Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First

Angelo P. Giardino, MD, PhD, MPH


Dr. Marsden Wagner's book, Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First, offers strong criticism of a number of shortfalls in the current maternity care system in the United States. However, the book does more that just hurl condemnation at the professional culture led primarily by obstetricians; it also provides a cogent set of recommendations and a road map of sorts toward a more woman- and child-centered healthcare delivery system.

The audience of the book is potentially broad and would include healthcare providers, policy makers, public health officials, and all who would advocate for a more patient- or person-centered healthcare delivery system. The writing is clear, succinct, and easy to grasp. Physicians, however, will find the book a difficult read because of the level of criticism lobbed at their profession. Dr. Wagner decries the medicalization of maternity care; he is sure to offend many with statements, such as "Hospitals are highly symbolic of the medical model of birth -- twenty-first century cathedrals with priests in white robes" (pg 187).

Physicians tend to see themselves as well-trained professionals who care for patients through the application of education and technology, and Dr. Wagner's allusion to them as "priests" of a cult of science runs counter to that view; the comment comes off as a sarcastic criticism of doctors and hospitals in general. However, despite the tendency toward inflammatory comments and phraseology, the book does contain a tremendous amount of information related to the maternity care system in America, as well as international comparisons and solid referencing (as evidenced by 31 pages of endnotes).

Dr. Wagner is eminently qualified to write about the maternity care system in the United States. He is a pediatrician and perinatologist, a former full-time faculty member at UCLA, and a former director of Maternal and Child Health for the California State Health Department. For 15 years, he also served as the World Health Organization's director of Women's and Children's Health. Now an independent consultant, he has written many scholarly papers and chapters, as well as authored over a dozen books all drawing upon his extensive clinical and scientific experience in perinatology and perinatal epidemiology.

Dr. Wagner is not shy about how he frames the issues surrounding the inadequacies that he sees as existing in the American maternity care system. He specifically states that the purpose of the book is to further an understanding of problems in the system with an eye toward ultimately moving beyond defining the issues and toward suggesting solutions. In the preface, we begin to get a sense of how strong the opinions to come will be as we read. Dr. Wagner writes, "I believe that an important part of the struggle for control of maternity care described in this book is gender-specific -- that there has been a paternalistic takeover of territory that rightly belongs to women and that did belong to women until relatively recently" (pg ix).

The arguments are exquisitely framed by the author's stated support for the underlying principles promulgated by the Coalition for Improving Maternity Services (CMIS). These principles are provided below because they give a snapshot of the author's own passionate views of wellness and the need to demedicalize and humanize the childbirth process:

  • Normalcy: Treat birth as a natural, healthy process

  • Empowerment: Provide the birthing woman and her family with supportive, sensitive, and respectful care

  • Autonomy: Enable women to make decisions that are based on accurate information and provide access to the full range of options for care

  • First, do no harm: Avoid the routine use of tests, procedures, drugs, and restrictions

  • Responsibility: Give evidence-based care solely for the needs and in the interests of mothers and infants (pgs 11-12, 182).

After reading about the "crisis" in maternity care, the subsequent chapters provide discussions of what might be expected in the future, such as efforts to control cesarean section rates and the debate about malpractice litigation. Dr. Wagner's detailed knowledge of the issues surrounding the off/against labeled use of the medication misoprostol (Cytotec) to induce labor comes into clear focus as well; the largely anecdotal evidence behind the off-label prescribing of misoprostol is described in terms of being the issue that pushed the author over the edge and made him into a medical whistleblower of sorts.

The comprehensive information from court cases and scientific investigation into the issues surrounding the use of misoprostol is in and of itself an illuminating study of how medical practices may become established with little to no evidence to support them.

Additionally, Dr. Wagner also spends a considerable amount of time discussing the positive influence of midwives on maternity care, especially around the routine childbirth. Owing primarily to his extensive international experience with World Health Organization (WHO), where he saw how midwives have had a profound health and wellness impact on the women that they serve, Dr. Wagner does a thorough job at making their value clear. One gets the idea that his recommendations for fixing the American maternity care system will have midwives playing a significant role -- a departure from the current "paternalistic" system that Wagner decries in the Preface.

Finally, prior to offering his solutions, Dr. Wagner takes aim at hospitals as well and criticizes the professional attitude among many in the healthcare industry, which almost seems to criminalize the notion of a home birth, while at the same time almost sanctifying the in-hospital birth process. To his credit, Dr. Wagner, whose scientific training and experience are impeccable, consistently offers up the literature that he is using and the rationale behind his analysis and conclusions.

The last 2 chapters are well worth the read because if one gets beyond Wagner's negativity toward the US healthcare system, the presentation of guiding principles, practical changes, and intended outcomes from the reforms that he proposes is masterfully done. The vision presented is one that is rooted in the value of a national health system that would universally provide care to all pregnant women, not just those with some sort of public or private healthcare coverage. Other aspects to the vision include:

  1. Promotion of at-home deliveries, especially for low-risk births

  2. Increased use of midwives for low-risk births

  3. Access to obstetricians for high-risk maternity care with a shared responsibility with midwives for the routine aspects of the care, even for the high-risk maternity patient

  4. Increased scrutiny, transparency, and accountability of the healthcare delivery system

  5. Continued education of maternity care providers

  6. A focus on public education on maternity care.

True to his advocacy purpose, Dr. Wagner then concludes the book with a 10-part action plan that he suggests as a road map for those in the audience who would choose to fight for the CMIS principles articulated above.

Regardless of the reader's agreement or disagreement with Dr. Wagner's assessment and vision, the road map is sound; from an advocacy perspective it would make sense if one were interested to take up the cause for a demedicalized and more humane childbirth process. For those who have reflected on the shortfalls in our nation's maternity care system, Marsden Wagner's Born in the USA certainly offers a challenging perspective by someone who knows a lot about what has and what has not worked.

Readers are encouraged to respond to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication via email:


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