The Business of Being Born has been called "the best film ever made on birth" by Ina May Gaskin (People), has been viewed by thousands, catapulted natural birth into the mainstream media (MSNBC, Goldman), and has helped to inspire a movement of women who see birth as a potentially natural, healthy, and beautiful experience (Levine). The movie draws on important revelation tropes - painting the dominant practices and establishment figures as (to some extent) self-interested and dangerous bullies, identifying prophets who offer a re-interpretation of the standard narrative, demonstrating the possibility of a new order of nature, truth, and love.
I think its a great film, and I've watched it at least 9x in the last three years. And even though I'm aware of the limitations of complex story-telling in films intended for large audiences, and I'm teaching a course partly to help people see that simple narratives "Can't Be That Simple" I felt a little stunned by the realization that a significant medical cover-up during the birth of the film-maker's own child may have been perpetuated in a film devoted to uncovering the lies of the medical model of birth.
The Film-Maker Gives Birth to a Baby and a Film That Includes the Birth of Her Baby
The director of the film, Abby Epstein, decided to include footage of her own pregnancy and birth in "Business of Being Born" despite some reservations (Women). At a check-up around the 30th week of pregnancy with her obstetrician, Dr. Jacques Moritz, the doctor tells Epstein that the fetus inside her is growing normally and that he supports her decision to work with a midwife. Moritz also shares his confusion about the role that Epstein's chosen midwife - Cara Muhlhahn, the midwife whose work the movie documents - will assign to him in his role as "back up". But the obstetrician doesn't focus on the issue of unclear responsibility - sensitive to Epstein's desire for reassurance and enthusiasm rather than complex reservations. Significantly, Dr. Moritz serves as a "legitimizer" for the mother-centered birth practices advocated in the movie.
Later in the film Epstein's friend Ricki Lake mentions persistently that she feels that Epstein's pregnant belly is surprisingly small. Epstein enters early labor with the fetus in breech position and after some time Muhlhahn cancels the hoped-for home birth and the film shows an all-too-stereotypical distressed taxi ride to the hospital around 2am resulting in an emergency cesarean-section by Dr. Moritz. After a scene showing Epstein's distressed and undersized baby Matteo, Epstein and Moritz are shown debriefing in the same office where he had reassured her about the baby's growth. The obstetrician explains that the fetus had become growth-restricted. Epstein asks why this important problem had not been diagnosed and Moritz responded that this situation was (paraphrasing) "Notoriously that its' diagnosed with a still birth. In fact, its usually diagnosed that way."
Moritz's answer apparently satisfies Epstein and the issue of the non-diagnosis receives no further notice for the remaining few minutes of the movie. However, Moritz's answer was not accurate, and the decision of the film-maker to include this inaccurate answer raises some interesting and possibly disturbing artistic/political/ethical questions about this revelation film.
Cover-Up?
Moritz's answer was not accurate - most cases of "Intra-Uterine Growth Restriction" (IUGR) do not result in stillbirth - one analyst produced data that 86% survive (Ross). Further, diagnosis of IUGR by practitioners while the fetus remains in the womb is common, through documenting an "Estimated Fetal Weight" (EFW) and comparing that estimate to normal growth curves for fetal development. Practitioners estimate fetal weight and development using a variety of tools and techniques including sequential sonography and fundal height measurement. And screening for IUGR, and associated head/body asymmetry can be implemented using a variety of Doppler scans, fluid measurements, and 3D ultrasonography (Ross). Some screening techniques are able to identify significantly higher than the majority of cases of IUGR in the fetus (Ross). Diagnosing Epstein's fetal IUGR would be entirely common and expected outcome of quality prenatal care, although the medical literature consulted didn't offer data on the percentage of cases that are accurately diagnosed prenatally.
It surprises me that Dr. Moritz, a respected obstetrician, offered inaccurate medical information regarding the prenatal care offered to the film-maker whose partner was filming the interaction. One could speculate that the obstetrician wanted to avoid pointing a blaming finger at the practitioner responsible for the prenatal care - the midwife Cara Muhlhahn. Lying to protect a colleague is a widely discussed dynamic in medicine (Wagner 23) and I can imagine that lying to protect a midwife would feel like a generous act of solidarity for this obstetrician, reportedly the son of a midwife himself.
To me, the more disturbing issue was that the film-maker included this disinformation unchallenged in the film, falsely representing one of the key aspects of her own baby's birth and obscuring a possible blunder by the midwife that most (but not all) of the film uncritically valorized.
Why the Cover-Up?
That Esptein was aware of the inaccuracy of Moritz's explanation is not certain. However, some facts seem to indicate it - the repeated inclusion of Lake's concerns which seem to indicate an awareness that the IUGR should have been diagnosed earlier, the inclusion of a blatant narcissistic interaction by Muhlhahn directly after the birth, and the fact that Epstein chose not to work with Muhlhahn again for her next birth. I've emailed Epstein and been told to expect a response within the next few days regarding this issue. However, lacking that response now, I'd like to address a few possible reasons why Epstein might have chosen to mislead her audience.
Epstein switched providers from OB Moritz to Midwife Muhlhahn at an unusually late date in her pregnancy, around the 30th week, with week 36 often considered the beginning of "full term". In an American Certified Nurse Midwives interview, Muhlhahn answered the question,
"Were you Abby’s prenatal care provider?"Thus, Epstein may not have wanted to depict Muhlhahn as responsible for inadequate prenatal care when Epstein had convinced her at an unusually late date to provide care for the pregnancy and birth.
Not until very late in the game. She was undecided about her choice of birth site and provider until after 28 weeks. Her early prenatal care was done by the physician in the film, Dr. Moritz. I had two prenatal visits with Abby and another scheduled two or three days after she went into preterm labor at 35 weeks. At 32 weeks, I knew the baby was breech" (Peaceful Parenting).
A second explanation for the misleading of the audience is that explaining all of the above, including necessary background in IUGR diagnosis, might have distracted the audience from the central issue of the film - the desirability of mother-centered birth practices. However, this explanation fails to explain why the false information would have been included rather than an accurate non-distracting explanation of the diagnostic failure.
A third possible explanation for an intentional choice to mislead the audience could be that the film-maker was aware of the American tendency to vilify medical practitioners who make a mistake. In one interview Epstein discusses the importance of reducing midwives vulnerability to malpractice lawsuits (Levine). In an article critical of the practice of Muhlhahn, Epstein is quoted as saying,
"She’ll put herself on the line way more than most people, like taking on a birth that’s a little more high risk that most midwives wouldn’t take,” says Abby Epstein, BOBB’s director. “It’s not that she’s a cowboy. It’s because she wants to serve these couples that say, ‘I trust my body. I believe in this process.’ She puts her ass on the line in a huge way every time she kind of steps out of bounds to help somebody" (Goldman).Thus, it may be that a sense of both loyalty to a respected pioneer as well as an antipathy to a common tendency of blaming practitioners led Epstein to partially disguise her midwife's possible blunder.
But another reason for a possible cover-up would be that an honest depiction of the IUGR issue might have harmed Epstein's political mission for the film - encouraging women to be less fearful of birth and to offer more consideration to working with midwives. Her consideration of the political impact of the film, and consultation with midwives regarding that impact can be seen in this quote,
" It was really the midwives who were most discouraged about the ending at first, but over time they also came to see the film was only going to benefit them. The final scene in no way detracts from their overall depiction in the film.”That the final scene doesn't "detract" from midwives may be true, but only because the final scene misrepresents the experience documented.
Or what if there wasn't any significant blunder? Muhlhahn's treatment of a question referencing her possible mistake reveals defensiveness and evasiveness. After mentioning that she only had two prenatal visits with Epstein - thereby implying that she didn't have a lot of chances to catch the IUGR - Muhlhahn minimized the significance of the emergency.
"Although Abby’s baby boy arrives safely, the physician says that Intrauterine Growth Restriction (IUGR) occurred. Do you want to talk about that?Muhlhahn's statement seems bizarre to me, in an interview that would be read by trained nurse-midwives (although maybe not anymore, the interview seems to have been removed from the ACNM site, perhaps as a result of Muhlhahn's ongoing controversies?). She correctly states that the birthweight would have been more troubling if the baby had 40 weeks of gestation. However, even with 35.5 weeks of gestation the baby was OFF the growth curve - smaller than even the smallest percentile of babies and approximately 30% smaller than necessary to be classified as IUGR (Peleg, Olsen). Thus her statement misleads readers of the significance of the undiagnosed medical condition and attempts to minimize the scale of her possible blunder. Its as if a doctor was asked about not diagnosing a tumor the size of a baseball near the kidney and answered, "It would have been worse if it had been the size of a softball."
In the film it appears like the baby was starving, everybody missed it, and the doctor saved the day. But the situation was misconstrued because of a critical detail that was lost during the emergency transfer. The physician who received the transfer was under the impression that the baby was 40 weeks. Abby’s baby was actually born at 35 ½ weeks. A 3 lbs, 5 ounces baby at 40 weeks would have been much more serious than at 35 ½ weeks" (Peaceful Parenting)
Does the Cover-Up Matter?
I believe the misleading of the audience regarding the IUGR of the film-maker's baby significantly harms the credibility of the film, particularly from the perspective of trained medical practitioners. A friend taught me the phrase, "We gain credibility in drops, but we lose it in buckets." Thus, even a small lie tends to undermine the trust gained in a hundred truthful interactions. I've spoken with and heard of several more medical practitioners who identified the misrepresentation of the non-diagnosis of the IUGR as a significant inaccuracy in the film, that diminished its credibility.
Further, the misleading of the audience regarding an important aspect of the film-maker's own birth reveals that the film does not dare to explore the complexities of prenatal care. This possible midwife blunder could have been used as an opportunity to explore the fallibility of all experts, to address the fact that midwives and obstetricians all make mistakes and that solutions and ameliorations to the issue of medical error should be sought. Instead the film focuses its attack on the medicalization of birth without any acknowledgement of the mistakes made by midwives. While I feel sympathetic to the argument that all sides shouldn't receive equal time in a presentation focused on critiquing an overwhelmingly dominant social practice I feel also that addressing these complexities, even in passing, offers significant benefits to the quality of the discourse and to potential outcomes of that discourse.
Thus, at this point and not having yet read Ms. Epstein's response to my queries, I conclude that including medical misinformation that obscured a case of significant midwife malpractice damaged the credibility and outcomes of an otherwise outstanding and paradigm-shifting film. I also conclude that we must critically investigate the claims and evidence of ESPECIALLY the people we most agree with, in order to avoid entrapment in dishonest and/or oversimplified representations of our situation.
Works Consulted:
Alexander, Peter. Perils of Homebirth. MSNBC video. 9/11/2009. http://www.msnbc.msn.com/id/21134540/vp/32795933#32795933 . Accessed 4/5/2011.
Anonymous. "Interview with Business of Being Born Midwife - Cara Muhlhahn". Peaceful Parenting. http://www.drmomma.org/2008_06_01_archive.html. Accessed 4/5/2011.
Anonymous. "Interview with Business of Being Born Midwife - Cara Muhlhahn". Peaceful Parenting. http://www.drmomma.org/2008_06_01_archive.html. Accessed 4/5/2011.
Anonymous. "Interview with Abby Epstein, Director of The Business of Being Born". Women & Hollywood. http://womenandhollywood.blogspot.com/2008/02/interview-with-abby-epstein-director-of.html. 2/20/2008. Accessed 4/3/2011.
Bier, Catherine. "The Benefits Of The Business Of Being Born". Giving Birth Naturally. http://www.givingbirthnaturally.com/business-of-being-born.html. Accessed 4/5/2011.
Goldman, Andrew. "Extreme Birth." New York Magazine. 3/22/2009. http://nymag.com/news/features/55500/. Accessed 4/5/2011.
Levine, Amy. "Interview with Ricki Lake and Abby Epstein on the Business of Being Born". Pregnancy & Baby. http://pregnancyandbaby.sheknows.com/pregnancy/baby/Interview-with-Ricki-Lake-and-Abby-Epstein-on-The-Business-of-Being-Born-6329.htm. Accessed 4/5/2011.
Olsen, Irene E. PhD, RD, LDNa,b, Sue A. Groveman, MSa, M. Louise Lawson, PhDc, Reese H. Clark, MDd, Babette S. Zemel, PhD. New Intrauterine Growth Curves Based on United States Data. Pediatrics. Published online January 25, 2010. PEDIATRICS Vol. 125 No. 2 February 2010, pp. e214-e224 (doi:10.1542/peds.2009-0913). http://www.pediatrics.org/cgi/content/full/125/2/e214. Accessed 4/7/2011.
PELEG, DAVID M.D., COLLEEN M. KENNEDY, M.D.,and STEPHEN K. HUNTER, M.D., PH.D.Intrauterine Growth Restriction: Identification and Management. American Family Physician. August 1998. http://www.aafp.org/afp/980800ap/peleg.html. Accessed 4/7/2011.
Ross, Michael G et al. "Fetal Growth Restriction." Medscape Reference. Updated 2/9/2011. Accessed 4/7/2011.
Wagner, Marsden. Business of Being Born. U of CA Press. 2008.
