When midwife-turned-memoirist Ellen Cohen had her first child in 1963, she says that women were routinely tied down during labor, had their genital area shaved, and were given sedatives whether they wanted them or not. Partners were excluded from the labor and delivery rooms, and babies were whisked away within minutes of their arrival.
“Several years after I had my kids—my son was born a year after my daughter, in 1964—I read an article about modern midwives, women who challenged this model. As soon as I’d finished it, I said, ‘That’s what I want to do,’” Cohen told RH Reality Check. “At that time there was no professional recognition of non-nurse midwives. As far as I knew, if you wanted to help women through pregnancy, and then deliver their babies, you had to go to nursing school, so that’s what I did.”
“I’m a city girl,” Cohen laughs, which is why she has always worked in public and private hospitals and community-based health centers in urban areas. She estimates that she has assisted in 1,400 births, aiding the affluent and the poor, the healthy and the sick, the native born and the immigrant.
These experiences form the crux of Laboring: Stories of a New York City Hospital Midwife, an anecdotal look back at Cohen’s nearly three-decade-long tenure as a midwife. By turns, the book is heartbreaking and exhilarating.
Cohen reports that the approximately 12,000 certified nurse midwives working in the United States are responsible for nearly 8 percent of all domestic births. “Ninety-five percent of midwife deliveries take place in hospitals,” she writes. “The public associates midwives with home births because of the media attention to that part of our practice. … My patients did not always have homes. They were randomly assigned to me in busy clinics and no-frills hospital labor rooms where it was often a struggle to give each woman the time and attention she deserved.”
Still, Cohen makes it clear that for her and her colleagues, midwifery was more than a job. She calls their approach “high-touch, low-tech” and emphasizes that it questions a medical model that favors intervention over natural processes.
“Most newborn and maternal deaths take place in hospitals because 99 percent of births take place in hospitals,” Cohen said. “But there are some processes, some interventions that may not be necessary. I’m referring to inductions and c-sections. Caesarians are now performed for one of every three births, even when there are no identifiable risk factors, when the mothers-to-be are young and of normal weight. I think the pattern of practice has changed so that there is now greater acceptance of c-sections by obstetricians and, to a lesser extent, by women, as a normal procedure for birth.”
On a more positive note, Cohen says that many medical facilities have stopped doing inductions before 39 weeks, a practice that has led to fewer newborns being placed in neonatal intensive care units.
“Over the last few years, the March of Dimes has been trying to inculcate the idea that no inductions or elective c-sections should be performed before 39 weeks because each week of fetal development, up to term, is important for the development of the lungs, brain, and nervous system. The prematurity rate has finally leveled off, and it may be because the idea of not delivering before 39 weeks has finally taken hold,” she said.
Still, premature births continue to occur, as do unanticipated complications, and Laboring is filled with stories ranging from the tragic to the triumphant. Although Cohen retired in 2005, the dramatic details she recounts make the book simultaneously jolting and memorable.
There’s Mia (not her real name), a young woman suffering from schizophrenia who had been brought into the hospital by emergency medical personnel after she was found, in labor, in a Manhattan subway station. Although she screamed that she was not pregnant, she admitted using both Thorazine and crack cocaine. By the time Cohen met Mia, the patient had already had an altercation with a medical resident. The doctor, frustrated by Mia’s refusal to consent to a vaginal examination, had urged her to sign out of the hospital. “In effect,” Cohen writes, he was “sending the patient out into the street to give birth.”
Mia did not follow the doctor’s orders. Instead, she became increasingly agitated as the contraction became stronger and more frequent. Eventually, Cohen writes, Mia leaped out of her bed and ran into a large, open area near the nurse’s station. “I ran right behind her,” Cohen recalls. “Mia leaned against the wall with the next contraction as the baby’s head emerged. ‘Squat down, Mia,’ I told her. She flopped on the floor on her back, refusing to open her legs and batting away my hands as I knelt beside her, attempting to help ease out the baby’s shoulder.” The baby delivered himself, Cohen continues, and was subsequently placed with a family member.
Laboring also includes stories about assisting prisoners who were forced to give birth while shackled—a practice that was officially ended in New York state in 2009. Other accounts introduce women who had previously lost children to gun violence or illness; women with gestational diabetes, pre-eclampsia, and other illnesses; babies born with health concerns; and pregnant teenagers, some of them abused and most of them scared. It’s a potent mix that celebrates the valiant work of a little-known, and often misrepresented, profession.
Especially insightful is a section about HIV and AIDS. “I worked in a research study that was incredibly gratifying,” Cohen told me over tea on a frigid afternoon in late January. “It led to the first breakthrough in prevention and to this day, it is one of the only breakthroughs we’ve had in limiting mother-to-child transmission of the virus.” That said, she admits that working with HIV-positive women in the late 1980s and early 1990s took its toll. The work, she says, was weighted down by secrecy since most of the women felt that it was essential that their HIV status remain hidden.
But beyond HIV and AIDS, Laboring includes revealing data about the impact of occasional stillbirths, birth defects, and delivery complications on staff. “Whenever there is a bad outcome,” she writes, “we’re told that because of liability concerns we should not talk to anyone about it. This leaves midwives and other health-care providers to suffer in isolation from feelings of distress, anger, and sadness. I always pushed my coworkers to do a major review of the cases that ended with a death or complications so that we could see if there was something to rectify.”
Despite this attention to detail, Laboring gives scant mention to male physicians who are sexist toward midwives and female nurses, bureaucratic missteps, or the weaknesses of the U.S. health-care system. Instead, it celebrates midwifery and the humane care its practitioners provide. As Cohen explained, “Physicians deal with disease and injury. Their education in the “normal” is largely to prepare them for the abnormal: When pathogens or tumors invade the body and the immune system is overwhelmed, when organs do not function properly, blood is lost, or tissues tear.”
“Midwives probably spend more time studying normal pregnancy and birth, with their many variations, than medical students. We do not view the “normal” as preparation for interesting complications,” she said. “The ordinary miracle of life is interesting enough.”