A dear childhood friend wanted nothing more than to be an obstetrician the entire time we were growing up.
Fast forward several decades, and she is an accomplished medical professional whose career includes spending multiple years as a neuro-oncological nurse, working exclusively with terminally ill patients. She loved her work, she was good at it, and she cared for patients from across four western states.
“What made you decide not to go into obstetrics?” I asked once.
“Too many hormones,” she replied.
I hear that. I’m due to give birth to my first child on February 2, 2024. Throughout my pregnancy, I’ve felt like I should write something, but I couldn’t figure out what. This morning, the spirit moved me, and before I begin the next phase of this grand adventure, I’m sharing a few thoughts.
Adieu, birth culture
The toxic divisions and extremism that define American politics show up in the culture and discourse around birth. I’ve come to refer to this swirling morass as birth culture. I was never into it, and now I’m over it. We can do better. Pregnancy and birth are by nature complex, nuanced, and sometimes contradictory. Let’s make more room for all those features in how we talk and think about these experiences.
It’s all natural
First, there’s the language. I’m so tired of hearing about “natural” childbirth. Presuming a child wasn’t reared in a metal womb a la The Matrix, any birth is natural.
There was a time in my pregnancy when it looked like I was headed for a scheduled Caesarian section. I was surprised at the thoughts and emotions that popped up in response. I realized that I had (logically) invested time and money into the idea that I was going to have a vaginal birth, and it was only as I was looking seriously at the possibility of a C-section that I realized how the language of birth culture treats these procedures as a “lesser” kind of birth.
I call BS. Birth is an act of self-sacrifice, however you do it. And giving birth via major abdominal surgery absolutely “counts.” If by “natural” childbirth we mean vaginal or unmedicated or physiologically driven, then let’s say that. But “natural” is a poor descriptor, and it needs to be retired.
Western medicine is not the enemy, it’s a tool
Within birth culture, there are some who subscribe to a medicalized approach, and there are others who express varying levels of skepticism about the use and efficacy of western medicine.
Books have been written on this topic. While lack of access to quality care is far from guaranteed in today’s America, it is notable that a significant body of public policy promotes access to these services for everyone. Can we do a better job? Always, but the point is that as a society, we have made progress: access to prenatal and obstetric care in modern America is a far cry from what it used to be.
At my paternal grandmother’s family cemetery outside of Livingston, Tennessee, I have stood among six or more generations of my ancestors. Many of the women would have birthed six, eight, ten, or more kids without access to neither prenatal nor obstetric care — probably until well into the 20th century. How many of the women buried in that cemetery died or were forever injured as a result of pregnancy and childbirth? How many would have jumped at the chance to avoid these outcomes? For how many would improved access to medical care have made the difference?
Yes, there is a conversation to be had about the medicalization of childbirth, probably beginning as early as the 18th or 19th century. Yes, we should acknowledge and talk about the systematic efforts of a male-controlled medical establishment to discredit and displace midwives and other female birth professionals. And we should continue to address disparities in health outcomes that disproportionately impact marginalized groups, including the appalling rates of maternal mortality that exist in the US. We should acknowledge that not everyone has a fulfilling birth experience. While trauma is an overused word, birth trauma is real. But none of this means that allopathic, western medicine is bad or ineffective or dangerous. It is a tool, simple as that. And given how complicated producing and birthing another human can be, don’t we want all the tools at our disposal?
Retreating into a corner limits our ability to move and think freely. I listened to an entire podcast with an Australian birth professional in which the word “epidural” was almost always preceded by the word “f***ing.” That kind of approach doesn’t expand the conversation — it digs us into trenches. And shouldn’t expansion be the goal in the Information Age? We have so many more resources available to us compared to my Tennessee ancestors. What harm could come from being curious, instead of dividing into identity-based tribes and denying that the other side has much to offer?
If knowledge is truly power, then it makes no sense to categorically deny an entire body of it.
Ask questions, connect dots
Trust, but verify. Going into pregnancy, that was the only area in which my life philosophy overlapped with Ronald Reagan’s. Coming out of pregnancy, my conviction has only strengthened.
Sometimes, you need to verify stupid things. “Hey, can I see that vial, so that I can verify you’re giving me the right vaccine?” I wish I had asked that after I learned that a medical assistant had given me a second flu vaccine instead of the tetanus and diphtheria update she was supposed to administer. I was, to put it mildly, pissed. Moving forward, I’ll always demand to see that vial.
Or there was the time that I went in for test A, and a major testing company performed test B, a test I didn’t ask for, didn’t want, and that wasn’t covered by my insurance. I learned about this right before I first heard the fetal heartbeat. At what should have been a transcendent moment, I had to work hard to set aside concerns about all the administrative wrangling it would take to undo the testing company’s error. No one should have to experience that. Fortunately, it’s probably a uniquely American concern (my Canadian husband made me laugh when he wryly described the US health system as “The worst that a lot of money can buy”).
Toward the end of my pregnancy, my providers told me that a 40-year old at 40 weeks gestation has the same risk of stillbirth as a 20-something at 42 weeks (for the record, 42 weeks is about the longest even highly permissive care providers will allow a pregnancy to go before insisting on induction). That relative risk is definitely good to know, but what about the absolute risk? Are we talking about a significantly increased risk of stillbirth due to age, or a small one?
The short answer, I found, was that there isn’t really great data, and it varies from country to country. That doesn’t change the bottom line: seek the data and assess for yourself. It’s not necessary at every turn, but it’s a good idea at critical junctures, and no one will do it for you.
After “Where’s the data?”, my next favorite question throughout pregnancy has been “What’s the physiological mechanism?” I ask because I’m curious. After all, I studied enough biology to be dangerous, and I loved my college physiology class. I spent three weeks dissecting a dead cat and learning about all the different structures and reactions that make life tick. Biology was my second major, and for a variety of reasons, I left it behind in my third year of college to go read and analyze Spanish literature. Yet it still fascinates me, and deeply influences how I think.
Case in point, and back to that question of age and stillbirth, I couldn’t get a clear answer from my care providers about the physiological mechanisms that might drive these risks. Then two things happened: at a late third trimester ultrasound, the technician and I were chatting (ultrasounds are great entertainment), and she noted a few small calcifications in my placenta. They indicated placental aging and were normal at this point. It makes sense — no organ lives forever, the old girl is getting tired, and the end is nigh. Ultrasounds apparently screen for this kind of thing throughout pregnancy, one concern being that if calcifications show up too early, it indicates trouble.
I didn’t think more about calcifications until I was meeting with my kid’s pediatrician-to-be. I told her about my search for data and physiological explanations for the associated link between maternal age and increased risk of stillbirth. She shared that placental aging is hypothesized to be one physiological mechanism that drives elevated risk of stillbirth in older moms.
At my next checkup, I asked my provider what the radiologist who read my ultrasound had to say about the level of calcification in my placenta. We were talking about induction, placental health was clearly relevant, and whatever I learned next would help inform our strategy.
The radiologist had noted nothing. I was left (not for the first time) having to remind myself that perhaps I’m just older and crankier than most first-time parents, and that as the great British philosopher Mick Jagger observed, “You can’t always get what you want.” I tried, mightily. And I hit a wall where I didn’t expect to find one.
While pregnancy does not need to be an independent research project, I’ve read my share of books and listened to my share of lectures and podcasts. I am grateful to have access to this information — in many ways, it was critical to helping me navigate the divides and situations I’ve outlined above. I also agree that there can be limits to the benefits of more information, more perspectives, and more data. You absorb what you can from reputable sources, and you go forward. But when your curiosity is piqued or questions arise, ask. ‘Tis better to give than to receive, and that absolutely applies to questions during pregnancy.
Parents are people, too
In this country, we assume that men have children and remain men, but women morph into a new subspecies of Homo sapiens called mommies. The world of pregnancy and birth becomes a threshold to the world of mommy blogs and mommy warfare.
At Christmas, I gave my husband a labor and delivery survival kit. It featured a bottle of good whiskey, some Reese’s Peanut Butter Cups (his favorite candy, later supplemented with a superior Canadian product), a t-shirt that said “Papa Bear,” and a few other carefully curated items.
Both sets of grandparents very kindly gifted us clothes, blankets, pacifiers, and little leashes to attach said pacifiers firmly to the kid. I gave the grandparents bilingual baby books to build up their libraries. Friends sent delightful onesies. For many good reasons, almost everything focused on the kid.
It wasn’t until my wise and loving cousin sent me a box that I realized how much everything focused on the kid. Mother to an almost one-year old, Mary assembled a box full of supplies I didn’t know I was going to need. It contained a variety of supplies for post-birth recovery, a giant chocolate bar, tea, and some odds and ends for the kid – a blanket, socks, and bizarre little devices that hold cloth diapers together.
This was a missing piece, I realized. And I was so grateful. When I called to thank her, she said that she sends similar boxes to any friends who are pregnant. I had historically sent a book to pregnant friends (for the record, it’s First Bite: How We Learn to Eat by Bee Wilson). Moving forward, that book is going into a similarly stocked box. Lo, I am become a Mom Box evangelist.
We focus on babies for all kinds of valid and wonderful, important reasons. We shouldn’t forget the people who have grown and hauled them around for 9 months.
I think this conviction is what drove my early insistence on using the term “fetus” instead of baby until fairly recently. Especially at medical appointments and in related communications, I found it helpful to use fetus because it kept the focus on both of us. It wasn’t intended as an act of selfishness, but an act of self-inclusion. Clearly, my offspring is important to me. And as the person responsible for its growth and wellbeing, so am I. We come as a non-negotiable unit.
On ethics: is it even ethical to have children anymore?
2020 found me in Japan, watching America come apart (my husband and I also had to learn to feed ourselves while being functionally illiterate, but that’s another story).
I arrived in Japan at age 36, and it was the first time in my adult life that I had the space to really consider whether I wanted to become a parent. After all, Japanese kids are exceptionally well behaved, and a great advertisement for parenting.1 But climate change and world events gave me pause. Becoming a parent was a life-altering decision — for both us and for the kid. Given Homo sapiens’ trajectory on earth, was it ethical to bring a kid into this world?
I actually worked up a book proposal based around this very question. I read books by bioethicists. I interviewed a Buddhist priest, a “growth critical” activist, and the organizer of the anti-natalist Birth Strike movement, which holds that the current state of global affairs makes it profoundly unethical for anyone to reproduce. I wrote sample chapters, and I wrestled. I also noticed that these questions about the ethics of reproduction kept popping up in media articles, although I was forever annoyed that they centered the opinions of people in their early 20s, not people who were closer to 40, like me. Focusing on 20-somethings to the exclusion of other age groups just doesn’t yield useful data when it comes to this question, especially given that in 2019, the median age at first birth in the US hit 30 for the first time.
Clearly, I’ve made my decision and reached some level of resolution. One of my favorite Billy Joel songs starts with “They say that these are not the best of times, but they’re the only times I’ve ever known.” We get the hand we’re given. Throughout history, people have reproduced amidst adverse circumstances.
It saddens me deeply that my kid will, within their lifetime, no longer see glaciers on Mt. Baker, the stratovolcano that looms to our east. It pains me that their childhood will include summer stretches in which we can’t play outside due to air quality issues caused by forest fires. It terrifies me that this kid may grow up in a democracy that is eroded and weakened. And if this kid is female, she’ll be born into an America where she enjoys fewer rights than I did.
Is it ethical to have children in a climate-changed world? I think so, or I wouldn’t have agreed to become a parent. That said, I acknowledge that parenting now mandates a higher level of intentionality and awareness than was required of previous generations. I’m sure I’ll be continuing to tackle the implications of parenting under climate change for the rest of my life, but it’s a decision I came to willingly and thoughtfully.
What I can do is raise this kid as sustainably as possible, teach them to be mindful about their own resource consumption, and help them become aware of the world beyond our home. And I can continue to talk in forums like this about the questions I’ve raised above. After all, is there anything more pressing, really, than the changed environment into which my husband and I are bringing this kid?
I’d like to think that in a small way, we’re off to a good start. Similar to how we did our utmost to avoid the Wedding Industrial Complex, we’re shooting to also avoid the Baby Industrial Complex. My cousin Mary (she of the Mom Box) has been enormously helpful in this regard. When I was about 5 months pregnant, she sent me home with a carload full of maternity clothes, baby clothes and books, cloth diapers, blankets, and a host of other devices that generated a flurry of text messages along the lines of “Umm…what does this thing do?” The vast majority of what Mary gave me had already been through several babies. I love that.
I had to buy a few pieces of maternity clothing, mostly because I needed to go to a wedding and several professional conferences while pregnant. Mary and I have spent my pregnancy laughing about our shared wardrobe, and it’s great. Her thoughtful gift helped me minimize textile consumption during pregnancy, and has set us up to keep this kid well clothed until they’re at least a year old. And when we’re done with all these goodies, we’ll send them back down I-5, in case Mary decides to have a second kid. We are the sisterhood of the traveling maternity pants.
Final thoughts
We can’t control much. Indeed, perhaps the only thing we control is our reaction. But this thin sliver over which we have jurisdiction requires us to think, choose and act with intention, now more than ever before. Having made the decision to become a parent, I take that very seriously. And I come back to information: we have more of it at our fingertips than any previous generation of Homo sapiens, and our circumstances compel us to ask questions. What does ethical parenting in a world of climate change look like? That’s what the next phase of this grand adventure is for.
There will be more to come on this blog, including more thoughts about cemeteries, an interview with a cemetery commissioner, whether sustainable economic growth is really possible, and what’s up with global shifts in birth rates. But for now, I have other matters that require my attention. I’ll see you on the other side.
* I’m not the only person to recognize this. For more, see David Sedaris’ satirical essay “Punching Down,” in which he concludes “So actually, maybe that’s the solution. You have a child or two, and then send them off to be raised in Japan until they’re eighteen or so, and have learned proper manners.” Full essay below:
Did you see this story about joriwon centers in S Korea? Sounds wonderful. Good luck this week!
For New Moms in Seoul, 3 Weeks of Pampering and Sleep at a Joriwon https://www.nytimes.com/2024/01/28/world/asia/south-korea-joriwon-postpartum-care.html?smid=nytcore-android-share
Sarah, congratulations! Awesome article, as always.