You'd think that between Erykah Badu's home-birth twitter and Ricki Lake's film success and the New York Times coverage that we'd moved beyond dissing home birth as fringe -- "extreme." Apparently not. The current New York magazine titles a feature about it "Extreme Birth." The piece, by Andrew Goldman, tries to be a character study of Cara Muhlhahn, the home-birth midwife and now memoirist featured in Lake's film The Business of Being Born. But after raising her to a teetering pedestal, crowning her "the fearless -- some say too fearless -- new leader of the home-birth movement," Goldman shoots her down. It feels more like a character assassination -- of both her and the movement.
This is unfortunate for many reasons. As Goldman himself admits, routine maternity ward monitoring, inducing, and anesthetizing have added up to millions of unnecessary cesarean sections (latest CDC rate: 31.8%) -- a "hospital childbirth system gone insane." Midwives who attend home birth provide a much needed, safe alternative. But Goldman can't quite buy that (or manage to cite any research one way or another). He claims that Lake's movie "de-radicalized home birth, conflating it with garden-variety natural childbirth and allowing Muhlhahn, largely unchallenged, to argue for its safety."
Here's the deal on safety: The American College of Obstetricians and Gynecologists claims that it isn't safe; the American College of Nurse Midwives and the American Public Health Association claim that it is. The research evidence clearly demonstrates that birth outside the hospital with a trained midwife is not only as safe for the baby, but safer for the mother, provided she is considered "low risk" -- a healthy woman carrying one full-term, head-down baby.
What does Goldman mean by "garden variety natural birth" and where can you get one? The sad truth is that it's an uphill battle to avoid unnecessary intervention once you check yourself into a garden variety U.S. maternity ward (I call this "pushed birth," and it is epidemic). In many places, like NYC, there is very little gray area between the extremes, if you will, of home and hospital. And freestanding birth centers are great if you can find one, but there's no real clinical difference between there and at home: every piece of equipment at a birth center a midwife can bring to a home birth. If labor isn't progressing normally or a complication develops in either location, you transfer care to the hospital.
This concept of transporting a birth from home to hospital is a toughy, especially for reporters -- it looks like failure. The anonymous OBs quoted in New York magazine call transports "dumps" and "train wrecks." In reality, transports are normal and appropriate. These are the women who actually need advanced medical intervention; most just need pain relief or antibiotics (the C-section rate for planned home birthers is under 5%). The option of transport to a fully equipped hospital is what keeps home birth safe. Supportive physicians embrace the role of providing appropriate medical intervention and emergency care, rather than demanding that every woman give birth in the hospital and be treated as if she's an emergency.
Several times in the New York piece, Goldman thinks he's catching Muhlhahn in flagrant malpractice, but this is because midwifery standards and obstetric standards differ so, and because Goldman is relying on a cultural bias that obstetrics is more scientific. But it's not.
Yes, hospitals and physicians restrict women to 24 hours of labor after their waters have broken (many providers want you induced with Pitocin immediately after membrane rupture), but that's just standard protocol, not science. The best, largest study actually showed that a woman can labor four days without risk to the baby. Goldman also sanctions Muhlhahn for underestimating a baby's weight, and quotes an OB who claims she should have known the baby was "too big." But again, the evidence shows that even the highest-tech ultrasounds can be off by two pounds, and that it's impossible to predict which babies' shoulders will get stuck. Even ACOG doesn't recommend inducing or sectioning based on size guesstimates.
The truth is, standard maternity care is not evidence-based care (see this recent report.) And this is why more women are interested in giving birth at home. Not just so they can have candles and music and a better "experience," but because they know that checking into a hospital means exposure to preventable risks.
Which is really the shame in all this. Because most Americans are skittish about home birth, and no woman should feel it is her only option for a regular 'ole, supported, physiological birth.
As for the higher-risk births (twins and breeches for instance), the ideal setting is a hospital in theory, but midwives like Muhlhahn may agree to attend them at home because they know that their clients have zero chance of a vaginal birth otherwise. They feel an obligation to support women's choices and help them avoid unnecessary surgery. And they have the skills to do it (the current obstetric training for breech delivery is a cesarean section!). The system is shameful to an extreme.
Can you provide a source to this study?
I think that both sides of this argument need to find a common area in the middle where the system helps a woman decide what is best for her individual situation.
The only truly extreme birth is an ignorant birth. Before I made my decision to try and give birth at home this time I talked to my mother, grandmother, and great-grandmother about their labor and delivery experiences and looked back on my own experiences (having to cross my legs and hold the baby IN until the doctor got to the hospital - both times with different OBs.) Experiences of family are a far better indicator of homebirth success than statistics. If there is an emergency or complication during my labor and delivery I will gladly go to the hospital and be thankful it is an option. I will not feel like I am somehow less of a woman or mother if the plan changes due to necessity.
I am not a statistic. Neither is any other woman that has given birth. If we are treated (by midwives, OBs, or reporters) with one-size-fits-all opinions, it's no wonder no one can have a conversation about this without arguing.
I think that's where the story gets interesting, and where the New York piece feels narrow. Women and good providers are faced with all sorts of less than optimal choices because the system is so broken and because midwives have been marginalized and maligned.
Lindsay
Let me turn it around this way: the very small number of women who choose medically unnecessary cesareans are turning a low-risk birth into a high-risk birth (twice the blood loss, risk of infection, longer recovery, less likelihood of breastfeeding, higher risk that the baby will be born premature, need a NICU, and suffer respiratory problems--just to name a few). Where are the articles shaming their doctors?
Think about this: The ethical standard in medicine is NOT to use unproven interventions, except in the context of research to evaluate their effects. Surgical birth, as well as all of the other medical procedures, performed in hospital births are interventions. Home birth is a physiological normal process.
And what if we did know the answer? What if we knew that breech babies do better in hospitals? What if a woman presents to a midwife and the woman refuses hospital care? What do we do? Arrest the woman? Force her to birth alone without an attendant, because we don't agree with her decision? Organized medicine supports the rights of mothers to make risky decisions about their maternity are ALL THE TIME (amniocentesis, planned cesareans prior to the onset of labor, epidural anesthesia, augmentation of labor, etc.). In fact, frequently, it's not even the mothers who are making the decisions. It's the providers. There is a double standard of choice when it comes to maternity care. Risky choices are acceptable when the provider prefers them and unacceptable if the patient prefers them
One has to wonder what part financial incentive plays in all of this . . .
Here's the other point that's absent from your article: informed consent. Ultimately, women (all adults) have the right to make decisions about their medical care, about the procedures done to their bodies. And in a “hospital childbirth system gone insane,” higher risk women who want physiological, optimal childbirth may choose the risks of giving birth at home over the risks of the hospital. And these women are extremely lucky to have access to midwives willing to attend them. Let me tell you, some women are choosing to go completely *unassisted* because they can't find or afford a willing midwife. That's extreme. But it's still a woman's right to make the choice that she feels is best for her and her family.
Ina May thinks that the single-layer suturing may be a contributing factor to the risk of rupture. Also
the consensus at the conference was that hospital VBAC's are usually induced and there are quite a few reasons why induction can also increase the risk of rupture. More info is available at the Midwifery Today website.
OK, so your critique centers on the higher-risk births, and what you deem to be inadequate collaborative care. Again, I think it's the writer's responsibility to contextualize here. There is a de facto BAN on vaginal birth after cesarean in this country. 800 hospitals have policies flat-out banning it. Almost all the rest make it really difficult to achieve. And forget about having a physiological birth if you're VBACing. They want you in bed, on that monitor (again, not evidence based). They want you pushing that baby out in the worst possible position.
There is not a ban on VBAC in this country, although the need for 24 hour immediately available staff makes it impractical for many small community hospitals to offer it. And liability issues work against physicians encouraging it. The de facto wisdom is that no one has ever been sued for doing a cesarean (though I'm sure there are exceptions out there) and many have been sued for not doing one they should have known was needed, or for not doing it soon enough.
In this case I'm not sure you were slighted by your editors. You chose this particular midwife as a vehicle to write a story about home birth and its validity/safety. And I truly am thrilled to see this topic getting so much coverage these days. Years ago when I was just becoming interested in this, editors wouldn't touch it. Now it's a story, which is fantastic.
Glad to be here.
I never intended to write a story that used one midwife to present an argument for or against home birth. I profiled a midwife who has arguably become not only the mouthpiece of a movement, but the most sought after home birth midwife in New York City. Both my wife and I saw The Business of Being Born, all our pregnant friends saw it, and the woman with the 86 hour labor in the piece saw it. Part of her husband's comfort with the idea of home birth came from the imprimatur she received as a result of being featured in the movie. "A blue chip midwife" is how he referred to her. And we considered her for the same reason. But reporting that ended on the cutting room floor because of length restrictions quoted some midwives in the home birth community who say she is considered something of a renegade, willing to do some things that other HB midwives might not be. Abby Epstein, the director of the film, is quoted saying the same thing when she refers to her willingness to take on "a birth that’s a little more high risk that most midwives wouldn’t take." My strongest critique of BOBB--one that I recently mentioned to Abby--is that they featured her without noting that she is a polarizing figure in the midwifery community.
I have to say, I'm surprised by your carelessness in attacking my piece, given the meticulousness of the research you seemed to compile for your book Pushed, which I very much enjoyed.
Deserve. This is where the confusion is. What we deserve is sound, evidenced based, respectful, maternity care, not a perfect birth. Being confused on that point is a symptom of entitlement, and still buys into a medical model that has been advertising perfect births in exchange for blind trust in a broken system.
What I read between the lines of Mr. Goldman's particular spin on Ms. Mulhan is someone educated on the ills of our maternity care system and a little uncomfortable, and slightly put out, that the providers who are actually delivering the goods, in this instance homebirths with good outcomes, are a little rumpled, a little real, a little mouthy, and playing outside the rules of a broken system.
It is going to take the competent, bold, big ovaried, and overworked midwives of this country along with families who get that they deserve good maternity care, not perfect providers, who are going to make systemic changes regardless of where that care is delivered.
Birth injuries happen. Is insurance or our government failing disabled persons and those caring for them so much that malpractice insurance has become a financial safety net? That’s the bigger issue. Why would it be a midwife's responsibility to carry malpractice insurance?
And thanks for pointing out my mistake in grammar. I need all the help I can get.
Mr. Goldman, certain midwives are just as disturbed as mothers across the nation that the vast majority of women have NO choice of a vaginal birth in a hospital in the event of a breech, twin or vbac birth. It is not informed consent if your hospital of choice does not offer the option. And while these births do carry greater risks, the choice of whether to assume those risks belongs to parents, not our health care system. Hospitals cannot force women to make only the choices they prefer. By attempting to do so they drive these mothers to seek the care of midwives who still respect their ability as parents to weigh the risks and make their own choices.
I don't know about the rest of the country, or twins and breeches, but I'm pretty sure that there are opportunities for VBACS in the labor and delivery ward with a practice like Dr. Moritz's who I interviewed for my piece. My piece was about New York City birth, not the rest of the country. So, as far as NYC, I'm not sure I completely understand the argument for the home VBAC when a hospital VBAC is available.
But I have to say, my issue remains the same as the one I mentioned in response to Jennifer Block's post: if home birth midwives are going to tout the safety statistics derived from practices or countries that have a rigorous standards of risking out patients, they should use the same rigorous procedures for risking women out. Of course, they won't do this, because many midwives are committed to giving women the vaginal birth they are less likely to get in a hospital, a group of women who by definition would be considered "high risk" and not included in these stats. So my beef is not with midwives doing these births; it's using these statistics in an inappropriate context.