered just as many
babies, paid only $3,500 a year. I the midwives run into a problem they
are not usually sued. I they have a patient who gets into trouble, they are
going to consult an ob-gyn, so an ob-gyn will be involved and available to
be sued, Qualtere-Burcher explains. So they will always drop the lower-
level proessional. Im told thats pretty typical.
It is partly this constant ear o being sued that leads most obstetriciansto see themselves as managing the pregnancy, dictating to pregnant
women what they should eat, how much weight they should gain, and
how many weeks they will allow gestation to continue beore medically
inducing labor. Tey react strongly and swily at the rst sign that
something might be wrong, whether the issue is a high blood pressure
reading or the suspicion o a larger-than-average baby.
O course obstetricians have a laudable reason or wanting to
monitor their clients behavior: Tey want their patients to have healthy
pregnancies and healthy babies. But they also have nancial incentivesand proessional concerns that have little to do with a pregnant womans
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THE BUSINESS OF BABY20
health. No pregnant woman should have to sit or an hour in the waiting
room because a doctor has overbooked clients in order to maximize prots.It is wrong or care providers to hand out samples o expensive prenatal
vitamins, or to undermine a womans condence about breasteedingbeore shes even had a baby by giving her ormula samples and coupons.
Tis is why pharmaceutical salesmen are not allowed into the doctors
oces, and women who receive prenatal care rom Harvard Vanguard
Medical Associates, where Brian and Stephanie practice, are not given ree
samples o branded products.
We have never allowed ree pharmaceutical samples to be given to
patients because nothing is ever ree, Brian explains in a ollow-up
email. We also do not give out new baby bags with ormula samples orallow any product placement in our patient handouts. Several studies have
clearly shown that clinicians are very clearly swayed by all o these subtle
orms o advertisement and promotion. I have gone so ar as to orbid
drug lunches and pen distribution.
It is also wrong or doctors to prescribe radical medical intervention
beore trying less invasive ways to x a potential problem. reating
gestation as an illness or an accident waiting to happen not only takes
the joy out o pregnancy, it also creates the opportunity to interveneunnecessarily and potentially do harm. Expectant moms and dads whoquestion their providers, seek a second opinion, or ask or gentler or less
invasive care are oen met with scolding, bullying, or genuine surprise
(Why wouldnt you want that test? No other patient has ever reused it!).
During my our pregnancies, I discovered I didnt need stressul prenatal
testing and intervention; I needed wholesome ood, time to exercise,
sunlight, quality sleep, eective ways to destress, and riends and amily
to listen patiently to my hopes and ears and give me hugs when I cried
(pregnancy is an emotional time). Te best prenatal care happens when
health care providers take the time to really listen to their clients, examinethem gently, oer evidence-based advice, and support gestation as a
natural, healthy, awe-inspiring, lie-changing event.
Dr. Qualtere-Burcher believes that healthy women having normal
pregnancies should go to midwives, be they certied nurse midwives who
work in a hospital or proessional midwives who deliver babies at home. He
points out that in European countries such as Ireland and Norway, where
the maternal and etal mortality rates are much lower than in the United
States, midwives, not doctors, provide prenatal care. Like Dreger and her
partner, Qualtere-Burcher and his wie chose not to see obstetricians. Tebirths o his own three children were supervised by midwives.
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GESTATION MATTERS: The Problem with Prenatal Care 21
Midwives do a much better job caring or pregnant women than
Im able to, Qualtere-Burcher conesses. I wish all OBs would work intandem with midwives. We can always be there or backup i something
goes wrong.
American College o Obstetricians and Gynecologists gross receipts or the
20092010 scal year: $80 million
Average salary o a high-risk obstetrician: $446,886/year
Average salary o a hospital midwie: $100,000
otal cost o prenatal visits with a doctor: $3,940
otal cost o prenatal visits with a homebirth midwie: $1,300
Cost per minute to have pregnancy supervised by a doctor: $15.00
Cost per minute to have pregnancy supervised by a homebirth midwie: $1.67
Ingredients in GLUCOLE (gestational diabetes test): glucose syrup, maltodextrin,
puried water, acidity control compound E330, preservative E211, cola aroma, oodstu
color E150, and carbonic acid
Money spent on prenatal vitamins per year: more than $336 million
Nine-month supply o brand-name prenatals: $1,169.55
Nine-month supply o generic prenatals: $134.91
Cost to eat organic kale: $1.99 a bunch
Jennifer Penick: My Midwife Knew Me Better After One Hour
Than My OB After Four BabiesJennier Penick, thirty-two, a mom o fve rom La Vista, Nebraska, liked herobstetrician. He was always personable during prenatal appointments. It was truethat she oten had to wait as long as an hour, and that once she had to reschedulean appointment because he was running behind, but she just assumed that washow things worked. Then she ound another option.
I grew up military so when I got out o that lie an ha to pic my own octors,I i it pretty ranomly. My husban an I int now better. I was twenty-two
when I got pregnant or the rst time. When our OB nally came into the room,he woul get through eerything as ast as possible, listen to the babys heartbeat,reassure us that eerything was oay, an rush to the next appointment. I honestlyint thin there were any alternaties. I int thin miwies still existe in theUnite States.
My rst birth int go ery well. The OB tol us that he wante to inuce me
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THE BUSINESS OF BABY22
because he was concerne about the size o the baby. I was thirty-seen wees.He tol us it woul be better i we inuce because the smaller the baby the easierit comes out, an theres less chance o neeing a C-section. We int want to be
inuce. I ha hear rom enough people dont get inuce, because it hurts wayworse. But when he tol us, Youll hae a better chance o a aginal birth! weagree to the inuction. At thirty-eight wees, one ay I was inuce with Pitocin,an then the obstetrician broe my water. I ha an epiural, but it only wore onone sie an I was in excruciating pain. Ater an hour an a hal o pushing, theoctor trie to get the baby out with orceps. When that int wor he wheeleme in or a C-section.
My son, A.J., weighe 7 pouns 3 ounces. I was completely ope up onpain meication an exhauste. I only hae one picture o my son an me ater
he was born an it always maes me cry. The worst part is I ont hae anymemory about the birth. The only thing I remember is saying to the octor, Hewas suppose to be bigger, thats why we went through all this. The octor intsay anything. He int apologize.
I got pregnant again when A.J. was just nine months ol an we went bacto the same OB because we werent sure where else to go. He was supportie ous haing a vBAC [aginal birth ater Cesarean]. Im only e-three. I hae notorso, an I only gain lie twenty pouns in my pregnancies. Theres nowhere orthe baby to go but out, which is why I loo so big. The octor gure it out this
time an wrote LARGE FOR GESTATIONAL AGE on the outsie o my chart. Iorgae him. I tae some responsibility or not oing my own research an maingmy own ecision. He was ery nice to us no matter how much in a hurry he was.I neer remember him being gru or upset or lie I was a bother. But he enitelyint tae his time or get to now us. I I saw him at the grocery store he woulnthae a clue who I was, een though hes eliere our o my is.
My ourth birth in the hospital was pretty awul. The octor barely mae itan the nurses ept saying, dont push! dont push! Wait or him to get here!The resient who ene up eliering the baby int now what he was oing.
So when a miwie opene a birthing center, The Miwies Place, in our area lastdecember, I ecie to elier there. She too time to tal about my past meicalhistory an births. My miwie new me better ater one hour than my OB iater our babies. It elt lie she care. She hant booe e people or that hour.She mae time to sit an tal to me. She explaine there are tests but that I coulopt out o them i I wante to an she woul sign the paperwor. I always hatebringing my is to the obstetricians oce because I elt lie I ha to tell them toeep still an be quiet. At the birthing center there are toys or my is to play
with. My three-year-ol was so excite because she coul go on the rocing horse.
It was so much less clinical. I int eel lie I was waling into this scary placewhere eeryone was resse in scrubs an white coats waiting or something togo wrong. Eery time a baby is born at the birth center the miwies a thebabys ootprint to the wall outsie the birth rooms. Instea o fimsy paper gownsan pin paper rape oer your thighs, you wear a fuy plush white robe anytime you hae a proceure. I chece my own weight an bloo pressure. When
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GESTATION MATTERS: The Problem with Prenatal Care 23
I neee a Pap smear, the miwie warme up the speculum so it woul be morecomortable. Its o to tal about a nice Pap smear! But they just care about yourcomort. I wish we hant waite so long to mae the switch.
But when I was thirty wees pregnant, I oun out that the birth center woul notlet me hae my baby there, because o my one prior C-section. I was heartbroen.My husban an I toure the hospital that bacs up the birth center; Ie ha rienselier there who ha goo experiences an I thought I coul mae peace with it.But I coulnt. At thirty-two wees I tol my husban I wante a homebirth. Thatsnot easy in Nebrasa. Certie nurse miwies are not legally allowe to attenhomebirths in our state. But I ha a rien who is a homebirth miwie who agreeto assist us, een though it was last minute an she was ue two wees ater me.
Three o my our babies ha been inuce with Pitocin an I ha epiurals
or all our births. This time we let the baby ecie when she was reay to come. Iwas pretty miserable the last month. I thought I woul be pregnant oreer. I got apeicure, ha acupuncture twice, an trie herbs but I was still pregnant. At orty
wees e ays, on August 29, 2012, I woe up eeling lie my bac was a wall opain. I pae aroun the house unable to get comortable. This was it! We lleup a birthing tub in our liing room an when the pain got really intense, Aamcame in the water with me. He isse my hea an tol me I coul o it, that Ione it our other times beore, een though I sai I coulnt an I wante to leae.
Our aughter, Unity dale Penic, shot across the pool at 6:36 a.m. She
weighe 8 pouns 11 ounces an was 20.5 inches long. Our biggest baby yet! Ionly ha one tiny tear that int nee stitching. My miwie staye or a ew hoursto be sure eerything was oay. Ater she an my oula an the photographer alllet, there was no parae o nurses, octors, an other sta interrupting us eeryew minutes to chec me an the baby or to tae the baby away to the nursery. It
was just us, learning how to be a amily o seen.