I have to precede this review by saying up front that the topic of this film -- the "business" of childbirth, the skyrocketing Cesarean section rates in the United States, and the impact of managed births and unnecessary childbirth interventions on mothers and babies -- is a topic near and dear to my heart. When I heard a while back that Ricki Lake was involved in producing a documentary about homebirth and midwifery, I was immediately intrigued. I recalled hearing through the natural childbirth circle in Seattle that Lake had had a homebirth with her second child, after a first birth in a hospital with all of what many women have come to accept as the "usual" childbirth interventions, and I was interested that she was now using her ability to reach women through her talk show to advocate natural childbirth.

So to be fair about my perspective going into this documentary: I am a mother of five, and I have had babies in just about every way you can have them: an induced hospital birth that resulted in a forceps delivery, a caesarean section, and then three natural births with midwives, two at home and the last in a hospital after six weeks in the hospital on bedrest for preterm labor. I think it's safe to say I've had a lot of experience with childbirth in its various iterations, but those experiences are, of course, my personal experiences. Nonetheless, the impact of my natural births in particular has necessarily shaded the view I'm likely to have of any movie that concerns the topic of natural birth -- but I also think that anyone watching a film like this is going to come to it with their particular biases in place. Now you know mine.
Exec producer Lake enlisted director Abby Epstein to help her make a documentary about childbirth in the United States, and a documentary on this subject couldn't be more timely. The film presents some shocking stats about the business of childbirth in the United States, many of which I was familiar with from my own research on birth over the past decade. The film starts out by telling us that in every other developed nation in the world -- including the five with the lowest infant mortality rates (Japan, Singapore, Sweden, Finland and Norway) midwives are the primary source of care for 70% of birthing mothers. The United States stands alone among developed nations, with only 8% of births attended by midwives.

Epstein does a thorough job of dissecting the cold, hard facts about the history of modern childbirth that's led us to a place where nearly one-third of American births are Cesarean sections, and makes solid case against the OB/GYNs who primarily view birth as an emergency waiting to happen rather than a natural process most of the time. If all these interventions, all this fetal monitoring, induction of labors with pitocin, epidurals and elective Cesareans are really about ensuring that more births have a "happy outcome" -- meaning a live, healthy baby and mother -- then why, Epstein asks, is the mortality rate for infants in the United States among the worst in the industrialized world, with a death rate of nearly five babies per 1,000 births?

To get the answers, Epstein looks to the international community of natural birth advocates, including OB/GYN researcher Michel Odent, the "godfather" of natural childbirth, whose research on natural birth and water birth is well-known and frequently cited in the natural birth community, and Ina May Gaskin, one of the most well-known midwives in the United States, and a frequent lecturer on midwifery and home birth. She also talks to Dr. Marsden Wagner, former director of Women's and Children's Health for the World Health Organization,and her own OB/GYN, Dr. Jacques Moritz at Saint Luke's Roosevelt Hospital, who actively supports Epstein in her journey to seek a natural homebirth (a decision she reached after she unexpectedly ended up with her pregnancy and birth playing a key role in the arc of the film); Dr. Moritz becomes Epstein's midwife's backup in the case of an emergency.

Epstein, the pregnant women who are her subjects, and the natural childbirth advocates she interviews raise a plethora of questions, including why insurance companies often balk at paying for midwifery care, birth center births and homebirth, when a hospital birth is both significantly more expensive (in New Hampshire, we learn, a routine hospital birth with no complications runs $14,000, versus $4,000 for a normal birth with a midwife -- which includes all prenatal and post natal care) and statistically far more likely to result in an undesirable outcome for both mother and baby. If managed births in hospitals and all these interventions aren't resulting in better outcomes for mothers and babies and cost so much more to boot, Epstein asks, what's really going on here with the business of childbirth in the United States?

She brings out some data that may hide at least some of the answers: that Cesarean section is the most commonly performed surgery in the US, to the tune of $14 billion a year (the Cesarean rate in 1970 was 5.5%, in 2004 it was 29.1 percent, and it's over 40% at many hospitals). Litigation is key too -- in a 1999 survey, 82% of physicians said they performed a Cesarean section to avoid a negligence claim, and many midwives and birth centers have had to shut down because of the soaring cost of malpractice insurance. Convenience is a factor, too; the film discusses the rising trend in "designer" births -- planned Cesareans where the doctor performs a tummy-tuck on mom at the same time, and Dr. Michael Brodman, Chief OB/GYN at New York City's Mount Sinai Hospital, in an interview for the film, cites a study that revealed the peak hours for Cesearean section are 4PM and 10PM. It's obvious," Brodman says, " that four in the afternoon is 'It's late in the day, I don't know what's going on here, I want to get out of here;' and the ten o'clock at night is, 'I don't want to be up all night.'"

The convenience of doctors over what's best for mothers and babies is also an issue in the position most hospitals want women to give birth in -- on her back, with feet up in stirrups -- the worst possible position for birthing a baby. Medical anthropologist Robbie Davis-Floyd, interviewed in the film, notes, "Putting a mother flat on her back literally makes the pelvis smaller, makes it much more difficult for the woman to use her stomach muscles to push, and therefore makes it much more likely for an episiotomy to be cut, or for forceps to be used, or for the vacuum extractor to be used." Obestetrician Dr. Ronaldo Cortes demonstrates how the woman on the birthing bed, with her feet up in stirrups, is the preferred position for most doctors because it's what's easiest for them -- not what's best for birthing the baby -- and then shows the low stool he uses to catch babies with the mother in the much more effective squatting position he prefers to have mothers use.

This film isn't just boring statistics and interviews with experts, though. Epstein follows several women in New York City through their pregnancies and homebirths, and shows what natural births -- including Lake's second birth, at home in her own bathtub -- really look like. For women, especially, who have never seen a picture of birth outside the typical hospital births full of interventions that are shown in movies and shows like "A Birth Story," seeing what a natural birth really looks like is a revelation. The film shows what happens when a midwife-attended birth suddenly needs intervention, too -- Epstein's own plans for a peaceful home birth are shattered when she goes into labor early with her baby in breech position, and her back-up OB/GYN has to deliver her baby, Mattias, with a Cesarean section.

To be perfectly fair, this is not a film that sets out to give equal weight to hospital births with interventions; Lake and Epstein are clearly working from the assumption that women are exposed to plenty of information from that side of the homebirth versus hospital birth, midwifery versus OB/GYN discussion, and have set out here to provide primarily information about natural childbirth. Epstein's own birth is a bittersweet conclusion to the tale that ultimately serves to underscore the point of the film -- there was probably nothing that could have prevented the need for her son to be born by Cesarean section, but while she's happy that Mattias came out okay in spite of his early arrival, Epstein admits that the nature of his birth disrupted both bonding and breastfeeding, and that she feels cheated out of the birth she'd hoped to have.

The Business of Being Born currently has a limited theatrical run in New York, Los Angeles, San Francisco and Seattle, and will be available to women everywhere through Netflix in February. Check out the film's official website for further information.