Literary Mama writing about the many faces of motherhood
The Business of Being Born

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A couple days after my first son's birth, I walked down the street of our busy neighborhood with my baby in a sling, awestruck. Everybody I looked at, I realized, every child, every adult, had come out of a woman's body. I walked home slowly, mind-boggled at the wonder of it all. I was still a little stunned by my short, hard labor, and felt like I had been initiated into an amazing new society; I wanted to tell my birth story to anyone who would listen, and wanted to hear other women's stories. Now, nearly four years after I gave birth to my second son, I still often find myself in groups of women that drift into sharing birth stories; we commiserate over past pains, cheer for supportive attendants, and, as we tell our stories, come to a better understanding of this sometimes joyous, sometimes traumatic, always transformative event.

Better understanding is the impulse behind the documentary, The Business of Being Born (2008). Producer Ricki Lake, unhappy with the interventions she experienced during her first child's birth, set out to research American birth practices. She and director Abby Epstein (who became pregnant during the filming) dig up incredible documentary footage and still photos to create an informative, gripping film that should interest anyone concerned with healthcare in the United States, especially parents and parents-to-be. The film illustrates the changes here over the past century, from a standard of midwives and home births, to a new standard of hospital births (including the dreadful, dehumanizing practice of "twilight sleep," common in the twenties). The drop in home births -- from 95% to 1% -- does not correlate with a drop in newborn mortality. In fact, the filmmakers discover, the United States spends more, per birth, than any other developed nation in the world and yet has the second highest newborn death rate.

The film's thesis is that American birth has become a business that benefits neither mothers nor their children, but only the insurance companies which have developed, with the cooperation of hospital staff, an expensive, drug- and instrument-dependent system to manage an admittedly unpredictable but usually uncomplicated process. In hospitals, a cycle of interventions typically unspools something like this: if labor doesn't progress at a pace which satisfies the doctors, pitocin is administered to speed up and strengthen contractions beyond what a woman's body can typically handle, so an epidural is administered to help her manage the pain, but the procedure renders a woman unable to walk, which slows contractions, which leads to increased pitocin, which can put a baby in distress, which can lead to a vacuum extraction or c-section to ensure a safe delivery. In my case, three hours of hard, irregular contractions sent me to the hospital shaky, scared, and drug-seeking; the triage nurse discovered I was fully dilated, led me to a room, and told me to push. Reenergized, recommitted to my plan of an un-medicated birth, I asked if I could have a moment to gather myself and catch my breath; before I knew it, a shot of fentanyl was going in my arm. My son was born so quickly, I doubt the drug affected him any (it certainly had no effect on me), but I was still angry about the quick, needless shot. I resolved to bring a doula with me the next time.

Despite their strong argument, the filmmakers maintain an even-handed, even occasionally humorous, approach to the topic, interviewing a range of medical professionals about childbirth and their role in the process. They speak to young doctors who have rarely seen an unmedicated vaginal birth; public health officials who worry about the risks involved in home births; midwives who view their role as "guardian of safety and the witness of [the birth] process." They include conversations with pregnant women and their partners as they make plans for their births, and the film depicts several moving births, from Ricki Lake's own bathtub home birth to director Abby Epstein's emergency c-section, and a variety in between. And lest the film ever get too heavy, they offer clips from the Monty Python hospital sketch, with John Cleese as a bumbling, egocentric OB, who responds brusquely, when his moaning patient asks what she can do, "Nothing, dear! You're not qualified. Sedate her!"

This arrogance is not limited to fictional doctors, of course; even some of those who support women's desire to birth without a parade of interventions can be condescending or even narrow-minded in their argument. One researcher discusses the negative effects of c-sections, including how the surgery interferes with the body's ability to produce oxytocin, a hormone which stimulates the production of breastmilk and produces a state of euphoria in the new mother which helps her bond with the baby despite the pain of postpartum recovery. Monkeys that deliver by c-section, he states flatly, refuse to care for their young, as if this should seal the case. Human mothers, of course, care profoundly and well for children they didn't birth themselves, birthed via c-section, or birthed prematurely and aren't able to hold for weeks or months. We aren't monkeys.

The film doesn't end with a ringing call to action, nor a suggestion that we all picket hospitals. It spares the didacticism in favor of a quieter conclusion: birth is an incredible natural process -- and one we don't support well enough in this country -- but the circumstances of a birth don't determine the future of that mother and child. Director Abby Epstein, after all, wanted a home birth; she discusses her hopes and fears carefully both with her hospital obstetrician (who supports her choice and offers to be backup) and with her midwife, the fabulous Cara Muhlhahn, a former labor and delivery nurse with years of birthing experience (who jokes ruefully that she's "going write the book, 'Home Birth Midwife begged for cesarean!' Because (she) did."). But when Epstein finds herself going into labor prematurely with a breech baby, Muhlhahn assesses the situation and gets Epstein promptly to the hospital for a safe delivery.

Eight months later, with the healthy boy playing happily between them, Lake asks her friend about the abrupt change in her birth plan, "Do you feel cheated?" "Yes and no..." Epstein replies, wistful about her son's rough start, their initial difficulty with bonding and breastfeeding, but now at peace: "that's how he needed to come." Every mother should be able to feel this way.

My first son came hard and fast - we joke that it's the only fast thing he's ever done. For my second, I hired a doula to join us at the hospital, even though everyone said (because of my labor history) it was a big waste of money. She spritzed the room with lavender water, brought me ice chips, and ran interference with pushy nurses. When they shrugged and said "You're not making much progress," my doula looked me in the eye and said, "Your baby is coming at his own pace," protecting my freedom to lie in the bath, sleep, and slow dance with my husband. Seventeen hours later my second son emerged calmly, sleepy from his long journey. I hold onto my sons' birth stories now, feeling grateful and lucky - especially lucky after all I've learned from this film -- knowing that how they came to me was the best way for us.


Caroline M. Grant served on the editorial board of Literary Mama for over ten years, including five as Editor-in-Chief. She is currently Associate Director of the Sustainable Arts Foundation, which provides grants to writers and artists with children.

She is the co-editor of two anthologies: The Cassoulet Saved Our Marriage: True Tales of Food, Family, and How We Learn to Eat (Roost Books, 2013) and Mama, PhD: Women Write about Motherhood and Academic Life (Rutgers University Press, 2008). Her column, Mama at the Movies, ran on Literary Mama for six years; she has published essays in a number of other journals and anthologies.

She lives in San Francisco with her husband and two sons; she writes about food and family on her blog and at Learning to Eat. Visit her website for more information, including clips from her radio and television events.

Caroline is former editor-in-chief for Literary Mama.


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I have been wanting to see this movie ever since it came out. I am so glad you wrote about it here. It's sad that birth has become so medicalized. I had a terrible hospital experience with my oldest child and then my two others were born at home.
The Business of Being Born was an amazing doc. Women should be informed about the medicalization of birth and the way birth used to be in all its stages--both good and bad. However, I think you missed a very important point about this doc. Most of the women in this movie were white (except for one) and most of them live very cushy urban lives. What about low-income women? Women of color? While I really did love the flick and its approach, I couldn't help but feel a very large portion of soon to be mothers were left out. Is home birth--at the moment-- only for the financially able? And if so, what can we do to change that.
I loved this film and love this review, but I also agree with Liz. I think we need to see more insurance companies and Medicaid covering home birth if we do not only want it to be an option for the rich. Of course, it is hard for anyone to get good education about these issues currently, so people who are busy with surviving are at an extreme disadvantage. Interestingly, in Texas cities, there has been a bit of the reverse trend with nurse-midwife-assisted hospital births. City doctors have allowed the nurse midwives to handle births at the county hospitals that serve the indigent but when women with more financial resources in the community have found out how much better the experience is with even the nurse midwives than with the OBs, and when the nurse midwives began being popular with private pay patients, doctors have run them out of town, convincing the hospitals to rescind privileges. Sigh.
Thanks for your comments, all. Liz, you raise a good point about the people depicted in the film; I think the filmmakers opted for coherence and unity in focusing on one--interesting and charismatic--midwife, and while her clientele is fairly diverse, it's not an accurate sample of the range of women using midwives and doulas. And obviously that range continues to be limited by economics; as long as medicaid doesn't cover midwives and doulas, many women, unfortunately, won't have access to them.
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