Marsden Wagner, MD, MS University of California Press, 2006 Berkeley, California, USA 295 pp, $24.95, hb

Born in the U.S.A. sets out to explain why the maternity care system in the United States is not putting women, children, and families first. Examining the structure of obstetrical care more thoroughly than most books about childbirth, it helps readers understand why present maternity care services are often unsatisfactory, why choices are limited, and why women’s basic human rights ignored or abused. It offers a wealth of examples, insights, and critiques, based on the stories of many women and Dr. Marsden Wagner’s extensive national and international experience.

Why is obstetrical training based on illness, fear, and risk? Who is responsible for foisting the “climate of doubt” on women and practitioners that permeates the whole society? Who benefits from unyielding obstetrical routines that interfere with the birthing process? Why depend so greatly on drugs and machinery? Why use insufficiently tested procedures and drugs, endangering women’s and babies’ lives and health? Why pursue territorial battles against midwives and midwifery?

Wagner writes that obstetrical strictures too often serve to protect and preserve obstetricians’ interests, while putting family physicians and midwives at a disadvantage and depriving women of autonomy and choice. In the chapter “Tribal Obstetrics,” he describes students entering a surgical specialty in which all birth is presented as a potential disaster requiring their skills, skills that they alone possess. Not educated to deal with normal labor and birth, they still put themselves forward as the only appropriate attendants. This obstetrical training (Wagner describes it as a kind of initiation into a primitive tribe) eventually leads to entry into the elite, influential American College of Obstetricians and Gynecologists (ACOG), which has assumed and exerts a great deal of unmerited power. Managed and monitored by ACOG, physicians must then adhere to standards of practice, presented as incontestable truth that is not, in fact, borne out by studies. However, by not observing ACOG’s standard of practice, physicians may jeopardize both job and reputation. When problems occur, members may be more loyal to one another than to the mothers, their patients.

Unnecessary and hazardous interventions have long since become routine, not so much for the benefit of women, but for the convenience of hospital personnel and the financial welfare of the institution. They affect every woman who gives birth in a hospital, who must either refuse them or give in to the “cascade” of interventions that occur when she accedes to the first one, be it an IV, induction of labor, or epidural. Wagner presents a list of 21 obstetrical practices that should not be done at all in normal labors, according to studies summed up in the Cochrane Collaboration. Although obstetrical textbooks are finally beginning to advance evidence-based practice as a goal, most obstetrical research involves either nonscientific “let’s try it out” conclusions, which all too often turn into medical dogma and even tragedy (e.g., the past use of x-rays, DES, and thalidomide), or falsely scientific, rushed studies based on a paucity of cases, faulty methodology, or both.

One of the most egregious examples of a drug being used “off-label” on millions of women for its convenience and ease of administration is Cytotec (misoprostol). Originally approved by the Food and Drug Administration (FDA) for stomach ulcers, but contraindicated for pregnant women because it causes strong uterine contractions, it is nonetheless used to induce labor, despite well-documented tragic and deadly effects such as uterine rupture and infant death. (The FDA, World Health Organization, and other organizations were joined by Searle, its manufacturer, who issued a press release in August 2000 warning against its use for cervical ripening and uterine stimulation.) As these results become more widely publicized, who will be responsible for regulating its use?

Wagner provides examples of physicians who ignore or misinterpret reputable studies to justify their practices or advance their careers. He also condemns ineffectual institutional review boards and peer reviews for too much collusion between participants and for suppression of evidence. When childbearing women, their families, researchers, and practitioners need to gather information and data, they find too little transparency in the disclosure of maternity care statistics, and a lack of medical accountability in general.

Despite its well-documented advantages for women and babies, midwifery represents a threat to obstetrical practice, earnings, power, and control, as do planned home births. And despite obstetricians’ practice of defensive medicine, lawsuits abound, in part because they serve as the only recourse for women and families who have no other access to effective complaint processes. However, the chapter “Rights and Wrongs” mentions several legal and legislative channels that do exist through which women can affirm their professional and human rights.

Wagner believes that to make changes it is essential to envision solutions. He advocates for a national health care system, which would be cost-effective and strengthen the monitoring and regulation of obstetrical practice. He lists some of the challenges, such as the incorporation of midwifery and obstetrical expertise into a team effort; the education of practitioners and lay people in the normality of birth; the preservation of the right to litigate (a necessary evil); taking political action; and working for change as individuals, in groups, childbirth education associations, midwifery organizations, and advocacy coalitions such as the Coalition for the Improvement of Maternity Services (CIMS). Given Wagner’s assessment of the pervasiveness and restrictiveness of obstetrical control, it is interesting and encouraging that he ends on a positive, hopeful note—as if change were really possible.

Born in the U.S.A. is densely and passionately written, each chapter backed up by excellent documentation and enriched by a wealth of experiences. Wagner’s words and tone are often provocative, but today’s emphasis on highly interventive obstetrics desperately needs this kind of personal investigative writing. The book’s forthright views should give mothers-to-be, practitioners, administrators, lawyers, and legislators the information and courage to change a system that is not so much “broken” as adapted to the needs of those in power rather than to the women they are supposed to serve.