The Trouble With Advocacy Films 8
On of the parenting lists I read mention a film called the business of being born, a documentary advocating midwifery, home births, and generally questioning the US’s extensive use of hospitals for child birth, as compared to Japan and Europe. I’m sure it is a great film and highly informative to lots of people, and I understand it ends with an interesting counter note as the director gives birth herself and ends up having a hospitalized birth due to complications with her pregnancy, but the trailer I find on the homepage reminds me of the perils of advocacy documentary film making; in particular how they tend to play fast and loose with facts and statistics.
The movie has the Bowling for Columbine trifecta: it’s about life and death, it’s about how America is worse than the rest of the civilized world, and it has a celebrity sponsor (in the form of Ricki Lake). Now, having grown up in Canada and generally being of the liberal persuasion on social issues, in theory I should be predisposed to embrace discussions about what’s wrong with the US, and in particular those that involve health care. However, as I watched the trailer, I had a bit of a sick feeling in my stomach.
First of all, I have to embarrassingly admit here that I am not sufficiently well informed on midwifery and/or home birthing to really be able to discuss the matter one way or the other. When it came to our own child I don’t think the issue ever came up (although there was discussion about a Doula), and I guess I lacked sufficient curiosity to investigate it myself.
That said, I have some first hand (and no, I’m NOT trying to suggest I have a clue what it is like to physically give birth to a child!) knowledge of the institutional birthing process and cultural norms in Canada and the US, and that is where I take issue.
The killer bit of the trailer for me was the bit where it was suggested that the US “stands alone” in the prevalence of “institutional” births. They are of course comparing the US with Japan and Western Europe, but the US’s friendly neighbour to the north is about even more fond of institutional births.
The trailer states “The United States has the second worst newborn death rate in the developed world”, and talks about a “maternity care in the United States is in crisis”. The implication being that these things are all related. Once again though, there’s the Canada problem. When you look at infant mortality rates worldwide you will notice that the US is one of the worst performers of what we traditionally think of as first world nations, but it isn’t like it is way outside the average for the first world. So, while it sounds ominous to be “second to last in the developed world” (and looking at the stats you might see how a number of nations have to be asking why they don’t count as developed), in reality there isn’t a huge statistical gap pointing to a “crisis”. Secondly, you’ll notice that Canada scores better than the US, pulling ahead the UK, Portugal, Ireland, Italy, New Zealand and South Korea, while giving Australia and Austria a run for the money.
An amateur statistician will look at this data and say that if anything it suggests that prevalence of institutionalized birth has at best a limited relationship with infant mortality, and certainly there is little evidence of a causal relationship. A professional statistician might demand to look at actual data on medical intervention rates in other countries and observe that many of them have nearly comparable if not equivalent levels of various medical interventions, including Cesarean births (the rise of which may actually have more to do with factors unrelated to preferences of doctors *or* patients). Indeed, staring at the data, I imagine a few factors that seem far more likely to be the key factors attributable to the US’s higher rate:
- Socialized medicine. On the chart I found, the US’s infant mortality rate for 2007 is 6.4. The top country on the list is Sweden, with a 2.8. So, the difference between the US’s “bottom” ranking and a top rating is 3.6 deaths per 1000 births. As such, factors which primarily effect only a small minority of the population can have a pronounced effect. So right away, I’m thinking that the very nature of the US’s private health care system implies that poorest people in the country will get substandard health care. In fact, I’ve read about all kinds of problems with pregnant women basically not seeking health care until after their contractions start (and sometimes not even then) due to fears about medical bills, let alone those who receive substandard care because of their limited means. This of course hampers effective medical intervention for births with complications. This factor is actually highlighted in the press kit that the movie hands out, although there doesn’t seem to be a connection made to how this would explain differences in infant mortality rates relative to other developed nations. It’s a tragedy and needs to be better addressed (sadly, this is often more a problem of educating the public than an actual economic problem), but this problem is almost the opposite of overuse of hospitals and doctors for birth. Looking at the list, I can’t find a single country without socialized medicine that ranks above the US.
- Immigration. Each year, the US accepts more immigrants per capita than any nation in the world, and that’s only counting the legal immigrants. That means, you’ve got a comparatively (to other nations) large segment of the population who weren’t born and raised in your medical system, weren’t treated by your public health initiatives, haven’t enjoyed your standard of living, weren’t subject to your public health education campaigns, and weren’t subject to your general public education system. Now, in some cases their public institutions at home will have better prepared them than their adopted country, but it can’t help but skew your statistics towards the global average (which is *substantially* worse than the rate for “developed nations”). Again, looking at the data, I see “developed” nations which I tend to associate with high rates of immigration (the US, Canada and Australia) ranking lower than those I tend to associate with low rates of immigration (Sweden, Japan, and Norway).
- Aggressive attempts at viable births. This is one of those “lies, damn lies, and statistics” bits. There is no uniformity in how infant mortality data is collected. Each country reports its own statistics, and what counts as births and deaths is heavily impacted by political and social standards and agendas. It’s a tricky problem, where you get penalized for trying: what do you count as a birth? If you’ve got a child that for whatever reason needs to be born prematurely at say 25 weeks, the odds are really not good. In the US, they’ll give it a go anyway and their success rate under such circumstances is, AFAIK some of the best, if not the best, in the world. The thing is, if you just give up and don’t record it as a birth, you’re going to look a lot better than that other guy who gives it a go and fails three times out of ten. I found this article looking at Cuban vs. US infant mortality rates which makes exactly this point. Now, this is partially a function of the US’s institutionalization of the birthing process, but I have a hard time accepting criticism of it beyond the notion that perhaps these heroic efforts drain medical resources that might otherwise be directed towards births in poorer families with better chances for viable births.
The film also wonders why insurance companies freak out about home births (duh! when you are an insurance company you don’t care much about marginally –from an economic standpoint– better outcomes in the normal case: what you’re scared about are those really bad outcomes where “you could have done better” that involve trial lawyers, massive jury awards, and completely blow your actuarial tables to smithereens!). It talks about various medical mistakes made over the years, from X-rays to thalidomide, without recognizing the extend to which modern medicine has learned from these examples (there’s a reason why almost every medication on the planet says, “pregnant women should consult their physician before taking this medication” and why hospitals are now cautious about overly invasive mechanisms for monitoring births that are without complications). It also talks about the dramatic change in the rate of institutionalized births from 1900 to present day, but fails to mention the improvements in infant mortality rates that occurred concurrently (I’m sure this was to avoid having the audience make assumptions about correlation being causation with regards to infant mortality rates ;-).
This is the kind of analysis and discussion that often is conveniently overlooked by advocacy films, which by their nature are focused on the emotional core of a story more than facts. This is exactly why I find it so hard to treat such films much differently from pure fiction.
I have little doubt that there are issues with our cultural and medical norms with regards to childbirth. I know that medical liability is so skewed that doctors are often better off ordering tests and prophylactic procedures and medications that address 1% cases, even if there are negative outcomes for the patient (I have to imagine a doctor’s worst nightmare is working on the birth of a child whose parents are trial lawyers ;-). I know that pressures from increased medical care costs have lead to patients being pushed in and out of hospitals at faster and faster rates. I’m sure there are things that could have gone better with my own child’s birth. However, much as I’m aware of the dangers of judging a book by its cover, I have a hard time feeling like the best way for people to become informed about these issues is by watching this film.
Chris, You make some great connections that do indeed affect the statistics of birth ( ie, immigration levels, determination of viable birth, and nations with socialized medecine), however you are telling everyone to skip a movie that you haven’t ever seen. That seems to go against the moral tone in which you write. Wow, I want to call you mr. brussel sprouts.
And yet in your own writing you reveal the greatest issue of this Birth Choice movement that is growing not only in America, but round the globe. You do not know what you could have denied or requested around the birth of your child. There is far too little consumer awareness of the protocol and procedures of birth attendants! This in itself has caused an unchecked situation where agendas of both hospital administrations and medical staff (based greatly on the fear of liability) indeed manipulate the events within labor and delivery.
It has been said that mothers’-to-be and fathers and families research mortgage and new car acquisitions with in depth fervor and yet leave the investigation of the birth process (biological and how it is administered by birth attendants) up to the hands, hearts and minds of others. Granted, we do not live in a society where we might have been around birth numerous times to ask questions as a child and familiarize ourselves with it. No, sadly our gut responses to birth are based on overdramatized movies, Nielson-driven editors and other media blitzes.
And even though you seem to position emotionality as a bad thing, I can only imagine the road of emotional discovery you went through participating in the birth of your child and the experience of your partner.
This film and others like “What Babies Want,” are not only imperative in the Birth Choice Movement, but offer a greater glimpse into how to be a conscious consumer about birth. And even though you seem to avoid the emotional connection, birth experiences are the most emotional experiences of our lives. Every participant should be viewed as an emotional being: you the father, the mother, the newborn and the even the birth attendants.
You have bitten off what I believe the forces behind the trailer of the Business of Being Born expected audiences to sit up and pay attention. Sadly it is statistics, the safe, emotion-free insight that most Americans find the easiest to address.
I thank you for addressing that flaw in our society’s attention span and also ask you to find time to privately explore your memories/experiences of the journey of your child’s birth, as it seems that you question its roll out. This questioning is the begining of becoming concious consumers of pregnancy and birth, or as I like to view it, protectors of the greatest rite of passage in human civilization. You might have another child or your children or other families near you might have another child and only in sharing our experiences do we realize that we are not alone.
The quality of birth can increase for everyone once we allow ourselves individually and as a collective society to consider that a “good birth” means more than the statistical viability of mother and newborn. There is so much more in a good birth that I wish all people to experience.
Jessica Deltac Therapist in Southern California
If you haven’t watched the film, shouldn’t the title for this article be “The Trouble with Advocacy TRAILERS?” Trailers are designed to grab your attention and this trailer did that….if only you would watch the film before you critique it!
While I didn’t watch the film, I did grab the press package that is distributed by the filmmakers and looked specifically at the press notes, which did include a section highlighting the facts behind the film’s argument. While they did raise a few good points, for the most part it confirmed the impression I had from the trailer that most of the content of the film is playing fast and loose with statistics and facts.
The title of the article is informed by my experiences with a number of documentaries that I have watched. This film was picked upon because it was a new film that I’d encountered and at least at first glance it seems to hit all the notes I feared it might.
As for trailers…. a good trailer should grab your attention and make a case for why you would want to devote some time to watching a movie. It should not misrepresent, mislead, or misinform. Most importantly, it should make a convincing case about what is different about this film that I should watch it before the countless other films that I have not watched. In this case, the message I walked away with was that while the filmmaker likely has done an excellent job of weaving together a compelling story, that the film had the traditional failings of an advocacy documentary. So my overall impression was that I’m not quite in a hurry to see it. If someone who has seen it has a different impression, I’m all ears.
I am not telling everyone to skip the movie. I am suggesting that if people wish to become informed about these issues there are better ways than by watching this film, which is entirely consistent with the tone of my writing.
There are lots of good reasons to see a movie, and many of them likely apply to this movie. I’m merely suggesting that, “I want to become more informed about this issue” shouldn’t be very high up on the list, particularly with fictional or advocacy films.
I should clarify this. I have a pretty good idea of what were my legal restrictions (which are more than I’d like them to be but for the most part are quite limited). Before educating myself on the protocol and procedures we chose to go with, I think I actually had a better idea of what is involved with a midwife (oddly enough, most of the kinds of fiction I’ve read have dealt more with the midwife scenario, and of course friends who have gone that route have been more likely to share about their experiences, so I really didn’t know much about how the institutional process worked until after we were pregnant). The ignorance which I spoke of was with regards to the facts about the pros and cons of midwifery. I really have no idea whether outcomes are better for either mother or child, or whether the rather aggressive campaigns against midwives during the early 20th century were really beneficial in terms of medical outcomes (I don’t consider the overall reduced infant mortality rates at all definitive).
I don’t really know about the general case, but I can say with confidence in our case that the opposite is true. Indeed, we bought a house the day before my son was born (kids, don’t do this at home), and I can tell you that the we probably spent more time fussing over the choice of pediatricians (let alone the whole birthing process) than we did over our house.
On the advice of others we went to courses on this stuff and went over procedure with our obstetrician, hospital, and to a lesser extent pediatrician, all of which were very clear about what was legally required and what was a choice (I’m sure this was out of fear of possible legal repercussions of us not being fully informed), and I recommend that others do the same.
Nobody suggested that we do the same about buying a house (indeed, the process was rife with a lot of “just sign here”).
It’s not an inherently bad thing. Emotional portrayals are one of the main reasons to watch a movie, and I don’t think it is necessarily wise to divorce one’s emotions when considering an issue either (in cases of involving a child, I’d argue such a pursuit is doomed to fail anyway ;-). However, one must recognize that molding the data to fit one’s emotions does not lead to an informative piece.
I don’t think one can honestly suggest that the trailer wasn’t pulling at emotional strings!
I think suggesting that the statistics are emotion-free is also highly misleading. There are a lot of emotions involved in a pregnancy, and a LOT of them have to do with the health and well being of the child. When I saw the trailer throw up the stat about infant mortality in the US, my immediate reaction was entirely an emotional one, and I think the folks who put together the trailer were counting on that.
Honestly, I’m at least as uncomfortable as you with thinking about this from the context of being a “consumer”, which makes me feel like I’m buying groceries and looking at ingredient labels. I was a parent, trying to do what was best (both emotionally and medically) for me and my family. Most of us can’t possibly hope to be fully informed, nor do we need to be, but you navigate through the process as best you can.
This is a very interesting discussion. I’m a European living in America and I’ve delivered 2 kids here so I can speak from my point of view having 2 very different hospital births. In Europe it’s very common for women to give birth without pain medication for example. Here in America, the first option given to you is pain medication with very little regard to how it can and does affect the outcome of the birth. It’s been proven that epidurals and c-sections go hand in hand and one doesn’t have to be a doctor to see the correlation there. Women’s bodies are build to give birth to babies not lay in the bed under pain medication not being able to feel your body working during labor. The baby has trouble coming through the birth canal because the hormonal/pain censors in the brain has been blocked by pain medication. All of sudden the baby is in distress and off we go in the surgery room. How many times have you heard a woman giving birth naturally meaning without any pain medication, needing a c-section? I gave birth naturally without any pain medication and the hospital staff on both occasion were horrified and actually amused because they thought they knew I couldn’t do it and also because they didn’t see the point why anyone would want to. After those reactions coming from 2 different hospitals and hospital staffs I got a good idea of the current medical mentality here in American and I’ve since learn how much the insurance companies and hospitals control the birthing process and are in it together. If you get the automatic epidural being offered, your hospital bill goes way up because now you’ve got the anestesiologist involved and you have to pay that person as well. I wanted to get out of the hospital the next day after having my delivery but my request was denied by the hospital and was bullied into staying by the hospital staff claiming that if I leave, the insurance company might not pay for my delivery. Now please tell me why a hospital would want me to stay for 2 days instead of 1 when me and my baby were perfectly fine. The only answer I can come up with is money. They were going to get more money from me and my insurance company. I can’t believed that I was so stupid and caved into staying. I’ve since learned that this is common practice by the hospitals. If I had known that, I would have walked out with our baby in our hands. After my own experienced with child birth here and American and knowing how different things work in Europe and the country I’m from, I’m so glad to see this film being put out to make people think. I haven’t seen this film myself so I shouldn’t fully comment but I hope to see it soon. One more point, I’d like to make is that from the many years that I’ve lived here I can see how many americans are brainwashed by the drug companies to need a medication for everything. The drug companies have such a powerful hold on the American society due to the money spent on advertising and lobbying on Capitol Hill. In Europe people are encouraged not to use medications unless completely necessary including over the counter medications. A good latest example of the over usage of medications is the cold medications being banned for young kids and babies because parent’s couldn’t be trusted to properly use them and because there wasn’t enough testing done on the side effects on the kids, yet these medications have been on the market for years without any regard to the responsibility of the drug companies and the FDA to make sure these medicines are safe to the age group they are intended to.
I guess it depends on your hospital/obstetrician. Our hospital offers a course in pain management above and beyond the beginner stuff. When we encountered complications during the birthing process, one of the first things that our obstetrician tried was cutting off the epidural, so I’d say that they were pretty aware of how it affect the outcomes.
Well, you’d kind of hope that you’d get some pain medication before they cut open your abdomen…. ;-)
Seriously, there are a lot of situations where a c-section is needed and/or safer that have absolutely nothing to do with pain medication or the condition of the mother at all.
I think, in this case, two is not enough. Your experiences sound very different from my own. America is a big place, and anecdotal evidence is not sufficient to make generalizations.
It sounds like the hospital staff were simply trying to look out for you. Normally they want to get you out of there as fast as possible. The norm these days is 1 day for a regular birth and 3 days for a Caesarean…. and the insurance companies will typically balk if you exceed those numbers.
I guess they’d make more money if your bed would otherwise be unused, but normally they can make more money if they get you out of there and use the bed for a patient that needs surgery or other hospital services. Particularly with all the hospitals that have been closed, empty beds are hard to come by, and a patient in a bed who doesn’t need hospital treatment represents lost revenue, not additional revenue Isn’t it possible that they were either concerned about your health for some reason and/or they really were concerned that you’d get shortchanged by your insurance?
No, that is incorrect. I know people who would have loved to have the extra day but couldn’t because their insurance doesn’t cover it.
You are misinformed on this matter. You may find this article in the NY Times enlightening. The original approvals happened decades ago when the medical community (not just the US) believed testing with children was unnecessary. The drugs in question were never okayed by the FDA for children under the age of 2, nor were they marketed that way (if you look at the “dosage” section on the bottles they usually say “talk to your pediatrician” instead of listing a dosage). Furthermore, the medications were banned not only because of safety concerns but because of evidence that they were completely ineffective. As for parents being “trusted” in the US, there may be cultural differences on risk tolerance… are those medications still for sale in Europe?
1) You haven’t seen the actual movie. 2) your own words: “First of all, I have to embarrassingly admit here that I am not sufficiently well informed on midwifery and/or home birthing to really be able to discuss the matter one way or the other. When it came to our own child I don’t think the issue ever came up (although there was discussion about a Doula), and I guess I lacked sufficient curiosity to investigate it myself.”
My suggestion: Don’t blog about a movie you haven’t seen on a topic that you are not sufficiently well-informed on. This is yet another example of the internet providing a platform for any Joe Blow to air his/her uninformed opinions for the masses to consume and often (unfortunately) take at face value.
You sound like a really inteilligent guy. Maybe you should wait until you’ve seen the movie and learned more about alternative birth options to blast it.
If your point is that advocacy films skew evidence in favor of the point they are trying to make, then draw from examples of the films you have actually watched instead of targeting just one film (which YOU HAVEN’T SEEN).
Which differs from an advocacy documentary in that said Joe Blow does need to have some money to burn. ;-)
Having a market place of ideas where the cost of entry is cheap is a net good thing. You’ll note that unlike an advocacy documentary, it is equally easy to present criticism of my ideas inline with the ideas themselves (yeah! we all win). Media such as this make it easier for alternative viewpoints, like alternative birth options, to get out to the general population.
You’ll note that I didn’t blast any point the film made about alternative birth options. Rather, I criticized the blasting of institutional births as found in the press materials provided by the film makers and by the film’s trailer. In some cases the information is misleading, and in others it is just flat out wrong. I do think that is important and relevant. If the film repudiates these points, I’d be very interested to hear about it.
The advantage of this particular film is that I was able to restrict my comments to content which is available on the web (the trailer and the press kit). This makes it easy for anyone reading the blog to view the material themselves and draw their own conclusions.