Whence Come We : THE AMERICAN WAY OF BIRTH <i> By Jessica Mitford</i> , <i> (Putnam: $29.95; 672 pp.) </i>

“By now she was steadily talking to herself & God -- ‘Ah, Tata Nzambi, mpasi za mpila yina”-- “Oh, God, pain like this . . “ my daughter wrote of Ma Charlotte, her closest friend in the village of Mfuatu, after twenty hours of labor. “As she walked around, it got totally dark--it was really strange out there on the lawn, with only her voice coming out of the dark. I started following her really closely as her cries got more desperate, and then she kneeled on the grass, and called to the infirmier, ‘Come here.’ He said, ‘No, you come inside.’ She said, ‘I can’t--the baby’s coming.’ Well, that brought him right over, carrying a kerosene lamp, and when he looked between her legs, there was a little black head of hair! So the two of us helped her to lie back in the grass with a pagne (loin cloth) spread underneath her . . . And as she pushed really hard, the infirmier gently pulled the baby, and seconds later it was out on the pagne, neat as can be.”

The Zairian Way of Birth.

Most women in the United States, my daughter among them, expect a dramatically different birthing experience from Charlotte’s. And yet the country that spends the highest percentage of its GNP on health care also, according to Jessica Mitford in “The American Way of Birth,” ranks 24th among industrialized nations in infant mortality. Mitford’s curiosity was aroused by the case of a young lay midwife in California facing “criminal prosecution for allegedly practicing medicine without a license,” and her experienced nose “scented the familiar aroma of a bureaucracy in the service of special-interest groups, hunting easy prey.” She set out to investigate “the whole vast, intricate American birth scene,” visiting hospitals and birthing centers from rural Tenessee to East Oakland and the South Bronx. Although her reach has exceeded her grasp, she has furnished an informative, highly readable, and often appalling account of her findings.

Mitford opens with a brief historical overview of the process by which, beginning with the persecution of midwives during the Inquisition, male physicians came to control and “medicalize” childbirth. Clearly not intending to cover 500 years in detail, she selects colorful figures to illustrate historical moments: the Chamberlen family, “greedy tightwads,” who invented forceps and kept them a family secret for over a century; Dr. Ignatz Semmelweis, who “both published and perished,” repudiated by other doctors when he discovered that they carried deadly puerperal (childbed) fever from vagina to vagina on their unwashed hands, making 19th-Century hospitals “hellholes of infection and death . . . frequented only by the poorest of the poor”; waggish Dr. James Young Simpson, who knocked out fellow guests at dinner parties with chloroform, until he turned it to more practical, if less hilarious, use on women in childbirth.

As these vignettes suggest, delivery has become an increasingly technological event--and an increasingly expensive one as well. Turning to modern times, Mitford sketches the general situation for the woman who can afford at least $7,000 for a birthing suite featuring “early American furniture complete with a four-poster bed and a charming cradle” and the woman, lacking insurance or prenatal care, who shows up; at the emergency room if she gets to a hospital at all. She then examines some of the people and procedures they are both likely to encounter.

Much of what she reveals is chilling. An obstetrical resident assigned to care for poor working-class black women dreams of his future: “You serve a different purpose in a private practice. You are a father image or a friend . . . Here we don’t give that kind of service to the patients . . . A lot of what you do in private practice is that, plus figure out what you are going to do with your money.” Electronic fetal monitoring has become routine, even though it tends to impede labor and increase the likelihood of delivery by Cesarean section. In some hospitals, C-sections account for more than a third of all births, many of them unnecessary and “timed for the convenience of the doctor,” prolonging the mother’s recuperation but providing increased revenue for both hospital and doctor.

Mitford then turns her attention to the certified nurse-midwives and direct-entry or lay midwives who offer women with low-risk pregnancies an alternative to the interventionist and “profit-hungry medical industry.” The former, more extensively trained in general nursing skills, usually practice in obstetrical facilities, whereas the latter attend home births, believing “that in more than 90 percent of cases childbirth is a natural procedure in which medical intervention is not only unnecessary, but often harmful.” Both, through long and concentrated experience, may be equally skilled in providing prenatal, delivery, and follow-up services. Moreover, not only are their rates of medical intervention impressively low, but they charge far smaller fees than obstetricians do.

This last point, Mitford believes, may explain the relentless hostility of the Medical Board of California toward home-birth midwives: “A highly regarded Berkeley obstetrician told me in 1990 that for a normal vaginal delivery his seven-member medical group charges $2,365; for a Cesarian, the fee goes up to $3,220, to which must be added, of course, the ever-escalating hospital bills. In the San Francisco Bay Area a midwife’s fee for prenatal care, attendance at birth, and subsequent house calls runs about $900 to $1,200. As the majority of home-birth clients are middle-class women with ample insurance for whom cost is not a major consideration, the midwives believe that the medical community’s vendetta against them is to a large extent motivated by fear of losing paying clients.”

Thirty years ago, Mitford published “The American Way of Death,” and funeral directors howled in outrage. People haven’t stopped dying, though, and the bereaved can, and often do, still spend a tidy fortune making sure Aunt Tilly gets dispatched in high style. But nowadays one can also arrange for a basic send-off for $395. I know; I’ve done so. Mitford’s point in calling for reform was not to eradicate funeral directors but to enable informed choice.

Obstetricians may similarly despise “The American Way of Birth.” But babies will go on being born, and some of them, alas, will be in trouble. In such instances, obstetrical care will always be essential, and every woman, Mitford argues in her epilogue, must be provided access to it. But for the majority of women, who enjoy healthy pregnancies and uncomplicated deliveries not requiring medical supervision, safe and economical alternatives exist, and women must be provided access to these as well. Owing to “the lucrative partnership of fee-for-service medicine and private insurance,” the universal access that national health insurance on the Canadian model would guarantee has been systematically forestalled, and Mitford seems less than sanguine that relief for the “37 million” or more uninsured Americans will arrive any time soon.

Mitford’s presentation, though less than thorough, is invariably entertaining. She has a gift for telling details and amusing anecdotes: “My mother,” she recounts, “asked what it felt like to have a baby, was hardly reassuring: ‘Like an orange being stuffed up your nostril,’ she said.” Mitford’s treatment of reproductive issues tends to be spotty and superficial, omitting altogether questions regarding spontaneous or induced abortion, infertility, surrogacy, and neonatalogy, for example. Nevertheless, it serves as a sprightly introduction to matters that ought to lie, like babies themselves, very near our hearts.