Chronicle of a birth foretold

Katy Talento, a health policy advisor in President Trump's first term, doesn't like hospitals much, even when they work. She uses her granddaughter's birth to explain why. A take worth considering.

(A long piece by UT standards, but worth your time. Buckle up!)

In February, Katy Talento — a “recovering epidemiologist” who served as a White House health policy advisor from 2017 to 2019 — wrote a remarkable Substack attacking American hospitals.

Talento drew on her personal experiences seeing family members suffer to illustrate her broader concerns. The headline gives a subtle hint where she stands:

Hospitals are Soviet-style Hellscapes Unfit for Humans

Despite her anger, Talento is no fool. The reality of her views is more nuanced. As she explains near the end of the piece:

When you have a bullet in your belly, a third-degree burn… [or] a heart attack, an American ER is just the place. When one of those patients doesn’t make it, you want their organs transplanted into someone who might be waiting in the OR down the hall...

The life-saving, acute services that are valuable are not profitable. They cannot be made profitable. They require an expensive crew of high-skill labor, cutting edge technology, the most expensive forms of ground and air transport, with 24/7/365 access for a catchment area that does not produce enough of these needs each year to recoup costs.

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To pay for that emergency care, we have moved more routine and profitable surgeries and procedures to hospitals, Talento argues. She makes the case doing so has had terrible consequences financially and medically.

Saving trauma or heart attack or stroke patients with minutes to live requires strict chains of command. But Talento argues outpatient centers or even at-home nursing services serve patients far better for routine care:

But that [hospital] culture of top-down authoritarianism loses all appropriateness and perspective when the stakes are routine, such as elective surgeries, cancer palliation, birthing babies. Nonetheless, the culture created for the trauma context infuses the entire complex so overwhelmingly as to inhibit or reverse healing and health rather than protect it.

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Talento is not an MD.

And I suspect many of the physicians who read Unreported Truths object to her characterization of “cancer palliation” or particularly “birthing babies” as routine. Midwives and doulas are fine, until they aren’t. Even in the early 20th century, English women had a risk of death in childbirth estimated at between 1 in 200 and 1 in 100. Today, the rate is about 1 in 10,000.

Nonetheless, Talento’s description of her daughter’s third labor and delivery is fascinating. The family’s (seemingly reasonable) requests for (moderate) autonomy ran smack into the hospital’s rigid (and no doubt liability- as well as financially-driven) obstetric protocols.

By the end, the new mother and nurses were so sideways the nurses called Child Protective Services on her. This is the medical equivalent of flight attendants deplaning and arresting a passenger who waits a few seconds too long to turn off a phone, a legal but very nasty abuse of authority.

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(The beginning of the process is a lot more fun.)

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Talento’s views are well worth considering, so I asked her if I could republish the portion of the piece about her granddaughter’s birth.

She graciously agreed, and even answered a couple of follow-up questions about what happened with CPS. (The whole article is available here, at her “AllBetter” Substack, and worth your time.)

Again, one does not have to agree with all of Talento’s take to understand how viscerally angry her family became at a system that insisted on treating a medically uncomplicated childbirth as a high-risk procedure — and along the way made the experience uncomfortable and exhausting.

Here it is, republished unedited:

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Last year, my daughter was due with her third baby.

She’d been induced with her first two babies, and so when her water broke naturally, she panicked. What does one do, when labor starts on its own, dear God in heaven?!

We showed up at the hospital about an hour later at 3 cm [Note: a three-centimeter cervical dilation, or early labor] - the same dilation she’d been days before at her last prenatal visit. The right thing to do? Send her home to labor naturally until things got real. That’s what they used to do, decades ago. But then babies might accidentally, you know, come out without the hospital cash register dinging in the background.

So, instead, they strap her in. First the IVs. Why can’t she feed and hydrate herself? She’s completely healthy. Oh right, because the c-section rate is so disgracefully high in this country that they starve laboring women for hours and hours on the not-so-off chance that they end up in surgery.

Then the fetal monitor which, despite our ability to land on the moon, is completely beyond our powers to keep in place on a big belly. Constant interruptions because the stupid monitor strap has moved.

Why do you need to monitor? This is a low-risk, no-drama situation.

“It’s protocol.”

What is the evidence of fetal monitoring improving outcomes rather than hastening the imposition of dangerous interventions?

Blank stare. “It’s protocol.”

What if she refuses?

“She can’t. It’s protocol.”

No really, what if she refuses?

“She can’t deliver here.”

So she can just walk out of here?

“Well, we’d have to call CPS.”

Ah yes, the CPS card.

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And so, like clockwork, the cascade of interventions began. First, of course, since she wasn’t actually in active labor (remember the 3 cm?), she was just sitting there for a few hours while nothing happened. Taking up a bed. Unacceptable.

Time for “augmentation.” That’s when they jack you up with pitocin - a synthetic counterfeit of the natural hormone oxytocin that is responsible for regulating uterine contractions to correspond with the rest of the hormonal symphony present in physiological birth (which no L&D doctor or nurse has ever actually observed).

Pitocin, unlike oxytocin, doesn’t wax and wane with the needs of the bodies involved, and instead just asserts itself aggressively and immediately. Unnatural, shocking, and unbearable contractions start within 30-60 minutes. Not the natural kind that gradually grow and build on each other, productively moving the baby when the rest of the body is ready.

My daughter was no exception. And so of course, the epidural.

The vast majority (like 80-90 percent) of women given pitocin end up with an epidural - almost 25-50 percent more than those not given pitocin.

Epidurals stop or slow the contractions. And often the baby’s heart rate. Failure to progress. Fetal distress. So then, emergency c-section. See how this works?

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I’m sure it has nothing to do with how the hospital makes more money if they can move women through the process in 12 hours, ending with a (dangerous, expensive) invasive surgery, and on to the next lady. Rather than sitting with a mother’s labor for the 48-72 hours it might naturally take under the oxytocin-suppressing hospital conditions.

Every mammal on earth retreats to dark, enclosed, solitude to birth their young.

That is the optimal environment of safety that signals their hormonal symphony to get to work. Any bright light, interruption or the slightest stress (caused by observation of others, noises in the woods, etc) causes cortisol to spike. Cortisol shuts off oxytocin. Uterine contractions slow or stop until the animal is safe again.

So you can imagine the cortisol/oxytocin impact of bright, fluorescent lighting, beeping, constant interruptions, monitoring, observation, and an entire culture built around fear-mongering this process as a medical, life-threatening emergency.

No wonder we have the highest, most disgraceful, most scandalous c-section rate of any nation on earth. Babies don’t come out easily under these conditions.

In my daughter’s case, that wasn’t going to happen. That’s why I was there.

Even still, after my granddaughter was born without a c-section, the shenanigans continued.

Mom and baby were moved up to a different unit at 1:00 am, naturally exhausted and wanting to just snuggle and sleep.

The new nurse comes in with a clipboard and insists on explaining how we need to keep track on this complex chart of the timing and amount of each poop and pee drop, each feeding, for how long, on which boob, and we have to make sure there’s no feeding the baby within an hour of the three-hour glucose heel-prick, and on and on.

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The nurse was actually surprised and butt-hurt when we told her, politely, to buzz off.

We will not be doing your chart-tracking. We will not be following your instructions. Leave us alone until morning.

They did not comply. That night was so miserable for my daughter, with the beeping and lighting and constant interruptions, she got no rest. In the morning, she had decided that it was neither good for her nor her daughter to spend another night there. Even though the hospital revenue model “protocol” demanded two nights.

Thank goodness I had warned her about the CPS card before they played it, or she might have buckled in shock. But she was prepared, and I was never so proud as when she stood her ground. We left that afternoon.

They did call CPS. Because, of course they did.

My daughter swatted that away later, but the totalitarianism of mindless and often dangerous hospital rituals knows no bounds.

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The childbirth section of Talento’s piece ended there, but when I emailed her I asked about the Child Protective Services call:

They REALLY called CPS? What did they claim? What was the excuse to call? And what happened next? Did CPS show up at your daughter's house, or just wave off the complaint? Was there an actual investigation?

Here was her answer, which strikes me as the ugliest and most indefensible part of the entire episode:

And yes, they REALLY called CPS. They claimed that she left AMA [Note: against medical advice]. They insisted on two days stay because they claimed the baby’s sugars were too low at one test right after birth, even though every time they tested her subsequently (every couple hours), the sugars seemed to be above the threshold...

The CPS people called my daughter within 24 hours of her leaving the hospital and wanted to come over RIGHT NOW. My daughter was at our house, and so she couldn’t do that. So they went back and forth a few times and my daughter agreed to meet the lady at a Chick-fil-A.

She wanted to know what happened at the hospital and why my daughter thought she could leave after 24 hours. She wanted to know if she had an appointment with a pediatrician scheduled (which the hospital had asked probably 10 times and wanted to know the pediatrician’s name).

When they met, the lady insisted on seeing her other two children, who were at daycare. My daughter told her to pound sand because there was no complaint or investigation about them. Eventually, the lady reluctantly admitted she’d close the investigation.

What was so horrific about this is that my daughter was adopted at age 12, after she’d been in the foster care system for 5 years and was horribly abused there, had begged CPS to move her and protect her siblings too, but they had investigated and put her back in the same home. So CPS was no laughing matter to her.

But she managed to handle it with grace.

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So a happy ending. Of sorts.

Again, what is so striking is that Talento’s daughter had a generally uncomplicated birth and a healthy baby, yet the experience was miserable for all concerned.

The reason, of course, is that Talento had the inside knowledge to understand the hidden (and not-so-hidden) financial incentives driving many of the hospital’s protocols — and the confidence to help her daughter push against them.

Both sides wanted a healthy mother and child. But the hospital preferred a speedy, highly medicalized (and not coincidentally more profitable) birth. The nurses refused to accept any challenge to their authority.

The result was a slow-motion disaster, even though nothing actually went wrong.

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All this for $5 trillion a year, $1.6 trillion on hospitals alone.

It’s hard to escape the feeling that at the moment the American medical-industrial complex is the worst of all possible worlds.

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Again, thanks to Katy for allowing me to excerpt the article. The whole piece is here:

Hospitals are Soviet-style Hellscapes Unfit for Humans