Catching Babies Blog Series: Tolerating Risk in the U.S. Maternity Care System
A series of interviews with author J.D. Kleinke on topics raised in his new novel, Catching Babies.
Today, I talk with J.D. Kleinke about risk tolerance, both as it pertains to his book, Catching Babies, and as it pertains to doctors, women, and the U.S. maternity care system as a whole.
Before I begin our discussion, a few warnings: to those who have not yet read the book, there are some mild plot spoilers in the following exchange between Kleinke and me. Read with caution!
And to those who are pregnant and want to “gestate in peace,” you might want to consider postponing reading either this post and/or the book. The births described in the novel are often high risk, high drama, and sometimes even catastrophic. (I know I have a lot of VBAC moms reading my blog, and the first chapter of the book involves a uterine rupture.) So please read with caution.
I hope that you take this in all sincerity when I say that I really, truly enjoyed Catching Babies. It is rare that one gets the chance to read a novel about the work and world of childbirth, and I found this reading experience to be a real treat.
Part of what I particularly loved was how you framed each doctor’s positions and values and decisions and career goals in terms of their life experiences, their “back stories.” By touching on each of character’s stories and unique personalities, and by offering a glimpse at the thread that connects them from who they were before medical school to who they are “now” in their last year of residency and their first year in their careers, you help to humanize both the characters in the novel and real-life OB/GYNs. This “humanization” is especially valuable in a culture and society that tends to either valorize or demonize doctors—that holds doctors up as infallible heroes or that denigrates doctors as uncaring butchers only out to squeeze another dollar out of their patients. (Perhaps I exaggerate this dichotomy, but I do see instances of these narratives quite frequently, especially in my work as a doula and maternity care advocate.)
As I reflected on the ways in which the characters’ “stories” (and really any person’s stories) influence who they are and what they believe at any given moment, I also started thinking about how individuals’ perceptions of risk—their evaluations of risk, their risk tolerance, their understanding of how specific risks fit within their own value systems—develop and change in light of their life experiences. And then I wondered: what makes different OB/GYNs respond to risk—risk in general, or even specific risks—differently? What makes one support VBAC, or vaginal breech birth, or a personal 70% cesarean section rate, while her colleague might deem each of these practices as “too risky”? Furthermore, what makes individual pregnant women respond to risk differently? How does their interaction with their care providers affect these responses? And how does Catching Babies address these very questions?
In part, I think it helps to look at the ways in which OB/GYNs are trained in order to answer these questions. For instance, in the large, urban teaching hospital where your characters worked, the labor and delivery unit saw an especially high number of high risk births and/or women who were uninsured and had received little to no prenatal care. And in “real life,” the vast majority of OB/GYNs complete their residencies in similar settings.
It seems to me that these early career experiences might make OB/GYNs overly-sensitized to the riskiness of pregnancy and childbirth. To make them, as some argue, “pathologize” pregnancy and childbirth on the whole.
This is not to say that there is not great value in honing the ability not only to understand and analyze risk but also to recognize and respond to a potentially dangerous pregnancy or birth-related complication as it develops. This is a remarkable ability, and one that “we” often look to OB/GYNs in particular to have. But these skills are markedly different from viewing pregnancy and childbirth as inherently and universally pathological conditions or experiences. And if one’s early and formative career experiences involve situations that are disproportionately saturated with risk, then one’s perception of risk throughout one’s career might be subsequently skewed.
To be clear, my thoughts about risk in relation to Catching Babies are not limited to doctors’ perceptions and tolerance of risk. It is just as important to take into account childbearing women’s understanding and evaluation of risk. What life experiences and values affect their tolerance and perception of risk? How do their experiences with their obstetricians or midwives affect the way that they perceive risk as it is associated with their own pregnancies and labors? And how should OB/GYNs communicate these risks—or rather, how should they be trained to communicate risk to their patients?
To this effect, I’ve also wondered who you considered your audience to be when you were writing the book. Were you writing “to” OB/GYNs and other maternity care professionals? To those interested in health policy? Or to any and every person who has an interest in reading a novel about the politics and difficulties and even viciousness of OB/GYNs’ residencies and early careers?
I ask these questions because I think that many subsets of your audience will interpret various scenarios in the book through the lens of their unique perspective on risk in regard to pregnancy and childbirth. What’s more, I a few of members of your audience might even be influenced by the way in which you present those scenarios (and here I am thinking in particular of the uterine rupture, the woman with gestational diabetes who required antepartum bedrest, and the difficult twin delivery). To this effect, by depicting so many high risk pregnancies and births alongside very few, if any, “normal” births, were you at all concerned that pregnant women reading your book would end up thinking that childbirth on the whole is a high risk endeavor? That a woman might walk away associating all VBACs with catastrophic uterine rupture, or gestational diabetes with diabetic coma, or all twin pregnancies with twin-to-twin transfusion?
Of course, it doesn’t seem as if it was one of your narrative responsibilities to depict just as many, if not more, “undramatic” and low risk pregnancies and births in Catching Babies. In fact, this would not have made much sense within the context of your story. But women in contemporary U.S. culture often see childbirth depicted on television, in film, and even in stories told by their friends and family as an unavoidably dangerous and risky event: not as a typically healthy, normal life experience that can carry risk and that sometimes requires medical intervention. And while your book’s purpose was not to transform this narrative, I do wonder if you have any insight how to provoke the sort of cultural shift necessary to transform women’s (and even doctors’) perception of pregnancy and childbirth from the former to the latter.
If I may, I do have one final question, completely unrelated to the topic of risk in maternity care: Why did you choose the title Catching Babies? I underscore ‘catching’ because I rarely hear doctors refer to themselves as catching babies. More frequently, they describe themselves as delivering babies. It’s how most people in the United States refer to the actual birth of the baby. What’s more, it’s often the midwives, the doulas, the maternity care advocates, and many mothers who prefer the term ‘catching’, primarily because of the way it places the most active activity, the most arduous work, in the realm of mothers: mothers deliver babies, and their doctors or midwives catch them.
Am I reading too much into your title choice? Or is it really as provocative as it seems?
Kristen Oganowski, CD(DONA)
J.D. Kleinke’s response:
Hi Kristen -
Thanks for the kind words, and I do recognize and appreciate the sincerity! And no – you do not exaggerate the perceived dichotomy about doctors…it’s exactly the thing I set out to debunk.
Wow, those are GREAT questions! You are a sharp observer and a good writer. Because your questions are mixed into your letter (pasted down below), I’ll try to summarize them a bit and then answer. Hope I got them right…
1. Do you think doctors have overdeveloped perceptions of pregnancy risk because of the nature of their training?
Absolutely. For numerous economic, organizational and practical reasons, all medical residents are deliberately overexposed to disasters among the poorest, unhealthiest, least insured, most vulnerable patients in society. And OB/GYN residents get a double helping of this because a pregnancy is two potential disasters for the price of one. This overexposure of course clashes in very weird ways with what happens when they cross over into private practice, from one extreme on the public health bell curve, back into the great big normal middle. But how couldn’t a doctor always be mindful of that long awful tail, of everything that can go wrong with a patient in a just a few minutes, when that’s where he or she trained, and in many cases, that’s where their intellectual curiosity, egos, and adrenaline all want to take them? This hyper-awareness of what can wrong during childbirth, even when in most cases nothing goes wrong, is probably the strongest argument for a system of maternity care completely re-architected around CNMs, with OBs as backstops for exceptions, problems, and complications, not as the first line of prenatal care and labor and delivery.
2. Do you acknowledge and account for patients’ differing perceptions of risk?
It’s not something I had time or room to explore in the book that much, but this is also a great question. The fundamental challenge faced by the collective world of maternity care is the incredibly broad heterogeneity of different women’s views toward pregnancy and childbirth. At one extreme are women who feel like the pregnancy is an invasion, a difficult and scary thing, and they want every possible technology mobilized to control the unknowns, ‘save’ them from it, minimize their fear and discomfort. At the other extreme are women who feel that childbirth is or should be a beautiful, natural, ritualistic experience, one almost bordering on the erotic, that should be cultivated and experienced as authentically as possible. And there are wild variations and permutations in between these two extremes, some of them realistic, some of them downright bizarre. One more variable along this continuum is a set of mostly untested but deeply held beliefs that many of the sub-clinical things that happen just before, during and right after a delivery – not the obvious things like fetal distress – still have a permanent impact on the long-term prognosis for babies, children, on into adulthood. I’ve heard this expressed in extremis by lay midwives that many of society’s biggest problems – like war, greed, violence, and certain forms of depression – all stem from our collectivized birth trauma, most of us having been born within a pathologizing system. Could be a ridiculous idea, or exactly so. It’s not like we’ll ever know. But it is an interesting concept, and something we should consider when we think about all of this. Because these beliefs – whether silly or true – just stir more expectations, hopes and fears into the mix for women. It would be great if we could correlate all this diversity of women’s views about childbirth with education, demographic group, or even health status, and use these correlations to figure out the best way to help match women with the right kinds of birth providers. But I think this broad continuum of beliefs are tied to things that are far deeper and more mysterious than those factors. I think views of the pregnancy experience, and the related risks, and whether to micromanage them or not for a specific pregnancy, all hit serious cultural, religious, and obviously psychological nerves. Ultimately, these patient perceptions of risk are probably wrapped up in things that go way back and tie into a woman’s earliest childhood experiences with physical safety or violation, her sense of agency or lack of control, her experiences of abuse – we’re talking the really dark stuff here – the sorts of things many women themselves are often not even aware of. But it is this broad continuum that gives rise to what is, by necessity, a very broad continuum of birth provider options in this country, from hyper-tech to off-the-grid – a continuum we need to acknowledge, deal with, and make as safe as possible for all women.
3. Who is the audience for Catching Babies?
Everyone who cares about women’s health and childbirth in America. Childbirth in this country is hospital-centric and OB-driven, and CNMs have mostly been appended onto that system, even while broadening its perspectives and tolerances for some of the risk factors we’re talking about here. And those seeking to reject or bypass the system altogether should still want to know exactly what they’re bypassing and why – and so this book is for them too. There are many would like to radically upend the entire system, rebuild it around midwives, and ship most of it outside the hospital, but they should not be holding their breath. This is the system we have, it’s the one the medical establishment has built and the insurance system has sanctioned, and structural things in health care in this country change very, very slowly, if ever. When I first started to snoop around inside the system, and look at how obstetrics actually functioned not just as a clinical discipline but as a culture, I was fascinated and, I have to say, a little horrified. I was fascinated by the culture of pathologizing and detachment, by the skewing of the system toward disaster prevention, by the absolutely brutal acculturation of the OBs. I’ve been screaming about the dysfunctionality of American health care since I stumbled into my first job in 1989, but with obstetrics I found the – please excuse the terrible pun – motherlode. It’s beyond dysfunctional. It’s all chaos and sanctimony, like most of the rest of health care in America, only in overdrive, with ten times the self-righteousness on every side of every argument. And so of course I couldn’t imagine that anyone would not be just as fascinated – which I suppose is the inspiration for all books. As a writer, your first and last impulse has be ‘wow – look what I found. Come look at THIS mess!’
4. Are you worried that ordinary readers who confront such a large disproportion of high-risk pregnancies and bad birth outcomes in the book are going to get the wrong impression about the prevalence of these occurrences?
Yes, and it’s why I do not recommend the book to anyone who is actually pregnant. Read it beforehand, or read it afterwards. Stress about your pregnancy outcome is actually one of the few verified emotional stressors in pregnancy known to adversely affect those outcomes. The cases in the book are clinical extremes because the book is really about what happens to all OB/GYNs, even as it is, thanks God, not about what happens to almost all pregnancies. This is also one more reason why I wrote this as a novel, and not a policy book, or a consumer guide. Like most novels, Catching Babies is about the dramas that occur at the edges of reality, the huge, life-altering events that will create or crush a soul – in the case of this book, the souls of doctors who have chosen this incredibly difficult specialty. But it should be obvious to all readers, purposefully from the first few pages, that these are not normal situations. The story is set in a big, scary, urban teaching hospital, most of these patients are the unluckiest of the unlucky – except for the occasional miracle. And the primary reason for this as my literary device is to show, not just talk about, what OBs are made to endure, on that road through hell known as residency. My hope is that when people read this, they’ll have some insight into a necessarily headstrong group of doctors they tend to worship or not like very much – that they will understand a lot more about a very hard-headed clinical perspective that many patients don’t understand or even find offensive.
5. How do we fix this impression, created by books like yours and other dramas on TV, that childbirth is far more traumatic than it actually is?
That’s a really hard question. Unfortunately, the bad news is what makes the news. I suppose the best way to reverse course is by normalizing childbirth every chance we get, in the real world. And this starts with greater involvement of the entire family in the process. Figuring out how and when it’s safe to deliver at home – and talking about it, rather than hiding it from authorities because it’s illegal in some states – is the best place to start. It’s the same solution to the similar problem we have with dying in this country. We hide it, don’t talk about it, hospitalize it. In the old days, you were born at home and you died at home, in both cases surrounded by family. It was normal. Then we got our technology, built our hospitals, and ghettoized these normal rites of passage inside institutions dedicated to coping not with the normal passages of life, but with dreaded illnesses we want to cure. As with everything else in the real world, we need to start talking about life and death openly, deal with our fears, and try and stop hiding all of it behind medical curtains.
6. Most OBs don’t say they are “catching a baby” so much as “delivering a baby.” Why did you choose this for the title?
You are exactly right. OBs use the phrase, but they do not say they are “catching a baby” with the same frequency that midwives do. And on the several occasions when I have heard it from an OB, it was almost derisive in tone, like the OB was ‘merely’ catching a baby, not going off to deal with one of those high-wire, high-risk feats they found more interesting or boast-worthy, the kind in the book. In fact, the first time I ever heard an OB use this phrase, I thought she did so to try and sound non-chalant about it, but I realized that she actually said it to boost her own confidence in her skills, to minimize some anxiety she might have but didn’t dare admit or show, a little bit of cowboy cool uttered for her own sake. And that obviously stuck with me. Beyond that, the title “Catching Babies” has multiple layers – it’s a double entendre, actually – but you are the first person to note this slight variation from the typical OB’s shorthand for things. I was actually much more interested in the wounded-healer themes you see in the book, and the provider-patient transference dynamics that drives so many of the stories. Without giving any of the plot away, I’ll just say that many of the OBs in Catching Babies are trying not to catch babies so much as catch themselves. Or they are willfully refusing to catch themselves. They are coming out of residence, at the entry point to the career world at an oddly advanced age, and it’s when all the big face-ups occur. No more constant school crises, what am I going to do now, who am I going to marry, am I going to finally have my own kids, deal with my own parents, marry this guy? That’s also why the cover photo. There aren’t that many babies in the story older than a few minutes, right? So you could very easily argue that the baby on the cover is actually one of the main doctor characters!
Catching Babies Blog Series:
Consider the Source: A new voice for maternity care reform: J.D. Kleinke (March 14, 2011 on Science & Sensibility)
Catching Babies Blog Series: Tolerating Risk in the U.S. Maternity Care System (March 15, 2011 on Birthing Beautiful Ideas)
Catching Babies Blog Series: Fear, Faith and Perverse Incentives (March 16, 2011 on The Unnecesarean)
Catching Babies Blog Series: Birth Sense Interview (March 17, 2011 on Birth Sense)
Catching Babies Blog Series: Refusal, Rights and Balance (March 20, 2011 on Mom’s Tinfoil Hat)
Catching Babies Q&A with J.D. Kleinke (March 14, 2011 on The Health Care Blog)
[Disclosure statement: I received a complimentary copy of Catching Babies from the publisher for purposes of this review and interview.]