Mark Sloan, author of Birth Day (Feb 8-21)

Please welcome Mark Sloan, author of Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth. Mark will be chatting on LibraryThing until February 21st.

Thanks for the Author Chat opportunity, Sonya!

I’m a pediatrician in Santa Rosa, California. I’ve been interested in childbirth and babies for a long time, having attended more than 3,000 births in my career. The short essays that evolved into Birth Day initially sprang from my labor room pondering—why is it so hard for humans to birth our babies, for example, compared to our primate relatives? (Hint: It’s not just about big heads.)

Over time my curiosity expanded, and soon I was reading and researching a host of birth-related topics: a newborn baby’s rapid womb-to-world transition; the rise of cesarean birth; the politics of labor pain relief; daddies and their pregnancy hormones (!); the sensory world of the womb, and much more.

Birth Day is part memoir, part science and history, with some gentle humor in the mix. The cast of characters is long, and includes Isis, Aristotle, Queen Victoria, Fernand Lamaze and Virginia Apgar, plus a pope, a couple of kings, the six wives of Henry VIII, an odd-looking British army surgeon with a very big secret, and four generations of my own family. And, of course, the thousands of parents and children who have allowed me to be a part of their lives.

I’ve particularly enjoyed interacting with readers by email and through my website, and I look forward to what I hope will be two weeks of unscripted (not to say chaotic) conversation in this Author Chat. So please, all questions, comments, birth stories, new parent experiences, and hard-earned pearls of grandparental wisdom are welcome.

Fire away!

Mark Sloan
www.marksloanmd.com

Hello Dr. Sloan,
It was kind of hard to find your chat, but I'm glad I did!
I Love your book, especially the first chapter! But I have a question, has medical education gotten any more humane since you were in medical school? Seems like you and your classmates were kind of "thrown to the wolves." Is it better today?
Thanks,
Mary Ellen

Good afternoon, Dr. Sloan,
First I would like to tell you how much I enjoyed reading your book. I found it to be not only hysterically funny, but also very fascinating and at times heartbreaking. I wish that I had the opportunity to read it before I had my 3 beautiful children. I would have been much better prepared and possibly, less stressed. Here is my question... I had 4 pregnancies, which resulted in 3 live births. Each pregnancy and delivery was completely different from my previous ones. My first pregnancy was a cinch. I had very little morning sickness and I sailed through it gaining a robust 50 lbs! Then came the delivery. I was in labor 36 hours and had to be induced (which was the case with all 3) My 8lb. 8-1/2 lb baby was delivered by forceps and I delivered her without taking any drugs. I came out of the experience pretty "banged up". I wound up spending a week in the hospital to recuperate. My second pregnancy was riddled with allergies, migraines, hypoglycemic episodes and sciatica. I gained 30 lbs. and with the help of pitosin, delivered my 8lb. 2 oz. son in 6 hrs. beginning to end. My delivery was a breeze compared to my first, but my son had the cord wrapped twice around his neck and was actually blue at birth. Thanks goodness, he bounced back quickly. He also had a high Biliruben count. Then my last child was by far my most difficult pregnancy and delivery. I had several gallbladder attacks during my pregnancy and was all set to have surgery, if needed, during my pregnancy. Fortunately, I made it through without surgery and still have my gallbladder to this very day. I had rhinitis and sinusitis throughout my pregnancy and was on a liquid diet through most of the pregnancy (at my physicians request). I still managed to gain 35 lbs. The delivery was 12 hours and I wound up being transported from one hospital to another...very long story. In the end, my little 6lb 14 ouncer was the hardest one to expell. I wound up breaking all the blood vessels in my eyes while pushing and her stubborness continues to this very day (but that's a different story). This is the longest prelude to a question, but here it is...Why or how is it that my pregnancies wound up being so drastically different? I had heard that typically childbirth gets easier with each child and birth weight increases. Another thing that was strange was that my labor pains were different with each one as well. During my last pregnancy, I actually went into the hospital with "false labor" and was sent home 4 hours later. It started up again 6 hours later. Looking forward to hearing from you.

Dr. Sloan,

I learned a lot reading your book. One of my favorite parts was the army surgeon with the secret, that was a pretty big secret by the way. I don't think I could have pulled that off. But I have a question about the writing of the book – what was your favorite part to write?

Hi Mary Ellen,
Yes, I think things have improved since the mid-'70s. There was a definite 'sink-or-swim' mentality on the part of a lot of the doctors who taught me. (Not long ago I Googled Mitch, the resident in my first chapter—not his real name, by the way—and found out he's in OB practice on the east coast; not surprisingly, his patient satisfaction ratings are terrible…) I teach med students and family medicine residents now, and though training is still exhausting, there’s more attention paid to the mental health of doctors in training. Which is a good thing, both for them and the people they care for.

Dear Claddaghgirl,
Thanks for your kind words about Birth Day. I’m glad you enjoyed it!

The old adage that labor gets easier with each baby is true in general—a first labor is usually longer than those that come later. But “in general” means just that. A lot of things can happen that make the next pregnancy and labor tougher than the last. Age, birth spacing, and a mother’s overall health all factor in to the mix. There’s a growing awareness that a mother’s health between pregnancies, and even before her first pregnancy, can affect how a pregnancy goes.

Then there’s this inescapable fact—sometimes babies and pregnancies are just different. Babies can be in different positions in the womb when labor begins, for example, and some are more active than others. I know many women who have had one or more “easy” pregnancies, only to have problems with later births. The opposite is often true, too.

I’m glad it all worked out in the end for you—it sounds like you have three beautiful children!

Mark Sloan

Hi Christophers,
I loved doing research, especially historical research. I came across the story of James Barry, the British army surgeon to whom you refer (and those of you who don't know the story should march right on down to your bookstore or library and turn to page 63 of Birth Day to find out. And no giving away the ending, either!) while looking up something else about the history of cesarean birth. The whole book was like that; a lot of accidental discoveries. I looked forward to learning something new every day.

Science, too. I had no idea about men and their own pregnancy hormones before I started Birth Day. That was an eye opener!

I also enjoyed writing the parts about my own family. I thought my wife, my children or my parents (and my siblings, cousins, aunts and uncles, etc.) might find the attention a bit intrusive, but they were great. I got to hear a lot about the old days on the farm from my dad, too, which was an added bonus of interviewing him about a father's birthing role in the 1920s and 1950s.

Take care,
Mark Sloan

Just checking in, Mark! Great site. Great book, too. I keep bragging about it (and bragging about you, too) to any friends who read (plus a few who can't) See you soon. - Pat Tyler

Thanks, Pat!

Hello Dr. Sloan,

I am a first-time expecting mom and science teacher, and I enjoyed your book very much from both perspectives. I especially enjoyed the evolutionary perspective on why our babies are born at a certain size and lacking many skills of other newborn mammals.

My question is this- from reading the book, it seems that the use of "milder" interventions like nitrous oxide during birth would be ideal for many women in the U.S. I am planning a drug-free birth but realize that some circumstances may be beyond my control, and want to be open to drugs during labor even though I don't like the paralysis aspect of the epidural or side effects of other drugs. Do you think that nitrous oxide would eventually be widely available in the U.S.? What is stopping doctors from using this (and other similar interventions) more widely here?

Thank you!

Dear Doctor Sloan,

Birth Day was an eye opening book for me - I only wish I'd found it while I was pregnant. So my new mission is to give a copy of your book to every family I know who is expecting.

Now I am just waiting around for you to enlighten the world about the next phases of life - infancy and toddler years! As a pediatrician I am sure you have much to share! Where can I look forward to reading more of your engaging writing works?

Thanks!

For effulgent7:
Hi,
You’re right—nitrous oxide would be a perfect pain reliever to have on hand for a woman who wants to have as “drug-free” a birth as possible, but who encounters a situation—her baby’s in an unusual position, for example—that is more painful than anticipated. Nitrous is self-administered from a hand-held mask and gets in and out of the system very quickly—anyone who has encountered nitrous at the dentist’s office already knows this. It’s not as powerful a pain reliever as an epidural, but it's perfect for taking the edge off and providing “good enough” labor pain relief, as the British describe it.

By the way, nitrous oxide isn’t really a “drug,” as we tend to think of that term. It’s a naturally occurring compound, discovered right along with oxygen in the 1770s. It’s produced in nature by the decomposition of organic material, and by such weirdly man-made sources as worm-farming (!), drag racing (!!), and fertilizer production.

In Birth Day I quote Judith Rooks, the renowned midwife, researcher, teacher, etc. (she wears a lot of hats) who describes the U.S. as an impending “epidural monoculture.” This is true—consider that more than 30% of births are now cesareans, and 80% or more of women who have vaginal births in many areas of the country do so using an epidural for pain relief.

I’m not attacking epidurals per se—they work marvelously well for most women who want them—but I do worry that with no good pain relief alternatives available for hospital births, we will soon reach a point where it will be difficult for women to have an unmedicated (or lightly-medicated) vaginal birth, because they won’t have the circle of female friends and relatives who have already gone through the experience available to support them.

This is a long-winded answer…sorry! I’m going to email Judith Rooks about the availability of nitrous around the country—I think it’s still extremely limited. Check back here in a couple of days and I should have more info for you.

For shwolfe1:
Thanks for writing! (And if you're giving copies to every woman you know is pregnant, I hope you know a lot of pregnant women!)

Birth Day has been an all-consuming experience for me. I'm planning on writing another book - probably a sequel of sorts - but as I'm still a full-time pediatrician it will no doubt take a while for me to complete it.

I know I'll have to include something about breast feeding and formula feeding in the next book. I grew up one block from the Mead Johnson Co. in Evansville, Indiana (manufacturers of Enfamil), and most days of my early childhood my neighborhood smelled like formula. Talk about being predestined! (And despite that early indoctrination, I've since learned that breast is by far the best...)

Thanks again,
Mark Sloan

For effulgent7 and anyone else interested in learning more about the use of nitrous oxide for labor pain relief, Our Bodies, Ourselves has an excellent ongoing discussion at:

http://www.ourbodiesourblog.org/blog/2008/05/expanded-discussion-of-nitrous-oxid...

Since I can't figure out how I even got here, I'll just piggyback onto Pat's comment. I really enjoyed reading the reviews--all of them astute and should be included in your paperback proposal.

Howdy Mark,
May I point out that men would enjoy this book too. I did anyway and like "shwolfe1" above, I look forward to your next foray into print. I hope that you get more help with promotion from the next publisher though, other people who have heard about Birth Day are not easy to find.
I'm going to get my youngest daughter to log on and check out this chat stop. She is pregnant with her second and is struggling with pain and restrictions due to being the not-so-pleased owner of a cluster of Gall stones, a couple of which have escaped and got perilously close to jamming up her liver and her pancreas. The decision is to stay cool and quiet until Bobo (the affectionate name fo the potential addition to the Simmonds family circus) is safely on the outside and then take away the gall bladder. Baby is due in July 2010 and, to a remote and concerned Dad, that seems like a very long time for my little girl to be hurting.
Do you have any words of encouragement for her? She is being treated and watched by the skilled staff at North Shore hospital in Auckland, New Zealand, and I'm comfortable with the advice and attention she has available.
Thanks,
Dusty.

Have to say your book (Birth Day) was worth it. Even though I had to buy it after I burrowed it from the library 1st time around. Then returned after I read the 1st 2 chapters of it. Basically, thought its the same as all of the others that I have read and etc. At the same time I'm an student of this subject ever since I can remember and life as well. In fact its not at least what I read so far. Expect for an Epidural part of it because he was pretty much for it and etc. Why did you choose the sources you did? Anyway, to me the sources aren't as in depth as to what I thought they would be. Understand that you wrote while still practicing then not practicing while writing the book. Like others whom did the opposite as you, but at the same time theres others whom did the same as you.

Hi Dr. Sloan,
I have been in to see you before, you took care of one of my best friend's (we have been friends since we were eleven) children, Ryan and Katie Jensen. We currently see your sister-in-law often, since she and Dr. Rubin help one another out.

I am also a member of Redwood Writers and bought your book at the conference. I have to say I started to read it immediately and rudely (trying to hide behind a folder during one session). I have two great little boys and have had 6 pregnancy losses, mostly early but one at 18 weeks. The misnomers of giving birth, I thought for sure I was a candidate for a simple birth. My mother delivered me at home in Korea, my grandmother acted as midwife. But my first live birth was an emergency C-section and my second was an 56 hour attempt at VBAC with a C-section again. I am now 45 and would love to have one last baby, my grandmother was 45 when she birthed her last one. Reading your book was exciting, thinking maybe I will be carry one last baby. Both of my term pregnancies occured while I was under the care of an acupunturist who I am seeing again.
Again, thanks for all the personal messages included in your book as well as all of the research. It was fascinating. And I still consider the birth of a baby as one of God's greatest miracles. My husband, who is not a religious man, says birth can not be a miracle because it is so commonplace, but he acknowledges how special each individual is. Keep up the good work.
Kind regards,
Cerrissa MacNichols Westby

Thanks for the link to the OBOS article -- I knew nothing of N2O use! I'm 6 months pregnant myself, and looking for very low-key pain relievers for my birth.

Now to go read your book!

Hello Dusty,
I've gotten a number of comments from men about Birth Day. Most have been about the "Daddies" chapter - they were surprised to learn that the physical changes in pregnancy aren't limited to a woman and her baby(!) Several appreciated the description of how childbirth evolved, how fathers came to be labor coaches, and the "guided tour of the newborn." One wrote, "You explained all the stuff I went through. Thanks!"

I'm sorry to hear about your daughter and her gallstones. That's a miserable problem to have during pregnancy, especially when she already has one child to care for. Fortunately it's a fixable problem, even if that "fix" seems an awfully long way off! Sounds like she's in good hands, though - please pass along my best wishes to her for a speedy recovery. Come July she'll be a busy mother of two, and her gallstones will be a distant, un-fond memory...

As to your difficulty finding other people who have heard about Birth Day, that's mainly a product of the time it was published. The first quarter of '09 was the peak of the economic collapse, and not coincidentally the worst quarter for book sales in 20+ years. Then, too, the media cycle was saturated with post-election and inaugural coverage, plus news on the economy. Books on those topics tended to get the most publicity.

Still, Birth Day is doing fine, and its audience is growing; check my website (www.marksloanmd.com) for media reviews and reader comments. And now, with your New Zealand connections, I'm ready to go global (or at least southern hemisphere). Spread the word!
Thanks for writing,
Mark

Hi mybodymyself,
Thanks for writing. I'm glad you found Birth Day "worth it." The sources I cite in the book are the tip of a very large research iceberg; I've got an entire file drawer (and a chunk of my computer memory) filled with articles that didn't make it into the book. It's a fascinating subject!
Thanks again,
Mark Sloan

Hi Mark and effulgent7, whose question about nitrous oxide I am responding to. Why nitrous oxide isn't more widely available is a long and complex story. I don't have time to go into it now, but I want to tell all of you—Dr. Sloan, who wrote the wonderful book, effulgent7, who wants to know why US doctors are enthusiastic about using complex, expensive, invasive methods and reluctant to use off-patent, simple, non-invasive methods like nitrous oxide, and all the readers and writers on this blog, each of whom has learned more about birth by reading Dr. Sloan's wonderful book. I have good news to share: The American College of Nurse-Midwives has just adopted a formal position statement on use of nitrous oxide analgesia during labor. It's too long to try to paste the whole thing in here, but I will try to insert the gist of it. The ACNM position statement is brand new. This posting on Dr. Sloan's LibraryThing discussion is the first time it has been aired on the Internet:

The American College of Nurse-Midwives endorses the position that women should have access to a variety of measures to assist them in coping with the challenges of labor. Among these should be nitrous oxide, which is commonly used in many other countries.

The experience of labor pain differs among women, and the response to pain is highly individual. Women should have access to a variety of approaches to promote comfort and reduce pain throughout labor. But women in the United States have fewer labor pain-relief options than women in many other advanced countries.

A blend of inhaled nitrous oxide (N2O) 50 percent and oxygen (O2) 50 percent is used as a major method of labor analgesia in many countries with high standards for safe and effective health care, such as Australia, Canada, Finland, Sweden, and the United Kingdom (UK). However, this has been a very rare option in the United States in recent years.

For labor analgesia, epidural administration of local anesthetic agents and systemic (intravenous or intramuscular) administration of opioids (narcotics) are the two most frequently employed pharmacologic methods in the United States. Nitrous oxide is a less potent analgesic than epidural or other neuraxial anesthesia, but may be more effective than systemic opioids, with the exception of intravenously administered, short-acting, very potent synthetic opioids, such as remifentanil. Nitrous oxide works by increasing the release of endogenous opioid polypeptide compounds (endorphins), corticotropins and dopamine that are produced in the mother’s brain. The analgesic efficacy of inhaling a relatively low concentration of nitrous oxide is limited; a few women report little or no benefit at all. Yet it is effective enough for the majority of women who try it, and most who have used it say that they were satisfied.

Some unique attributes of nitrous oxide are as follows:

1. Despite widespread and extensive use of nitrous oxide analgesia for labor analgesia in many countries since the early 1900s, no studies or published observations have identified significant adverse effects on the neonate. There is no increased requirement for neonatal resuscitation, and newborn alertness and responsiveness during the important early period of maternal-infant bonding and early effective breastfeeding are unaffected. It is safe for a woman to use nitrous oxide throughout the entire second stage of labor.

2. Nitrous oxide analgesia can be administered quickly, easily and safely and has a very rapid onset of action.

3. Nitrous oxide analgesia can be discontinued as quickly and easily as it is started. The effects begin to dissipate immediately after the woman stops breathing nitrous oxide and are completely gone within five minutes.

4. Nitrous oxide analgesia has no adverse effects on the progress of labor; the spontaneous vaginal birth rate is unaffected. Administration of nitrous oxide is not associated with increased risk of maternal or fetal complications and does not require more intensive or invasive monitoring.

5. After a brief period of explanation and supervision, nitrous oxide is self-administered through a mask that the woman holds to her own face. Self-administration allows the woman to determine when and how much nitrous oxide she uses.

6. If a woman doesn’t like or tires of using nitrous oxide, she can stop using it and begin using another method without residual effects from the nitrous oxide.

While nitrous oxide is not without side effects and will not be agreeable to or effective for every laboring woman, it is an inexpensive, simple, reasonably safe and effective analgesic. It is important that midwives know about nitrous oxide analgesia and be able to offer it to women during labor.

In accordance with ethical, evidence-based practice, the American College of Nurse-Midwives (ACNM):

• Recognizes that women need access to a range of options for pain relief in labor;
• Recognizes that the reasonable efficacy and safety of nitrous oxide as an analgesic for labor has been the subject of research that has supported its use as a widely accepted component of quality maternity care in other medically sophisticated countries;
• Recognizes the unique and beneficial qualities of nitrous oxide analgesia during labor;
• Recognizes that certified nurse-midwives and certified midwives can be trained to administer and oversee safe use of nitrous oxide analgesia during labor;
• Supports the education and training of certified nurse midwives and certified midwives in safe administration of nitrous oxide;
• Supports the education of women about the use of nitrous oxide as an option for pain relief in labor;
• Advocates continued research and evaluation of the use of nitrous oxide analgesia in obstetrical/anesthesia departments to facilitate the inclusion of nitrous oxide as an option for laboring women throughout the United States.

!!!!!
Judith Rooks

Hi Cerissa,
It's nice to hear from you. The Redwood Writers Conference was really well run and a lot of fun, and it's always great to spend time with other writers. I hope they'll invite me back again next year.

My grandmother was in her 40s when she had her last one, too, sometime in the 1930s, which made her a bit of a rarity at the time. Pregnancy at that age can be difficult enough nowadays, let alone back then. She wasn't one to talk about such things, though, so I don't know how it was for her. Since I work with the OB staff who'd be caring for you should you get pregnant, I know you'll be in the best of hands.

My view of childbirth is a kind of blending of yours and your husband's. Regardless of religious belief, it's a miracle that childbirth is so commonplace. The rapid-fire adaptations a baby makes to successfully exit the liquid world of the womb and survive out here with us air-breathers - emptying the lungs of fluid and refilling them with air, opening and closing blood vessels, squeezing blood from the placenta back into the body, rerouting the flow of blood through the heart and lungs, etc - are incredible.

It's astounding that birth goes right so often, and that's what inspired me to write a chapter about that womb-to-world transition. I think the day of birth is the most dramatic day of life, bar none.

Thanks for writing,
Mark Sloan

Hi Sonya,
First of all, congratulations on your pregnancy, which I hope is going smoothly for you. I was just about to address the issue of nitrous oxide use in the U.S., but fortunately Judith Rooks beat me to it, since she's the acknowledged expert on the subject (see her post in this thread). I humbly defer to her.

Judith wears many hats: midwife, teacher, former CDC epidemiologist, and tireless advocate for maternal and child health. She is the author of "Midwifery and Childbirth in America," a must-read book for anyone with an interest in the history and politics of American childbirth practices.

Judith was incredibly helpful (and patient!) when I was writing Birth Day, and I'm proud to call her my friend. She is a major driving force behind the effort to return nitrous oxide to American labor rooms, and as she is a bit of a force of nature, she'll no doubt succeed.

What will ultimately turn the tide, though, as I described in the section of Birth Day titled "Pain & Politics", is consumer demand. As has been the case since labor pain relief first became a major issue in the 1850s, things only change when a critical mass of women demand it.

Again, I'd refer interested women (and men, too), to the Our Bodies, Our Selves blog (http://www.ourbodiesourblog.org/blog/2008/05/expanded-discussion-of-nitrous) to join in the nitrous oxide discussion.
Mark

Judith,
Thanks for joining in the discussion, and for the honor of the first internet posting of the ACNM statement! I appreciate it.
Mark

Hi Mark,

One thing that struck me as I was reading BIRTH DAY was that it had a very personal and conversational tone. I felt as if you were in the room telling me a story about childbirth. This type of experience/sensation doesn't strike me often – Patti Smith’s JUST KIDS is coming close at the moment – and I think this form of storytelling through writing is a rare talent for a writer to have.

That said, my questions are related to your writing process.

1) What is a typical day like in your writing life?
2) What are you working on now?
3) What have you been reading and recommending lately?
4) Do you have a writing playlist (i.e., music you listen to while writing or music that inspires you to write)?

Thanks, and I can’t wait for your next book to come along!

Sharon

Hi Sharon!

Thanks for writing, and for the kind words about my writing. In answer to your questions...

1) What is a typical day like in your writing life?

I wish I had a typical day! I have to fit in writing around my real day job – my pediatric practice. While writing Birth Day I’d get up at 4:30 or 5 to work on it for a couple of hours, then try to do more at night and on the weekends. I did take off a couple of months from my practice during the middle of writing it, and then I tended to write in the morning and edit in the afternoons. I’m not much of an evening/night writer.

2) What are you working on now?

The flu season, mainly. It’s pretty busy in my office this time of year. I’m looking forward to getting going with my next book (“a sequel of sorts,” he said mysteriously…) as the winter winds down. I’m also working on a couple of talks I’ll be giving soon to the California Association of Neonatologists in San Diego, and at Douglas College in Vancouver, B.C. My Power Point skills are finally improving!

3) What have you been reading and recommending lately?

I’m partial to nonfiction. I’m a big fan of Ian Frazier (anything by him, espcially his book Great Plains), Russell Shorto (The Island at the End of the World), Ross King (Brunelleschi’s Dome; Michelangelo and The Pope’s Ceiling), among many others. I’m kind of on a 19th century history kick, too, after coming across some interesting characters from the 1800s in researching Birth Day. Most recently I read a Lincoln book, “Tried by War,” by James McPherson.

4) Do you have a writing playlist (i.e., music you listen to while writing or music that inspires you to write)?

I have a long writing playlist on my Mac. It’s mainly instrumentals, because I find that people singing in my ear while I’m writing is a bit distracting. I save the singers for when I’m editing – they keep me company while I move commas around.

Take care,
Mark

Hi Mark,

More questions!

Serendipitously, as I was prepping for a gender and technology class this a.m., I came across a couple of articles related to the topic of childbirth. The first was about a new policy at the St. John's Pleasant Valley Hospital in Camarillo, CA (http://www.vcstar.com/news/2010/feb/06/st-johns-pleasant-valley-forbids-midwife-as-of/).

Starting Monday, the hospital is banning midwives from delivering or assisting during deliveries at that facility. OB/GYNs who deal with higher-risk pregnancies are still able to use this smaller facility. The reason for the ban: St. John's doesn't have a neonatal intensive care unit.

Some question the move to ban midwives at this facility, as well as the claims that the hospital is simply trying to ensure the safety of the mother and child. In several discussions surrounding the midwife ban at the CA facility, individuals have pointed to a recent (Feb. 2, 2010) report on maternal mortality rates in CA (http://www.californiawatch.org/health-and-welfare/more-women-dying-pregnancy-complications-state-holds-report). This report notes that maternal mortality rates in CA have spiked in the past decade. Medical complications due to C-sections are listed among the reasons. (You describe many of these complications in greater detail in BIRTH DAY.)

The implication of these pieces is that technology is supposed to make the birthing process safer. At the same time, however, the overuse of this type of technology may have a negative effect on safety.

Are similar bans on midwives occurring in other states? Are maternal mortality rates increasing in areas outside CA? Are "battles" between individuals who promote a normal birth experience (i.e., midwives) and those who promote a more cyborg/science/technology experience (i.e., hospitals and administrators) increasing? How much of this is related to malpractice concerns?

Just curious,

Sharon

Hi Mark,

A couple of quick questions:

1. Are there plans for a paperback release of "Birth Day"? If so, when might we see it?

2. In respondinding to one of SHARSTOER's questions you said "I’m looking forward to getting going with my next book ('a sequel of sorts,' he said mysteriously…) as the winter winds down." I don't suppose you can give us any hints about this mysterious "sequel of sorts"? :-)

And, finally, even if I wasn't your big brother, I'd still be EXTREMELY impressed by Judith Rooks' endorsement of your work!!

Bernie

Hi again Sharon,
First, the disclaimers: I'm not an obstetrician, though I have observed a lot of obstetricians and midwives over the years in my work. And I don't know any particulars about the Camarillo hospital except what's in the article you sent (and the truly, um, "spirited" comments that follow the article).

Having said that, my impression is that this is more about local hospital politics than about California in general. The hospital's logic in banning the midwives simply doesn't make sense. Certified nurse midwives have a long track record of quality and safety; it doesn't make sense for the same hospital to continue to allow high-risk patients cared for by obstetricians to deliver there, if the concern is really about the lack of an intensive care nursery. There's likely something else going on, probably a local matter.

Where I practice nurse midwives attend a sizeable proportion of the normal vaginal births, and they do an excellent job. There is an obstetrician immediately available if they need help. We had a midwife for my daughter's birth, and would have had her for my son, too, except he had to be born by scheduled cesarean for medical reasons (a midwife did assist at the surgery, though). So while I don't pretend to speak for the whole state, I'm not aware of any larger effort to ban midwives. Perhaps a California midwife reading this could offer her perspective?

As to the rise in the California mortality rate (which is starting to look like a nationwide trend), you're right. Though worsening poverty and increasing obesity, with the chronic diseases that accompany it (especially hypertension and diabetes), are responsible for part of the increase, they don't account for all of it. It's hard to ignore the role of c-sections in the rise, particularly hemorrhage related to cesareans.

The American cesarean rate was 6% when I graduated from high school in 1971. Today it's about 33%. There are a number of explanations for the rise, not all of them convincing (see my chapter, "An Alternate Route", for details), but whatever the reasons it's clear that cesarean complications play a role in the rise in maternal mortality.

How do we reverse the rising cesarean rate? It's a huge challenge, and it will require much more support of women who want to give birth vaginally, from promoting prenatal health, to taking a more patient approach to labor, to providing women with more pain relief choices than are currently available in the U.S., to supporting women seeking a vaginal birth after a cesarean. (And Judith Rooks, if you're out there, could you weigh in on this?)

Having worked the "cyborg/natural childbirth" divide for many years, it's a complicated, often contentious place, but there are many, many good people working to change things.

Mark

Hi Bernie,

Did Mom put you up to this?

I'm making my paperback case to the publisher, but unfortunately much of the decision is apparently based on initial sales, which, thanks to the cratering economy a year ago, weren't as robust as they would have been a year earlier, or even if Birth Day had been published today. I won't know the final answer for awhile, but given the great reviews (especially in the childbirth world), I'm hoping to convince them.

And hey, the next book wouldn't be a mystery if I told you, now would it? A few clues: babies and parents, yes; vampires, werewolves, teenage wizards, Sarah Palin, and the dark secrets of the Catholic Church hidden in the Louvre... not so much.

Thanks, big brother,
Mark

Hi Mark,

You said: "I'm making my paperback case to the publisher, but unfortunately much of the decision is apparently based on initial sales, which, thanks to the cratering economy a year ago, weren't as robust as they would have been a year earlier, or even if Birth Day had been published today."

Can't you make a case for relative initial sales compared to other books published at the same time as "Birth Day"? (And I don't mean sales to family members when I say "relative initial sales".) I imagine that a lot of books had sales below expectations because of the economy. Can't you compare "Birth Day" with those initial sales, instead of initial sales of books during a healthier economy? Hope that makes sense.

And speaking of the economy, did you ever worry that maybe the hardcover version of "Birth Day" wouldn't see the light of day as the economic troubles started hitting the publishing industry?

Changing the subject a bit, how long did it take you to write "Birth Day"?

And I think your next book will be a big hit if it's about vampire/zombie parents and their cute babies...something like "Birth Day of the Living Dead".

Bernie

Hi Bernie,

I'm not sure really how long it took me to write it, since it was mainly a part-time effort. I know I had the idea in 2004, because I brought a two page summary to a one-day nonfiction publishing seminar at UC Berkeley that April (the working title was "The First Month of Life" back then). But there were long stretches early on when I put it aside. My best guess is that it would have taken me about a year and a half to two years if I'd been working at it as a full-time job. I'll punch in and punch out on the next one, though, because a lot of people have asked me that same question.

I will be making the case about relative sales - I'm sure I'm not the only author who took a hit back then. I didn't worry a lot that the hardcover wouldn't come out, though, because it was pretty far along the publishing pipeline when things got grim, economy-wise.

And I like that title of yours - very snappy! It's got "indie film" written all over it!

Mark

The publisher should remember that some books are sleeper hits. For example, the original HARRY POTTER books were sleepers until the third book in the series.

Sharon

Sharon,

I already told you - I don't do wizards! ;)

Mark

I am a Nurse Midwife in No. Calif. I have heard of this decision by this hospital to prevent Nurse Midwives from delivering at their hospital. I also know some of the individuals involved. My conclusion is that this has nothing to do with a safety issue but rather is a politically motivated and territory issue. The midwives are delivering at another hospital nearby. It makes no sense to ban midwives with lower risk clients from a facility that doesn't have a neonatal ICU but keeps MDs with a higher risk clientale delivering there.

I want to also offer to Mark Sloan a resounding congratulations on your book!
It is inspiring, thorough, fun to read, thought provoking and mindful. Thank you for providing so much information, inspiration and food for thought to all of us,
not just in the health care field, but also to women and families. Maybe someday we will have nitrous and other options available. I'm working on it!

Hi Mark—and Sherry Lester!

I'm glad you could respond to the info from another nurse-midwife in northern CA, Sherry.

But my comment, Mark, is about sales of your book and lack of a paperback version. Right now your book is selling for $15.47 on Amazon. Of course, with Powell's Books to patronize in Portland, I hate to buy from Amazon, but it's a great deal! Who needs a paperback when you can get the beautiful hard cover book for less than $16!!

All readers: I suggest you snap them up at this price. It's a great gift to give to every pregnant woman (or man, having hormonal changes during the gestation of his offspring), or to grandmothers and fathers, OBs, midwives, family physicians and pediatricians you use and are grateful to, medical students, etc. Where else can you get such an entirely enjoyable gift, so easy to wrap, for that price. I for one am going to stock up!

Judith

Thanks, Sherry. That confirms what I thought from reading the article about the midwife ban - the hospital's rationale didn't seem to make a lot of sense.

And please keep working on expanding labor pain relief options. I think once enough women get behind it, the American birthing scene will change.

Mark

Hi Judith,
As always, thanks for your support! I'm very happy with the hardcover edition of Birth Day - Ballantine Books did a great job. A paperback edition is more attractive to medical, nursing and midwifery training programs, etc., so it definitely has its uses, too. We'll see what comes of all this...

Thanks again!

Mark

Hi Mark (and Judith Rooks)

Judith said, of Birth Day: "It's a great gift to give to every pregnant woman (or man, having hormonal changes during the gestation of his offspring)."

Just in case someone might want to dismiss the idea of a man having hormonal changes during the gestation of his offspring...

When my ex-wife was pregnant with Dr. Mark Sloan's nephew Sam, the hair on my chest and stomach became coarser and darker. Coincidence? :-)

Bernie Sloan

My brother the zombie...

Hi Mark, Dusty's daughter here. Thought you'd like to know that my husband has read your book also, thanks to recieving it as a gift from a certain parent. He was facinated by it, as we had just had our first child, and at times he was brought to tears. Well done, may you have great success with it.

Hi there,
Thnaks for the kind words! I'm glad your husband liked it - it's good to hear that men like the book, too. I hope you're feeling better - sounds like an uncomfortable pregnancy you're having!
Take care,
Mark Sloan

Hey Mark,
What is the skinny on the NorCal Book Awards function in SF?
Do you know times, places, dates, etc?
I would prefer not to trust Ms. Porter's understanding (or mis-understanding) of things and Hazel and I would love to attend.
Some of the other readers who have written here might too.
Dusty