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High Risk: Stories of Pregnancy, Birth, and the Unexpected
Karkowsky offers a window into all that pregnancy, labor, and birth can entail—birth and joy, but also challenge and loss—illustrating the complexity of reproductive life and the systems that surround it. With historical insight and illustrative real-life stories Karkowsky unpacks what is involved for women, for a family, and for us as a society; and explores what’s at risk when these aspects of medicine remain clouded in mystery and misinformation.
312 pages, Hardcover
First published March 10, 2020
97 people are currently reading
3299 people want to read
About the author
Chavi Eve Karkowsky
2 books24 followersChavi Eve Karkowsky, MD, is a high-risk pregnancy doctor and a writer.
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July 28, 2020I would recommend this book to any woman who is contemplating a caesarean birth, or has had one and would like a 'natural' one for the next child, especially if you live in place with a small hospital. And even more especially if the hospital does not have a shift system for doctors.
There is a lot of data on doctors who are paid for each delivery to do caesareans rather than go home and let their patient be delivered by the next doctor who will get the money. A shift system does away with this. Almost a third of all births are caesareans, often not for medical reasons. Malpractice law in the US makes it harder to defend doing one for the wrong reasons, plus women request them as they think it's safer, or they are 'too posh to push' (ie. it will hurt too much). These days there are celebrities who don't want to push and don't want the scars, so they go the surrogate route.
By the time a woman is on her third caesarean section, the womb has a lot of scar tissue and there is the problem of placenta disease - placenta accreta spectrum, where the placenta implants into the scars, into the muscle and even into the bladder, bowel and blood vessels. That will be at the very least, massive bleeding on birth and possibly a hysterectomy. In the 70s, the rate of placenta disease was 1 in 4,000, in 2002 it was 1 in 2,500 with a mortality rate of 5-7%. The latest figures are 1 in 533.
So the best advice in the book is that if a woman wants to try for a vaginal birth after a caesarian she should make sure that her local hospital offers it, otherwise consider going to stay in a big city with hospitals that do offer it. Only 1 in a hundred VBACs will go wrong, but if something goes wrong it is likely to be a rupture where the caesarian scar is, that is dangerous for the mother, but especially if the placenta is involved, even more dangerous for the baby who is likely to be deprived of oxygen.
1% is a very low risk in a good hospital, just a very high one in a home birth. And for insurance companies, 1% might mean a lot of money to pay out. All medical procedures and tests in the US have to relate to the bottom line - what will be most profitable?
There is a lot of data on doctors who are paid for each delivery to do caesareans rather than go home and let their patient be delivered by the next doctor who will get the money. A shift system does away with this. Almost a third of all births are caesareans, often not for medical reasons. Malpractice law in the US makes it harder to defend doing one for the wrong reasons, plus women request them as they think it's safer, or they are 'too posh to push' (ie. it will hurt too much). These days there are celebrities who don't want to push and don't want the scars, so they go the surrogate route.
By the time a woman is on her third caesarean section, the womb has a lot of scar tissue and there is the problem of placenta disease - placenta accreta spectrum, where the placenta implants into the scars, into the muscle and even into the bladder, bowel and blood vessels. That will be at the very least, massive bleeding on birth and possibly a hysterectomy. In the 70s, the rate of placenta disease was 1 in 4,000, in 2002 it was 1 in 2,500 with a mortality rate of 5-7%. The latest figures are 1 in 533.
So the best advice in the book is that if a woman wants to try for a vaginal birth after a caesarian she should make sure that her local hospital offers it, otherwise consider going to stay in a big city with hospitals that do offer it. Only 1 in a hundred VBACs will go wrong, but if something goes wrong it is likely to be a rupture where the caesarian scar is, that is dangerous for the mother, but especially if the placenta is involved, even more dangerous for the baby who is likely to be deprived of oxygen.
1% is a very low risk in a good hospital, just a very high one in a home birth. And for insurance companies, 1% might mean a lot of money to pay out. All medical procedures and tests in the US have to relate to the bottom line - what will be most profitable?
May 15, 2021
This is a non-fiction memoir book. I have been wanting to read this book since it came out, but I know I needed to be in the right place to read this book. My first pregnancy I had out of issues, and I almost died do to HELLP Class 1. My twin boy pregnancy was easy on me, but twin B (Wesley) everyone was worried about since the beginning. I was one of the people that did not care what they found he was my baby, and I would have him. My mother in law had different opinions, but we do not talk about it today. My twins just turn 7 years old, and yes, my little Wesley has issues. He is prefect to me and my family. He is a happy boy. This book brings back several memories back to me. I had the test the book talked about using the mother's blood to see if their is something wrong with the baby during my twin pregnancy. The test just came out when they give me the opinion. My doctors also made me feel bad because I would not let him do the other test. I love this book lets me see the doctors view, but in my case there was no test that would change my mind. This book was written so well. I loved seeing the doctors point of view, and I agree with most of what is in this book. I really enjoyed reading this book. I won a kindle edition of this book from a goodreads giveaway, and this my honest opinion about how I feel about this book. (*)
July 9, 2023
Won 🏆 via goodreads giveaways, all my opinions are my own.
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3.5 stars 🌟 🤩 ✨️
Very interesting but also sometimes difficult to get through at times.. never was bored once I picked it up though.
The author didn't talk down to the readers, but just let you by the hand down memory lane.
Healthcare is wonderful but also frustrating and sometimes way too complicated. (IMHO, co-pays and deductibles are stupid) I always tell my sister, they got into the wrong business if they don't want to spend money.
Books like this can help us understand better and give us some insight when advocating for ourselves or someone we know. We know our bodies best, but its not always easy to describe what we are experiencing.
Hopefully someday we can fix what's wonky about the system 🙏.
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3.5 stars 🌟 🤩 ✨️
Very interesting but also sometimes difficult to get through at times.. never was bored once I picked it up though.
The author didn't talk down to the readers, but just let you by the hand down memory lane.
Healthcare is wonderful but also frustrating and sometimes way too complicated. (IMHO, co-pays and deductibles are stupid) I always tell my sister, they got into the wrong business if they don't want to spend money.
Books like this can help us understand better and give us some insight when advocating for ourselves or someone we know. We know our bodies best, but its not always easy to describe what we are experiencing.
Hopefully someday we can fix what's wonky about the system 🙏.
May 3, 2020
I had high hopes for this, and I was not disappointed. It was a great mix of informative & well researched + a topic I'm interested in + a tone & writing style that I loved. Highly recommend, though maybe not if you are currently pregnant...
February 4, 2020
I was hooked from the very beginning, but not because of the medical drama; not one of these stories is told in a way that feels sensationalized or exploitative. Even the occasional blood-and-gore descriptions of the worst-case scenarios are clinical rather than theatrical. From beginning to end, this book was grounded instead in heartrending, hopeful humanity.
This is obviously not a book you should read while pregnant or if you plan to be in the very near future, but with some safety distance, this offers some valuable insight into what to expect from your doctor-patient relationships, how the medical system can support you through the most difficult decisions and traumatic moments of your life, and how this enormous machine may sometimes fail you when its generalizations are not applicable to your individualized needs. Dr. K is brutally introspective about what works and what doesn’t, about her own shortcomings as a practitioner as well as her strengths. She consistently acknowledges her own privilege as a white woman in a position of power and her complicity in a system that unfairly disadvantages specific populations. Her voice is compassionate and unpretentious as she examines and contextualizes difficult ethical questions, and I’m grateful for this honest portrayal of what goes on behind the scenes to make modern medical care possible.
Thank you to the publishers for providing my ARC!
This is obviously not a book you should read while pregnant or if you plan to be in the very near future, but with some safety distance, this offers some valuable insight into what to expect from your doctor-patient relationships, how the medical system can support you through the most difficult decisions and traumatic moments of your life, and how this enormous machine may sometimes fail you when its generalizations are not applicable to your individualized needs. Dr. K is brutally introspective about what works and what doesn’t, about her own shortcomings as a practitioner as well as her strengths. She consistently acknowledges her own privilege as a white woman in a position of power and her complicity in a system that unfairly disadvantages specific populations. Her voice is compassionate and unpretentious as she examines and contextualizes difficult ethical questions, and I’m grateful for this honest portrayal of what goes on behind the scenes to make modern medical care possible.
Thank you to the publishers for providing my ARC!
September 20, 2022
This book was not just stories as the title promised, but rather, stories used as illustrations for essays about the state of various aspects of health care in the United States. At first this is disappointing to me because I had been hoping for stories but as I read deeper I saw the importance of the topics Karkowsky was highlighting and was impressed by the insights she gave.
January 13, 2022
I would have given this book a 5-star rating for content but for the way it was narrated, a 3-star. I had expected the book to be written in a more layman fashion, instead of infused with a lot of medical terminology and language. Though I learnt a lot, it also made the reading experience a little bit of a snooze.
My main takeaway from the book and Dr Chavi's experience is that no pregnancy is the same and there is no such thing as a "sufficient" amount of prep work mothers and doctors can take to prevent an undesirable pregnancy outcome. Of course, it goes without saying that actions obviously harmful to the baby (e.g. smoking, drinking etc.) should be abstained from, but no amount of reading, knowledge, or abstinence from pain medications (e.g. to not take pills to cure nausea when feeling nauseated during pregnancy) can protect a fetus/baby from harm. Although easier said than done, it is important for mothers to realise that their quality of life during pregnancy can, and should, take precedence over their pregnancy. "Sometimes the misery persists because the medical establishment still doesn't value the suffering of the mother over the smallest possible risk to her growing fetus. I wasn't about to die or require hospitalization, so nobody asked me if that was successful enough. I was losing function; I was losing my livelihood and a large part of what makes life fulfilling to me. But nobody asked me."
It is easy for mothers themselves (and perhaps their spouses/families) to assign blame to the mothers when an undesirable pregnancy outcome is met, but we need to learn that sometimes bad outcomes occur out of sheer bad luck or a random culmination of events that no one could have foreseen.
Also, I should probably give my mum a hug for tolerating 9 months of nausea for me lolol
My main takeaway from the book and Dr Chavi's experience is that no pregnancy is the same and there is no such thing as a "sufficient" amount of prep work mothers and doctors can take to prevent an undesirable pregnancy outcome. Of course, it goes without saying that actions obviously harmful to the baby (e.g. smoking, drinking etc.) should be abstained from, but no amount of reading, knowledge, or abstinence from pain medications (e.g. to not take pills to cure nausea when feeling nauseated during pregnancy) can protect a fetus/baby from harm. Although easier said than done, it is important for mothers to realise that their quality of life during pregnancy can, and should, take precedence over their pregnancy. "Sometimes the misery persists because the medical establishment still doesn't value the suffering of the mother over the smallest possible risk to her growing fetus. I wasn't about to die or require hospitalization, so nobody asked me if that was successful enough. I was losing function; I was losing my livelihood and a large part of what makes life fulfilling to me. But nobody asked me."
It is easy for mothers themselves (and perhaps their spouses/families) to assign blame to the mothers when an undesirable pregnancy outcome is met, but we need to learn that sometimes bad outcomes occur out of sheer bad luck or a random culmination of events that no one could have foreseen.
Also, I should probably give my mum a hug for tolerating 9 months of nausea for me lolol
April 8, 2020
A beautiful, powerful, important book on pregnancy and birth from a doctor who specialises in pregnancy and birth.
There are so many ways in which this book has educated me, devastated me, inspired me.
Set out into chapters following the path a pregnancy takes, Dr Chavi Karkowsky takes us on a journey through one of the most life-changing things that will ever happen to you. She sensitively and deftly explains procedures, decision making, and outcomes, and along the way takes you on a journey to discuss powerful things that you many never have thought of. The history and culture around morning sickness and HEG ("did we save enough of your life", oof); the usage of Medical Language, genetic testing including her own experience with it; intervention and along with it, consent; the challenges of trying to prevent stillbirth; the disparity between maternal death figures of white women and black women; and more.
If you're a woman, or know a woman, you should read this! (Although if you're pregnant, maybe leave it until baby is here.)
There are so many ways in which this book has educated me, devastated me, inspired me.
Set out into chapters following the path a pregnancy takes, Dr Chavi Karkowsky takes us on a journey through one of the most life-changing things that will ever happen to you. She sensitively and deftly explains procedures, decision making, and outcomes, and along the way takes you on a journey to discuss powerful things that you many never have thought of. The history and culture around morning sickness and HEG ("did we save enough of your life", oof); the usage of Medical Language, genetic testing including her own experience with it; intervention and along with it, consent; the challenges of trying to prevent stillbirth; the disparity between maternal death figures of white women and black women; and more.
If you're a woman, or know a woman, you should read this! (Although if you're pregnant, maybe leave it until baby is here.)
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July 5, 2025I really enjoyed this one! I’ve liked every book I’ve read this month about pregnancy and the complications that come with it, but this book especially stood out. The formatting of this story to talk about first trimester through the fourth trimester was a cool way of doing things, and I enjoyed all the stories of patients. I love getting report on patients that I’m not directly responsible for (haha) and this felt like a lot of that. Working postpartum nights, I am not privy to many of the decisions doctors make, so this felt like a sneak peak into the thought processes I don’t get to see at work. I’m interested that an MFM doc wrote this because I feel like every OBGYN at my hospital could write a similar book, because *so many people* are high risk and everyone has preeclampsia. Really enjoyed, would surely recommend!
March 28, 2020
If you ever look at my shelves, either the real ones or the ones here on Goodreads, you'll quickly deduce that medicine is a favorite subject of mine. I wasn't 100% sold on the idea of a book about obstetrics (I don't have kids, don't want kids, never have).
In my years working as an EMT and as a Paramedic, I had some exposure to labor and delivery, mostly on the non-routine end of things. I decided to give the book a whirl after reading the synopsis, and I'm glad that I did. Dr. Karkowsky is a talented writer, and shares from the perspective of the adrenaline junkie doctor, thus her work with the most complex and intense maternal-fetal medical cases. Now, that I could relate to.
In addition to describing interesting and challenging cases, she also conveys the complexities of every discussion and decision. From the importance of language (non-English speaking patient to doctor, doctor to patient, nurse to doctor, etc.) to the nuances of informed consent, to the ethics and agency involved in genetic screening, she vividly portrays many of the facets of her everyday experience.
The book is written with great compassion, deep thoughtfulness, incisive observations, and offers a look into a unique and interesting medical specialty. Definitely worth the read.
In my years working as an EMT and as a Paramedic, I had some exposure to labor and delivery, mostly on the non-routine end of things. I decided to give the book a whirl after reading the synopsis, and I'm glad that I did. Dr. Karkowsky is a talented writer, and shares from the perspective of the adrenaline junkie doctor, thus her work with the most complex and intense maternal-fetal medical cases. Now, that I could relate to.
In addition to describing interesting and challenging cases, she also conveys the complexities of every discussion and decision. From the importance of language (non-English speaking patient to doctor, doctor to patient, nurse to doctor, etc.) to the nuances of informed consent, to the ethics and agency involved in genetic screening, she vividly portrays many of the facets of her everyday experience.
The book is written with great compassion, deep thoughtfulness, incisive observations, and offers a look into a unique and interesting medical specialty. Definitely worth the read.
April 27, 2020
This work is an important reminder that pregnancy and childbirth--while often joyous events!-- have the potential to put women at great risk. I admired how Dr. Karkowsky used a variety of angles to examine some of the complex medical and social issues surrounding the treatment of young mothers. I also liked "shadowing" her throughout a typical day in labor and delivery.
October 27, 2020
An important reminder of the complications of pregnancy and its sometimes heart-breaking decisions. No political agendas here, just the reality that pregnancy isn't as simple as it appears on TV. Abortion is a terrible decision, but it needs to stay legal.
February 12, 2020
Fascinating stories and thoughts about childbirth from a high risk OB/GYN. I've been listening to a lot of birth stories and recently reading books about parents' birth experiences and doctors'. I appreciated her perspective. Highly recommended to give you a picture of why doctors make the choices they make.
January 13, 2024
This book opened my eyes to the reality that pregnancy and having a baby aren’t simply about cute tiny clothes, baby showers, gender reveals, and being an adorable pregnant person as society portrays. It’s a serious matter not to be taken lightly and quite possibly life-threatening. YOU CAN DIE trying to carry a pregnancy to term, give birth, or even after the baby is born (while recovering). Before advances in medicine (and even during the early years), many women knew that getting pregnant and giving birth could most likely end in their death. Many would make plans to provide long-term care for their child(ren) before giving birth in the event of their death, and now we’ve gotten so complacent as a society that we take living through it as a given.
In this day and age, with all of the advances we’ve made, it is still not a sure bet with our medical system geared towards focusing on the majority of cases rather than the special ones Dr. Karkowsky has highlighted. Some pregnancies can cause severe “morning sickness” that can lead to being so malnourished that the baby takes all of the existing nutrients in the body. Placental abruptions can lead to nearly uncontrollable bleeding. After the birth, if the uterus fails to contract and stop bleeding after all attempts to stop it, it must be removed. These are just a few of the cases and details mentioned. Still, there’s so much more valuable information in this book, including how the US medical and hospital systems work, types of delivery, complications in pregnancy and birth, etc.
I wish this was a mandatory read in high school health education classes for everyone so that there’s no misconception that having a baby is just so simple and easy. We should all take valuable consideration in deciding to have a child, not scaring anyone, but to understand the full extent of the probabilities.
If you are pregnant and scared of the unknown, this might not be the best book to read because you’ll focus on the worst-case scenarios, which might cause undue stress and anxiety. If you’re not pregnant or a person without a uterus, this is still an important book to read for insight into the seriousness of pregnancy and childbirth.
Overall, we can all benefit from learning to appreciate the difficulties people go through to bring new life into this world and comprehending the value of their lives (rather than just the potential for or the actual baby).
In this day and age, with all of the advances we’ve made, it is still not a sure bet with our medical system geared towards focusing on the majority of cases rather than the special ones Dr. Karkowsky has highlighted. Some pregnancies can cause severe “morning sickness” that can lead to being so malnourished that the baby takes all of the existing nutrients in the body. Placental abruptions can lead to nearly uncontrollable bleeding. After the birth, if the uterus fails to contract and stop bleeding after all attempts to stop it, it must be removed. These are just a few of the cases and details mentioned. Still, there’s so much more valuable information in this book, including how the US medical and hospital systems work, types of delivery, complications in pregnancy and birth, etc.
I wish this was a mandatory read in high school health education classes for everyone so that there’s no misconception that having a baby is just so simple and easy. We should all take valuable consideration in deciding to have a child, not scaring anyone, but to understand the full extent of the probabilities.
If you are pregnant and scared of the unknown, this might not be the best book to read because you’ll focus on the worst-case scenarios, which might cause undue stress and anxiety. If you’re not pregnant or a person without a uterus, this is still an important book to read for insight into the seriousness of pregnancy and childbirth.
Overall, we can all benefit from learning to appreciate the difficulties people go through to bring new life into this world and comprehending the value of their lives (rather than just the potential for or the actual baby).
May 9, 2022
Excellent. In today’s society of social media, influencers, and instant gratification, pregnancy is often portrayed as beautiful, glowing, seamless. And it can be, but, for some brave women, it’s just the opposite. Dr. Karkowsky draws back the curtain to show the more grizzly and insidious side of pregnancy and birth. This book is tremendous. The high risk pathologies discussed throughout hit so close to home that I felt like I was at work while reading.
September 15, 2021
I saved this to read after my last pregnancy as a special treat. I'm one of those weirdos who enjoys learning about worst case medical scenarios, but I also can be a bit of a hypochondriac (surely, these things aren't related). Now that I'm done having children, though, I felt ready to dive headfirst into the potentially terrifying and life-threatening condition that is pregnancy, and devoured this book over the course of several late, heart-pounding nights. Karkowsky does an exceptional job balancing personal anecdotes with a larger social analysis, but what I ultimately loved was her examination of realizations she's come to as a physician, such as how "scut [work] is love" and why compassion for the patient cannot be a physician's only guiding principle. These parts of the book also helped me better understand my own pregnancy and birth experiences and grapple with my complicated feelings about the well-intentioned but flawed and paternalistic medical establishment in which they took place.
August 31, 2020
This book was so compelling and resonant. The introduction is in many ways a testament to how I feel about my field of work, blending the intensity of the reproductive life course felt by each woman who experiences it with (some of) the social and policy implications of "women's health" being treated as a nominal issue. The main chapters mix dramatic stories of individual deliveries (my blood pressure rose while reading them, remembering the dramas of my own) with astute, thoughtful reflections on clinical practice and its human effects, including a necessary discussion of the horrendous racial inequities in maternal health outcomes in this country. I would eagerly read this book 10 more times.
August 8, 2020
As someone obsessed with birth and birth stories, I loved a lot of this book - I would have happily read one that was three times longer. The only chapter I wish there had been more of was the last one about maternal mortality and Black women. I got the sense throughout that the author was not writing for Black women or a Black audience, but rather trying to explain systemic racism to white women from a white perspective. I admire the effort but was wondering “where are your Black colleagues - not just here, but throughout the book?” It seems odd to only address it in depth in the last chapter, when medical racism has such a huge effect on all aspects of pregnancy and birth.
May 17, 2020
This was an excellent, compassionate, well-thought out book touching on a subject that doesn’t get enough attention. The author’s willingness to take a hard look at herself is what really made this shine for me. Too often with books like this, the narrator presents themselves as infallible. I loved the mix of research and personal stories, and the book was laid out well in terms of sections. The final section that detailed what a night in her role looks like was so compelling that I could have read many more pages like it. Highly recommend!
May 31, 2021
So interesting, less triggering than I thought it would be. It actually feels really good to understand some of the functions of what happened in my pregnancies instead of "This happens sometimes." But also I wanted to cry the whole time so still a little triggering I guess, which is probably unavoidable.
September 30, 2020
This book is so well-written and so important. I could not put it down. Highly recommended!
June 2, 2021
This book was a good mix of informative and entertaining thanks to all the anecdotal stories Dr. Karkowsky included. A great read for anyone in obstetrics!
August 12, 2024
This book was such a good read! I’ve been in a non fiction mood recently and this book was really good!
October 14, 2024
4.5⭐️ i would recommend this book to literally anyone/everyone (even men… as evidenced by the first chapter).
May 6, 2020
If you're considering this book from the childfree margins, my review is for you.
I'm in my mid-thirties, my tubes are tied, and I've always known getting pregnant and/or giving birth just wasn't for me. I picked up this book because it seemed to intentionally touch on a lot of things that matter to me regardless of my personal life, like the ways medical institutions can fail people of color, fat folks, poor people, and women in particular. It's all that, without being overly dry or burdened with policy or academic language. This also didn't seem to be the typical "but isn't birth just MIRACULOUS and the BEST THING A WOMAN CAN DO" that other books tend to try to umbrella all stories of pregnancy and birth under. Hallelujah. I found that even Dr. K's mentions of her own pregnancy and birth experiences are still relatable, well tempered, and not overtly sentimental.
I wouldn't say anyone with tokophobia or similar anxieties get out and grab this, but for those of us on the edges of the birthing process who seek to deepen our understanding of the things our friends, family, community, and the world at large may find themselves up against, and if you can handle some harrowing situations that are presented - please do. To balance the clinical realities of these tough situations with the humanity that the patients deserve is a big task, but this work delivers.
There are a few good mentions about the struggle of women to gain full reproductive autonomy when it comes to things like sterilization, which spoke a lot to my personal battles and experiences with the medical system. Chavi mentions the things I've always tried to keep in mind when it comes to being grateful that I navigated that system to the ends that I needed. And that is largely that, historically, certain types of women have disproportionately had that choice made for them: Native Americans, black women, institutionalized women, and others that were deemed "undesirable" for reproduction. This was one of the few parts of the book that I felt like Dr. K was getting away from the personal experiences of her and her patients and branching out a bit more, but I'm glad that she did include it in the conversation. I wish that she would have gone out a bit further and also included the plight of incarcerated women today giving birth shackled to tables, and some of the other more complex and compounded types of reproductive injustice that they face, but I understand that is a lot to ask without derailing why most people pick this book up. I'm hoping that in the future perhaps Dr. K encourages her colleagues to engage with those women and get those stories out there, to help bring public consciousness to those situations, and help to inform and change policy.
Chavi primarily speaks from her side of her experiences with patients. She acknowledges her power in these interactions, and puts it all up front that the format that she is choosing to take with this isn't necessarily a dialogue full of verbatim quotes, or ongoing discussions that take into consideration the other sides of her patients lives, or even just reflecting after the dust has settled and people are cloaked in the knowledge that hindsight may bring. The stories are a very in-the-moment retelling. She goes through these situations alongside these women at some critical points in their pregnancies, but ultimately, there is just too much to be done in the immediate Now of everything to build up and paint the nuances of the patients inner worlds. Be prepared for some 'and that's the last time I saw them' conclusions. In my opinion, it doesn't at all detract from the gravity of this work. If anything, it helps remind us that the work being done on these pages is the type that never stops barreling towards you.
I'm in my mid-thirties, my tubes are tied, and I've always known getting pregnant and/or giving birth just wasn't for me. I picked up this book because it seemed to intentionally touch on a lot of things that matter to me regardless of my personal life, like the ways medical institutions can fail people of color, fat folks, poor people, and women in particular. It's all that, without being overly dry or burdened with policy or academic language. This also didn't seem to be the typical "but isn't birth just MIRACULOUS and the BEST THING A WOMAN CAN DO" that other books tend to try to umbrella all stories of pregnancy and birth under. Hallelujah. I found that even Dr. K's mentions of her own pregnancy and birth experiences are still relatable, well tempered, and not overtly sentimental.
I wouldn't say anyone with tokophobia or similar anxieties get out and grab this, but for those of us on the edges of the birthing process who seek to deepen our understanding of the things our friends, family, community, and the world at large may find themselves up against, and if you can handle some harrowing situations that are presented - please do. To balance the clinical realities of these tough situations with the humanity that the patients deserve is a big task, but this work delivers.
There are a few good mentions about the struggle of women to gain full reproductive autonomy when it comes to things like sterilization, which spoke a lot to my personal battles and experiences with the medical system. Chavi mentions the things I've always tried to keep in mind when it comes to being grateful that I navigated that system to the ends that I needed. And that is largely that, historically, certain types of women have disproportionately had that choice made for them: Native Americans, black women, institutionalized women, and others that were deemed "undesirable" for reproduction. This was one of the few parts of the book that I felt like Dr. K was getting away from the personal experiences of her and her patients and branching out a bit more, but I'm glad that she did include it in the conversation. I wish that she would have gone out a bit further and also included the plight of incarcerated women today giving birth shackled to tables, and some of the other more complex and compounded types of reproductive injustice that they face, but I understand that is a lot to ask without derailing why most people pick this book up. I'm hoping that in the future perhaps Dr. K encourages her colleagues to engage with those women and get those stories out there, to help bring public consciousness to those situations, and help to inform and change policy.
Chavi primarily speaks from her side of her experiences with patients. She acknowledges her power in these interactions, and puts it all up front that the format that she is choosing to take with this isn't necessarily a dialogue full of verbatim quotes, or ongoing discussions that take into consideration the other sides of her patients lives, or even just reflecting after the dust has settled and people are cloaked in the knowledge that hindsight may bring. The stories are a very in-the-moment retelling. She goes through these situations alongside these women at some critical points in their pregnancies, but ultimately, there is just too much to be done in the immediate Now of everything to build up and paint the nuances of the patients inner worlds. Be prepared for some 'and that's the last time I saw them' conclusions. In my opinion, it doesn't at all detract from the gravity of this work. If anything, it helps remind us that the work being done on these pages is the type that never stops barreling towards you.
January 30, 2020
Wonderful writing that shares the writer’s perspective on the complete arc of pregnancy along with the role of doctors and the ways in which the healthcare system can work, but sometimes doesn’t. A compelling blend of stories of patients and care providers, plus historical background and context.
March 12, 2020
This book was hard to put down, and hard to pick up. Karkowsky strikes a great balance of sharing her personal stories as a Maternal-Fetal Medicine (MFM) Obstetrician, and a general overview of fetal anomalies and pregnancy complications. The book is well written, gripping, and often terrifying. She gives just enough dose of reality to make it feel real, and then appropriately highlights the more technical or bureaucratic aspects that are either essential for general understanding, problematic, or otherwise important. She covers problems often specific to each trimester, including both maternal and fetal issues. I loved her approach to handling everything from the delicate and difficult conversations of recommending an abortion to her views on the challenges women face on things as simple as checking into the hospital or getting treatment without racial bias. All I have to say is that I have a far greater respect and sympathy for the crazy dangers that all women who get pregnant face, and the physical, emotional, psychological, and institutional challenges they endure. Maternal-Fetal healthcare for women in the USA is great, but there are areas that can still be significantly improved. Ob's are amazing people!
July 9, 2022
“Amniotic fluid in third trimester is fetal urine, so if fetuses don’t get enough hydration to the umbilical cord, they don’t pee. In many ways, oligohydramnios is analogous to having a dry diaper in a newborn signals that the baby is dehydrated and that we should worry.”
“Tubal ligation in the United States does not have a benign past. There’s a long and shameful history of non-consensual medical procedures in this country, in particular regarding women’s sterilization. Many examples of involuntary or even compulsory sterilization programs have paved the roads of American policy. In the mid 20th century, up to 25 to 50% of Native American women were regularly sterilized without their consent, often when they were teenagers, many of them didn’t know this has been done to them until they unsuccessfully tried to conceive later in life. Similar stories exist with regard to disabled people or those with mental illness. Other racially discriminatory sterilization experiences tied to various eugenics movements litter our history. These programs usually targeted anyone without power: Intellectually disabled or mentally ill patients, women of color, or low income women. Generally, these surgeries occurred not because the patient wasn’t capable of consent, but because someone in power —her doctor, her parent, some government official —decided that the world would be better if she did not produce children.”
“Every part of the medical system failed Ayo had rules: the clinic, the pharmacy, the insurance company. The rules were generally put into place for good reasons. I think we would all agree that it is reasonable to review spending almost $7000 per month for medication on the taxpayers dime.
But that’s the very small picture. When we back out just a bit, we realize that the taxpayer is paying anyway. Ayo and her baby are both still on Medicaid. Ayo’s daughter’s NICU time cost somewhere between $1000 and $3000 per day. Per day. For three months. Anyone can do that math and figure out that we didn’t save any money.
Then there is a lifelong cost that Ayo’s daughter will incur from her preterm birth— eyeglasses, physical therapy, special education—all intervention she’s much more likely to need because of her extreme preterm birth, some of them perhaps for the rest of her life. Prenatal interventions are satisfying, not just on a personal level but also in a kind of dry cost benefit analysis that builds public health policy. Because even a small expense saved early enough leads to exponential savings throughout a life, so almost all prenatal interventions are worthwhile.
In actuality, the lack of progesterone was expensive for Ayo herself. I don’t just mean in suffering or lost work or years of trekking to specialist appointments or her lost dreams of returning to college, though those are all true. I mean that despite the many news outlets that may tell you that Ayo is a tax-sucking, anchor-baby-having leech on society, she is a taxpayer. She would probably pay more taxes if she earned more, but she can’t earn more while caring for one and now likely two special-needs children. That’s another way that pre-term birth costs us all money, for those doing the math.
The money, of course, pales in comparison with other things, like suffering and pain and fear and preterm-baby brain damage. But for those who merely want a spreadsheet, the numbers are pretty damning on their own. This was stupid and expensive, it turns out, not just for Ayo but for you and me, because we are part of the society that benefits when Ayo and her baby are healthy and productive.”
After a home birth gone wrong:
“During those morning rounds, the head of L & D, a venerable gray haired professor, made a point of standing up. He said something like this :”what you need to know is that invited the care provider in this case, the birth attendant, to be in the OR with us. I asked her opinion after the case. I will call her today, as well, to discuss the patient. I’m not doing any of this because I agree with how she practices. I don’t think she knows obstetrics better than me, better than us. I don’t agree with how she manages her patients in general, and I am upset about this patient in particular. But I do know this: if I include her in the patient’s care; if I don’t isolate her from the patient; if I show her that I respect her judgment, maybe next time she will not hesitate for so long to bring the patient to us. That’s what I want you to learn from this case.”
“In the Netherlands, homebirth is an entirely different entity. Planned home birth is a relatively common option – – 20% of women in the Netherlands have one. But this option, for them, isn’t outside the medical system. For this country, planned a homebirth is an integrated part of medical care. Strict guidelines exist for which patients are eligible for planned homebirth; midwives are credentialed; protocols exist for both routine maternal transfer and obstetric emergencies.”
“According to the CDC pregnancy mortality surveillance system, from 2011 to 2014, pregnancy related mortality rates for black women were three. Two times that for white women. When factoring and variables that protect against maternal mortality – – higher education, higher socioeconomic status, enrolling in prenatal care—those advantages do not protect black women; they reduce the risk of death, but not enough to make it anywhere near equal to risk for white women. This means that a black woman entering pregnancy is more likely to die. It also means that nothing else about her influences her risk of death in pregnancy in the United States as much as the color of her skin.”
“A 1999 study looked at physician recommendations for simulated patients with chest pain, where the actor-patients varied only in race, gender, and exercise habits. This study found that physicians were 40 percent less likely to recommend treatment for a heart attack, a cardiac catheterization, for women and African-Americans than for white men.”
Project Implicit —-take at least one of the quizzes
“Tubal ligation in the United States does not have a benign past. There’s a long and shameful history of non-consensual medical procedures in this country, in particular regarding women’s sterilization. Many examples of involuntary or even compulsory sterilization programs have paved the roads of American policy. In the mid 20th century, up to 25 to 50% of Native American women were regularly sterilized without their consent, often when they were teenagers, many of them didn’t know this has been done to them until they unsuccessfully tried to conceive later in life. Similar stories exist with regard to disabled people or those with mental illness. Other racially discriminatory sterilization experiences tied to various eugenics movements litter our history. These programs usually targeted anyone without power: Intellectually disabled or mentally ill patients, women of color, or low income women. Generally, these surgeries occurred not because the patient wasn’t capable of consent, but because someone in power —her doctor, her parent, some government official —decided that the world would be better if she did not produce children.”
“Every part of the medical system failed Ayo had rules: the clinic, the pharmacy, the insurance company. The rules were generally put into place for good reasons. I think we would all agree that it is reasonable to review spending almost $7000 per month for medication on the taxpayers dime.
But that’s the very small picture. When we back out just a bit, we realize that the taxpayer is paying anyway. Ayo and her baby are both still on Medicaid. Ayo’s daughter’s NICU time cost somewhere between $1000 and $3000 per day. Per day. For three months. Anyone can do that math and figure out that we didn’t save any money.
Then there is a lifelong cost that Ayo’s daughter will incur from her preterm birth— eyeglasses, physical therapy, special education—all intervention she’s much more likely to need because of her extreme preterm birth, some of them perhaps for the rest of her life. Prenatal interventions are satisfying, not just on a personal level but also in a kind of dry cost benefit analysis that builds public health policy. Because even a small expense saved early enough leads to exponential savings throughout a life, so almost all prenatal interventions are worthwhile.
In actuality, the lack of progesterone was expensive for Ayo herself. I don’t just mean in suffering or lost work or years of trekking to specialist appointments or her lost dreams of returning to college, though those are all true. I mean that despite the many news outlets that may tell you that Ayo is a tax-sucking, anchor-baby-having leech on society, she is a taxpayer. She would probably pay more taxes if she earned more, but she can’t earn more while caring for one and now likely two special-needs children. That’s another way that pre-term birth costs us all money, for those doing the math.
The money, of course, pales in comparison with other things, like suffering and pain and fear and preterm-baby brain damage. But for those who merely want a spreadsheet, the numbers are pretty damning on their own. This was stupid and expensive, it turns out, not just for Ayo but for you and me, because we are part of the society that benefits when Ayo and her baby are healthy and productive.”
After a home birth gone wrong:
“During those morning rounds, the head of L & D, a venerable gray haired professor, made a point of standing up. He said something like this :”what you need to know is that invited the care provider in this case, the birth attendant, to be in the OR with us. I asked her opinion after the case. I will call her today, as well, to discuss the patient. I’m not doing any of this because I agree with how she practices. I don’t think she knows obstetrics better than me, better than us. I don’t agree with how she manages her patients in general, and I am upset about this patient in particular. But I do know this: if I include her in the patient’s care; if I don’t isolate her from the patient; if I show her that I respect her judgment, maybe next time she will not hesitate for so long to bring the patient to us. That’s what I want you to learn from this case.”
“In the Netherlands, homebirth is an entirely different entity. Planned home birth is a relatively common option – – 20% of women in the Netherlands have one. But this option, for them, isn’t outside the medical system. For this country, planned a homebirth is an integrated part of medical care. Strict guidelines exist for which patients are eligible for planned homebirth; midwives are credentialed; protocols exist for both routine maternal transfer and obstetric emergencies.”
“According to the CDC pregnancy mortality surveillance system, from 2011 to 2014, pregnancy related mortality rates for black women were three. Two times that for white women. When factoring and variables that protect against maternal mortality – – higher education, higher socioeconomic status, enrolling in prenatal care—those advantages do not protect black women; they reduce the risk of death, but not enough to make it anywhere near equal to risk for white women. This means that a black woman entering pregnancy is more likely to die. It also means that nothing else about her influences her risk of death in pregnancy in the United States as much as the color of her skin.”
“A 1999 study looked at physician recommendations for simulated patients with chest pain, where the actor-patients varied only in race, gender, and exercise habits. This study found that physicians were 40 percent less likely to recommend treatment for a heart attack, a cardiac catheterization, for women and African-Americans than for white men.”
Project Implicit —-take at least one of the quizzes
December 7, 2019
This author’s voice is so compelling. Dr. K had me hooked and I finished this in one sitting. Especially loved a section that describes play by play what happens in an overnight on call shift in Labor and Delivery. It’s amazing the amount of patients and intense situations doctors have to juggle in hospitals. I loved being inside the brain of Dr. K for a couple hours.
Reading this book made me long for a doctor who works in a small practice: a more personalized and less chaotic approach to healthcare.
For those who have an interest in the doctor-patient relationship, the downfalls of the healthcare system, or how to translate doctor-speak, pick this one up. Just don’t read it while pregnant - this book is full of worst case scenarios.
Thank you to the publisher via Edelweiss for an ARC.
Reading this book made me long for a doctor who works in a small practice: a more personalized and less chaotic approach to healthcare.
For those who have an interest in the doctor-patient relationship, the downfalls of the healthcare system, or how to translate doctor-speak, pick this one up. Just don’t read it while pregnant - this book is full of worst case scenarios.
Thank you to the publisher via Edelweiss for an ARC.
September 8, 2020
I was fortunate enough to have Dr. Karkowsky be the fellow on duty when I gave birth to my eldest child 16 years ago. I have followed her writing since then and expected that I would enjoy this book. I didn't expect that several chapters would make me cry, moving effortlessly between explaining the most technical details and seeing the large, urgent human picture that they fit into. I already knew Dr. K was a masterful doctor, but it has been a privilege to see what an extraordinary storyteller and deep thinker she is too.
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