The Midwives Alliance of North America (MANA) recently released a study that shows the positive outcomes of home-births for low-risk mothers who plan to deliver at home with a skilled birth attendant. Shortly after, a study by researchers at New York-Presbyterian/Weill Cornell Medical Center reported an increase in “relative risk” of neonatal mortality in home births was released. The media backlash that ensued has been typical of previous findings regarding midwives and home births.
Okay so, who’s telling the truth here? Is home birth safe or not?
Well, both studies are right and wrong in some regards. Let’s brake down a bit about how medical studies go and then get on the point about home birth studies in particular.
Both the MANA study and the New York-Presbyterian/Weill Cornell Medical Center’s studies were meta-studies. That means that the data is pulled from information gained from records and the results of previous studies and statistics, not through means created specifically for the study in the way you would think of a classically designed psychological study with “blind” and “double blind” testing. This sort of study design is almost necessary to consider any aspect of birth risk as anything else comes with sticky ethical issues, but it lends itself to a variety of criticisms.
For one, these sorts of studies can come with a tremendous amount of selection bias. In the case of the New York-Presbyterian/Weill Cornell Medical Center study and the notorious Wax study on home birth, the choice to include unplanned and unattended home births has been lambasted for seeming to be intentional to produce negative results. In the case of unplanned and unattended home births, the rate of infant mortality is not surprisingly higher as it can be due to a complication in the first place and the families are unprepared on how to handle a surprise home birth. The Wax study was so widely criticized (mostly by international journal review) because it not only included these numbers, but was quite misleading about the facts and study selection process in the abstract. Regardless, the Wax study’s findings are quoted in debates on home birth safety as high up as Congress.
Home birth studies lead by midwives are not immune from selection bias and there have been legitimate claims to such from critics in the past. Where the conversation gets frustratingly murky for skilled home birth attendants, however, is on the topic of “risking out” clients. So often when this is brought up in rebuttals to positive outcomes for home births, it is made as this crazy slander against the results. Yes, positive home birth outcomes come largely in part from rigorous prenatal screenings. Why, why, why is this talked about as some area of rarity and almost coincidence amongst medical retorts? This is something that should be praised. When a woman determines that she would like to have a home birth, it is a midwife’s job to perform regular check ups with the pregnant woman to ensure a greater possibility of positive outcomes for both mama and baby. This is why prenatal visits with midwives are on average 30-45 minutes long versus the average 7-10 minutes with a doctor. Here, too, however, is where many home birth studies show fault by sometimes glossing over the rate and results of hospital transfer and thus transfer of care (since U.S. midwives are not granted co-management of labor in cases of transfer as most midwives in industrialized countries are afforded).
The definitions of risks and outcomes must also be acknowledged. It must be understood that the definition of “healthy” for mama and baby often differ between the medical community and midwives. A new mother can walk away from the hospital with an unnecessary morbidity (re: injury) such as fourth degree tearing, hemorrhage, or C-section and be considered “healthy” if she is alive and doesn’t need re-hospitalization. Home birth studies often have different views of positive outcomes and can often include mother’s state of mind before, during, and after delivery, something more medical studies often lack.
This is an important point when discussing the choice of care provider and location for delivery. When any study that shows that midwifery care is a safe (and sometimes safer) option for delivery comes out, there is a crazy amount of “mother shaming” that accompanies it. Mothers who choose home birth are often portrayed as selfish. Why are we still doing this? Why are women still lashing out at each other over choosing a home birth? Shouldn’t each mother want to walk away from a birth feeling like her body is intact? Shouldn’t she and her family feel like they had a positive and empowering experience no matter where and who with she delivers? Is a “healthy” baby all that matters when mom is infected, stitched up, sore, with an epidural headache or a 6 inch incision that is so painful she cannot lift her baby? This is not the case for every woman who delivers in a hospital, but the C-section rate is an alarming 1 in 3, far higher than any study shows returning a positive outcome weighing out the risks involved. Any woman choosing to deliver with a midwife or at home or without an epidural or with a planned C-section or with fentanyl injection does not in any way lessen the experiences of the women who chose something different. It’s profoundly unproductive to be speaking amongst ourselves in this way. In fact, it’s downright cruel. Women should not be shamed for having a home birth any more than they should be shamed for having a C-section, regardless of the outcomes. This negative speech is present on both sides with some radical birth workers claiming rampant misogyny and greed amongst OBs and the prevailing notion that midwives outside of the hospital are unskilled witches serving a selfish lefty minority. No one is serving the broader U.S. female population by spurring such negligent dialogue.
The media frenzy that accompanies these studies is somewhat infuriating. While the need for a nation-wide discussion on the care of pregnant women is absolute (we have the worst infant and maternal outcomes in the industrialized world and spend tens of thousands more on our maternal health care system than any other country), having it framed in the world of media soundbytes can be lethal to progress. This is and should be an open forum, but giving Amy Tuteur and the Skeptical OB blog, a purposely decisive forum with the sole purpose of lambasting midwives and those in their care, air time as well as turning to Riki Lake as an expert is misdirection.
So what should we be talking about? Well, The Daily Beast* had a nice article on where mother’s must lie in the debate. How thoughtful to actually include them in the discussion! Barbara Katz Rothman** has a thoughtful article on Science and Sensibility’s blog (the evidence-based wing of Lamaze International) on understanding the terminology of risk in studies on birth. This is an essential component to understanding what these studies are actually saying. Unfortunately, this doesn’t seem to have brought on renewed discussions about the MOMS for the 21st Century Act (H.R.5807)***, a bill proposed by Rep. Lucille Roybal-Allard (D.-CA) or expanding midwifery and out of hospital birth coverage under the Health Care Act. The fact that ACOG (the American Congress of Obstetricians and Gynecologists) and the American Association of Pediatricians have both in the past year started to budge slightly on the issue of home birth (from “no no no way” to “well, it’s not the best, but sure”) hasn’t been brought up much. And let’s not forget (though the media seems to have not ever even bothered to pay attention to this point) that this is the same ACOG that released a study in it’s own journal claiming that 2/3 of the standard practices in it’s general guidelines have been shown to be not evidence based, but based more on opinion of doctors****. Why is that not being brought up in the discussion of this most recent study? Importantly, the topic on poor reporting of infant and maternal deaths and hoping to reach some level of standardization in these reportings is fundamental to this debate. How can families really decide for themselves if the data can’t be read clearly across the board? How can they make decisions for themselves and how can policy makers best serve them if certain data is selectively reported or left out? The immoral Ina May addresses this clearly in her book, Why Birth Matters*****, which can serve as a helpful guideline in interpreting this confusing data.
The truth of the matter is, we have a culture in the U.S. where the body politik politicizes the body through the bodies of policy. Bodily autonomy is a heated debate, nowhere more so than in women’s reproductive policy. However, to fully engage in the debate over expanding birth options to reflect the better outcomes of peer nations, it is crucial to remove this out of the realm of a solely feminist issue. The U.S. as a nation is paying ridiculous amounts of money to keep itself gridlocked in an unsafe maternity care system where mothers, babies (both male and female), and their families (men and women alike) are suffering. Their suffering physically from unnecessary procedures, financially from things like poor infant outcomes from early inductions and re-hospitalization from drug resistant infections, and emotionally from judgmental backlash and feelings of inadequacy. This is not the path to creating a robust society with a healthy population (See Michel Odent’s Primal Health Studies). It is not the path to reducing our nation’s bloated health care system (See Eugene DeClerq’s Birth by the Numbers). It is not the path to empowering families to make their own decisions about the health of their children, something that will carry on with them for a lifetime. If having healthy women actively choose to deliver at home under the care of a skilled midwife can make some dent in this situation, why is it so hard to support it? Wouldn’t this help put midwives in charge of healthy, normal births at a much lower cost and leave more room for OBGYNs to practice their professional expertise (that is, reproductive pathology and surgery) to the cost and health benefits of everyone? Midwives recognize that they need doctors for the 2-3% of women who develop complications. They recognize that the women who are risked out of the option of home delivery (this is a smaller number than you might think since many complications in birth still do not require hospital treatment or operative delivery) need hospitals and doctors for proper care. Having more women safely deliver at home will not shut the doors of hospital birth centers by any means. Keeping this debate in the realm of heuristic fringe or doctor bashing will not help to improve outcomes for mothers, babies, or their families. There needs to be a moment’s pause to step back and reframe the debate entirely so that the U.S. can move forward.
And in the end, the desire for women to make an informed decision for themselves about their health and the health of their growing families needs to be put above any public health debate.