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1. 1. ejwillingham 4:00 pm 08/24/2011

   Thank you for writing this. I’ve tried to articulate what I’ve found to be a spectrum of reasons women have for pursuing homebirth (here: http://daisymayfattypants.blogspot.com/2010/08/in-defense-of-reproductive-choice.html). I also appreciated a comment in the thread on the post from “Becca” (here: http://isisthescientist.com/2011/08/23/your-home-birth-is-not-a-feminist-statement/#comment-25968) and a couple of comments after it; they articulate what I’d like to say very well.

   We had a homebirth for our second child, with a certified nurse midwife who had OB backup (the same OB who delivered our first child in the hospital, actually), within minutes of the hospital. Had there been available in our community a birthing center associated with the hospital that also had nurse midwives, we’d've used that. We did not select this route because of feminism. We selected it because of what the hospital did to our first son in the hours and days following his birth.

   That said, any consideration of women and childbirth isn’t only feminism, it’s humanism. It’s humanist to want to provide the best and safest birth and birth experience we can provide. We can’t exclude women’s desires and needs, as women are a necessary part of the birth equation. No, it’s not all about the mother. But it doesn’t happen without her.

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2. 2. kclancy 4:10 pm 08/24/2011

   I read your post, Emily. It was beautiful and thoughtful. And I appreciated Becca’s comment too — I actually wrote a comment of my own this morning, but it never showed on the site. Maybe it got eaten.

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3. 3. kclancy 5:10 pm 08/24/2011

   Dr. Isis couldn’t comment here herself, so I thought I’d post her response:

   http://isisthescientist.com/2011/08/24/in-reply-to-kate-clancy/

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4. 4. nthmost 6:11 pm 08/24/2011

   Thank you for writing this, Kate. As someone who gave birth to her first and only child at home (which was the plan), but who also has to distance herself from the homebirth “scene” due to dangerous amounts of woo-woo exposure, I’ve done more than my share of disentangling the two to explain why I eschewed the hospital delivery bed.

   I was more than a little rattled by Dr Isis’ anti-home-birth stance, since it’s not actually scientifically sound. When you look at the statistics for birth outcomes in the US within the past decade, you can see

   The medicalization of birth has drawn the responsibility of healthy pregnancy and delivery away from the mother and into the hospital, which depresses rates of positive outcomes for everybody. The choice of doing a home birth is not a choice any woman can take lightly, and so she is much more likely to prepare herself in as many ways as possible to ensure a low-risk pregnancy and healthy birth.

   Indeed, no MIDWIFE in existence allows any woman who chooses a home birth to forgo a healthy diet, appropriate amounts of exercise, and total knowledge of the entire birth process — including the understanding that medical intervention can sometimes be necessary.

   Meanwhile, the medical establishment would have women believe that the only preparation they ought to do is to pre-register at the hospital of their choice and get tested for STDs and gestational diabetes.

   I wrote an article about why I planned a home birth, and it has everything to do with maximizing statistical odds of producing a healthy baby (and mommy!) within the present cultural/medical context.

   http://nthmost.com/2011/05/why-i-planned-a-home-birth-and-you-should-too/

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5. 5. kclancy 7:34 pm 08/24/2011

   Thanks so much for your comment nthmost. I think that was what I was trying to get at about different interpretations of the same evidence. I look at .6% mortality odds for a home birth and think, wow, that’s not too bad, and not that different *from an individual’s perspective* from .3% odds, particularly if you are getting adequate prenatal care, have a low risk pregnancy, do all the other stuff you are supposed to be doing. Frankly, as a privileged white woman I probably have all sorts of things going in my favor here.

   From a public health perspective, those numbers get considered entirely differently. And they should. And they should drive more acceptance of certified nurse midwives.

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6. 6. RowanMcGregger 8:18 pm 08/24/2011

   This is a topic very close to my heart. Not having direct access to statistical data on hand (rather than using often biased news reports), I can’t counter the claims made on “Dr. Isis’s” site with fact. My experience is, of course, anecdotal. However, for her claims, there is equal claim all over the internet that is just as valid and speaks to the opposite, statistically. Simply Google (or other search engine) “Homebirth Statistics” and you will find a wealth of confusing data from all over the world to wade through. I can certainly cite places in the world where a home birth would be preferable than a hospital birth, like this one:

   http://www.dailymail.co.uk/news/article-2001422/Busiest-maternity-ward-planet-averages-60-babies-day-mothers-bed.html

   Could you imagine?

   I have had eight ‘successful,’ vaginal deliveries, all pain medicine free including a set of twins. Except for two of my deliveries, I wish I had home birthed. Why? Because of how I was treated, how limited my options were, how my ‘birth plan’ was treated, and the drama these so called ‘trained professionals’ drew down upon me during and after my labor/delivery. I would have been much happier in my own home surrounded with loved ones. What made the difference for the other two deliveries was level of care and the relationship I had with my care provider. I was trusted to have some kind of knowledge of myself and the process. I was trusted to have some voice in the decision making. The irony is that both of those deliveries were surrogacies and the remaining five were my own children. I could go on, but I will sum up to the important details.

   We did not attempt a home delivery, in most cases, because of the fear my husband had for the outcome. He did not want his wife and child to suffer or die and he has only the confusing statistics and personal experience to go with (mostly hospital births). He, however, felt equally awful about the way we were treated and would have seized upon another option if it were there.

   Until we can improve upon the care mothers are receiving and, at least in more western countries, remove the dollar amount from the equation, home births may continue to rise. This is not a symptom of what is better, but a symptom of what is -wrong-. Current politics in the U.S. aside, more of the babies coming into this world are because of intentional desire and sometimes difficult process to achieve those children. I can think that such desire for children would breed the desire for the perfect birthing experience, especially since we are having fewer and fewer babies per family (on purpose). Sharing your doctor and nurses with other unpredicable birthing situations, dealing with belittling staff for your personal choices, being treated like a criminal for issues that are beyond your control, and yes, being lectured about the quality of parent you are during your birthing moments are all too common.

   Every article that I have read with an anti-homebirth rhetoric has built from or worked with some kind of strange TV studio version of the real process homebirth mothers go through to come to this very important and sometimes scary decision. The anti-homebirth movement need to remember that, while the outcome is sometimes difficult and sometimes tragic, it’s not their birth. It’s really no less or more tragic/difficult than a hospital birth. The experience is ours, whomever we are, and until professionals start acting like professionals, more and more people will seek out ways to own their very personal and important experience. Mothers/couples who do the research and make choices are not idiots for doing so regardless of what they decide. They are hoping to be careful and make the best choices for themselves and for their children. If only more people would be so careful rather than simply trusting what they were told, perhaps our mother/infant mortality rates would decline. The U.S. doesn’t exactly have the lowest numbers world wide: http://unstats.un.org/unsd/demographic/products/indwm/tab3b.htm#tech
   https://www.cia.gov/library/publications/the-world-factbook/geos/us.html

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7. 7. AmyTuteurMD 10:38 pm 08/24/2011

   Actually, there is tremendous overlap between the homebirthers and the anti-vax crowd. Most homebirth advocates are anti-vaccination and they suffer from the same lack of knowledge of basic science, statistics and logical reasoning.

   It’s important to understand that homebirth is a fringe movement. Only 99.5% of women give birth in a medical setting. The women who make up the homebirth movement are not representative of anybody but their small subcultural group.

   And it is, indeed, a subculture that is predicated on notions of biological essentialism and feminist anti-rationalism. Homebirth advocacy is a subculture of privilege. It is restricted to Western, white women who are relatively well off and have immediate access to state of the art medical care.

   I will leave the issue of empirical claims aside for the moment, since you said that you did not wish to discuss them now. However, I do think it is important to note that all the existing scientific evidence as well as CDC national statistics and statistics from individual states such as Colorado that license midwives shows that planned homebirth with an American homebirth midwife has triple the risk of death of comparable risk hospital birth.

   Moreover, MANA (The Midwives Alliance of North America), the organization that represents homebirth midwives, REFUSES to release their own death rates. They have amassed a database of 23,000 homebirths. They have publicly offered the data to those who can prove they will use it for the “advancement of midwifery.” Even those who meet the standard of proof must sign a legal non-disclosure agreement promising not to release the death rates to anyone else. The fact that MANA refuses to disclose the death rates of homebirth midwives is a big red flag.

   You wrote: “I also think it’s important to question the motivations of hospitals, who have a lot of money at stake were women to start choosing birth centers or home births at a higher rate.”

   Since homebirth represents only 0.5% of births, it represent only 0.5% loss of income for hospitals and doctors. On the other hand, it represent 100% of income of homebirth midwives and that is who is driving the homebirth movement.

   The homebirth movement in the US has been shaped by women who want to call themselves homebirth midwives, but don’t want to complete the education and training that is required to be a CNM or to be a midwife in the UK, the Netherlands, Canada, Australia or ANY first world country.

   Led by Ina May Gaskin, (who has no education in midwifery, no training in midwifery, and let one of her own children die at a homebirth), “birth junkies” got together and gave themselves a pretend degree: certified professional midwife or CPM. Any confusion with CNM is intentional on their part.

   The CPM is not really a degree. It is a post high school certificate. It is not recognized in any other country in the industrialized world, since it doesn’t meet their standards for education or training.

   Homebirth midwives are now engaged in a coordinated campaign to make money from that pretend credential. That is what is at stake. Homebirth midwives may say that it is about choice, but women in every state have the choice to give birth at home. And women in every state have to choice to be attended by anyone they choose. So no one is interfering with women’s choices.

   What’s at stake is the ability of these pretend midwives to bill for their services. As biological essentialists, they have tried to convince women that a vaginal birth and extended breastfeeding are the only way to be authentic and empowered. As feminist anti-rationalists (and lacking basic science education), they have tried to convince women that science is “male” and that women should rely on intuition and other ways of knowing.

   They have engaged in a protracted and mendacious smear of modern obstetrics. Just one example: homebirth advocates are fond of claiming that the US ranks behind many other first world nations in infant mortality. What they don’t tell you is that infant mortality (death from birth to one year of age) is the wrong statistic; it is a measure of pediatric care not obstetric care. The best measure of obstetric care is perinatal mortality (death from 28 weeks of pregnancy to 28 days of life) and according to The World Health Organization, the US has one of the lowest levels of perinatal mortality in the world. Homebirth midwives offer similarly mendacious critiques of “obstetric interventions.”

   I’m not about to tell you that American obstetric care is perfect. It isn’t. But the solution is not to exchange highly educated, highly trained obstetricians and certified nurse midwives for a bunch of women who are unqualified to be midwives anywhere else in the first world, who won’t tell us their own death rates and who are nothing more than birth junkies who want to get paid to hang out at other women’s births.

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8. 8. kclancy 12:12 am 08/25/2011

   Amy, please read two of the comments above yours, both by scientists who have had home births, and link to their own birth stories and their own justifications for their home births, before you paint all women who advocate home birth with the same brush.

   Also, you may notice that nthmost, at least, describes a home birth with a CNM. There are places in the country where this is possible. I understand your criticism of CPMs and MANA. But there is still variation within home births, and there are still evidence-based reasons to avoid a hospital.

   I appreciate that you acknowledge that American obstetrics are not perfect. With the kind of research that I do on the evolutionary biology of women, it’s hard to not see it as broken.

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9. 9. AmyTuteurMD 1:16 am 08/25/2011

   There is no scientific evidence that American homebirth is as safe as hospital birth.

   All the existing scientific evidence as well as state and national data shows that homebirth with a homebirth midwife triples the rate of neonatal death and homebirth with a CNM doubles the rate of neonatal death.

   There is also scientific evidence that shows that homebirth advocates are 8X more likely to reject vaccination than women who give births in hospitals.

   Finally, almost every single empirical claim put forth by homebirth advocates on the benefits of homebirth are flat out false.

   If women want to have a homebirth, that is their right, but they cannot make an informed decision unless they understand that is increases the risk of neonatal death. Almost no homebirth advocates understand this because homebirth websites and publications are filled with false information.

   Finally, there is nothing particularly feminist about homebirth just as there is nothing particularly feminist about rejecting vaccines. Both are medical decisions based on incorrect information about risk, and typically are associated with a failure to read and understand the relevant scientific literature.

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10. 10. Anony 1:17 am 08/25/2011

    This has been quite an interesting series of comments to follow. There is clearly a visceral reaction taking place, though I find it interesting that reaction seems to be coming mainly from proponents of hospital births. As with most things, I suspect results are highly context dependent, so it troubles me that there are such sweeping generalizations being used.

    Home-birther = anti-vaxxer = totally irresponsible parent. Really?

    CPM = CNM = doulas = bad people looking to overthrown the nice happy picture of hospital births. Really?

    As a former hospital patient for a severe disease (spending >6mos in the hospital; in fact at a teaching hospital for Dr. Amy’s alma mater), I can tell you that (surprise!) there is a wide range of competency in the medical profession too. There was a doctor I banned from coming back into my room because he/she checked a stool sample then tried to hand me a thermometer with the same gloved hand. To paint a picture of a totally competent medical profession fighting against these crazy folks (and using a favorite subliminal attack by dropping in the term ‘feminists’) is also completely irresponsible. So let’s tone the rhetoric down.

    Before going forward I want to acknowledge that my child was born in a birth center under the care of CNMs; I support that birth environment given the right circumstances. But I would be remiss in not pointing out a few things Dr. Amy states in a very qualitative manner that I feel requires a more measured, quantitative consideration (I’m also an engineer and don’t tolerate such analysis from my colleagues). She accuses homebirthers of trying to smear the modern medical profession, but she spent her time doing a pretty nice (though vague) hatchet job in the other direction. First, she claims 99.5% of mothers give birth in hospitals, and 0.5% are home birthers. Where are people who use birth centers, the ‘oops, we gave birth in the car’ people, etc… in this configuration? Surely you need to cite some #s better since some info is missing. Plus there is undoubtedly multiple socio-economic factors going on here. Yes, relatively well off white women are one population interested in home birth. But what about the poorest? At our birth center we saw two populations there; upper class white women and very poor, typically immigrant, women since the birth center was cheaper than the hospital. Surely similar skewing can be expected in the home birth scene. How do the mortality statistics skew with socio-economic status?

    Dr. Amy also cites a different statistic from infant mortality (perinatal mortality) and says the US has ‘one of the lowest levels of perinatal mortality in the world’ but that just sounds like political double talk. How do we actually compare to the rest of the industrialized world? Are we best? If not, who is and why?

    And it is important to acknowledge that there is a lot of financial interest both ways. Sure, doulas and midwives make money from the business of being born. But they’re not typically the ones I see driving BMWs. What happens if all of a sudden 10% of women in the US decide they want home births? Hospitals and insurance companies, and doctors lose big. Everyone has vested interests and calling one side out without acknowledging the equally vested interest of the medical establishment is just irresponsible.

    I think it is important to realize there are scales of gray in all these arguments. All doctors are not good or bad; same with midwives, doulas, and those who want home births. This country has a lot of issues interlinked with multiple socio-economic factors and desires for empowerment; to not acknowledge and explore them is the irresponsible thing. Nothing is so cut and dry as Dr. Amy wants to make us think. Doulas and midwives can be amazing, thoughtful, wonderful people committed to providing the best possible birth environment. Medical doctors can kill people because they’re overworked, poorly trained, badly supervised, or just bad at their job. And vice versa. I think it is important to actually read what this post was about and to not just jump in with knee-jerk, inflammatory rhetoric that totally obscures what should be a rational discussion.

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11. 11. ejwillingham 1:23 am 08/25/2011

    From Amy Tuteur: “Most homebirth advocates are anti-vaccination and they suffer from the same lack of knowledge of basic science, statistics and logical reasoning.”

    I am not part of that “overlap,” as my methodical work countering anti-vax nonsense attests (e.g., http://daisymayfattypants.blogspot.com/search/label/vaccines and http://blog.pkids.org/authors/). This very stereotyping can only hinder any progress you may allegedly hope to make in convincing people not to opt for homebirth, which I assume is your goal.

    Nor do I lack knowledge of basic science, statistics, or logical reasoning, as my education, published research, and writing attest. What I do have, however, is an almost visceral negative reaction to the haughty attitudes some in the medical–and specifically gynecological–profession have about women who give homebirth even a bare consideration and the dismissive response to the spectrum of reasons women may have for choosing or considering it. It’s so easy to bash people condescendingly over the head with one’s superior knowledge (couldn’t we all sit around and do that about our fields of expertise?), and it’s even easier to preach to an adoring choir in an echo chamber. What’s more difficult is modulating one’s writing and other communications to really reach beyond that choir. If you’re not trying to do that, then you’re simply talking to hear your own voice. I’ve learned that over the years as I’ve worked to promote vaccination as a rational decision for parents. What is the purpose of writing any of what we write if not to reach people who are uneducated about it? If you think your target audience–I am, of course, still assuming that you have beneficence in mind here–if you think they lack the knowledge you have about statistics, basic science, or logical reasoning, why are you not able to find a way to impart that knowledge to them in a way that they might understand without insulting them in the process?

    If you’re not modulating your condescension toward and disdain for the very population you seek to serve (right? that’s the goal?), then you’re certainly not making any genuine effort at reaching people who might be on the decision-making fence, many of whom find themselves there precisely because of the condescension they’ve faced from practitioners of the medical profession. There is an obvious middle ground here for women, one that people with voices of power could help achieve were they to use those voices for something beyond displaying their alleged superiority and indulging in comfortable stereotyping.

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12. 12. Anony 1:33 am 08/25/2011

    One last thought I forgot to mention. The perinatal mortality statistic (from 28 weeks pregnancy to 28 days post birth) happens to capture a large range (28 to 38 weeks gestation) where hospitals are incredibly good environments to give births and where home births are not a good option. Probably not a good metric in the context of comparisons to responsible home births or those with midwives in birth centers (which have very narrow windows – ~38 – 42wks gestation). How about statistics for only pregnancies that make it to 38 to 42 weeks gestation so the comparison is getting closer to apples to apples?

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13. 13. AmyTuteurMD 1:50 am 08/25/2011

    The perinatal mortality rate is stillbirths from 28 weeks of pregnancy through term pregnancy, labor and birth + neonatal deaths from birth to 28 days. It does not mean premature babies plus term babies.

    It is more accurate than infant mortality for two reasons. First, it does not include deaths from 1 month to 1 year, such as those due to accidents, SIDS, etc. Second, it does include deaths during labor, and stillbirths that occur as a results of not responding in a timely fashion to pregnancy complications.

    According to The World Health Organization, perinatal mortality is the best measure of obstetric care.

    As to why the US does not have the best perinatal mortality rate in the world, it is important to be aware that African descent is a risk factor for perinatal mortality independent of income. The countries that have better perinatal mortality rates than our are the “whitest” countries in the world.

    The take home message is this: assessing the quality of obstetric care requires understanding the different types of statistics available, the suitability of each type of statistic as a measure of obstetric care, and the risk factors that differ among populations.

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14. 14. nthmost 3:43 am 08/25/2011

    AmyTuteurMD, your own article shows better perinatal outcomes for births attended by CNMs than by MDs.

    http://www.sciencebasedmedicine.org/index.php/the-tragic-death-toll-of-homebirth/

    The conclusion to draw from this is that homebirths shouldn’t be attended by amateurs. Or perhaps that doctors shouldn’t be delivering babies at all, with their shoddier record and all.

    You can counter this by saying, “well, doctors see all kinds of births, not just the low-risk ones attended by CNMs”. But then you’d be admitting that the entire issue of birth outcomes is context-specific.

    Anyway, for a low-risk pregnancy, the issue of survival rate of mother and child totally misses the point. The question becomes one of quality of birth experience and related metrics.

    For example, the rate of Caesarean section for routine vaginal birth goes way up for hospital births.

    Why does it matter how the birth happens, as long as mother and baby are alive and well at the end of it? Because, seemingly contrary to the belief of most doctors, I think it’s appropriate to ask the question, “HOW well?”

    A C-section is major surgery. An episiotomy is a hard wound to heal. Higher rates of postpartum depression are associated with C-sections, possibly due to lower rates of oxytocin release than for vaginal delivery.

    Also, it’s hard enough to establish a proper breastfeeding relationship without also trying to heal from major abdominal surgery and/or a perineal knife wound — particularly in the US where women are expected to go back to work 6 weeks after giving birth (or less).

    My research revealed that doing a home birth would probably result in higher quality-of-life along every postpartum metric. And (anecdotally speaking) I was right.

    Oh, and in case it wasn’t implicit in my earlier comment, I’m a homebirth advocate who is also staunchly pro-vaccination.

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15. 15. ejwillingham 9:32 am 08/25/2011

    “The take home message is this: assessing the quality of obstetric care requires understanding the different types of statistics available, the suitability of each type of statistic as a measure of obstetric care, and the risk factors that differ among populations.”

    What is required to provide quality obstetric care?

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16. 16. kclancy 9:52 am 08/25/2011

    “The perinatal mortality statistic (from 28 weeks pregnancy to 28 days post birth) happens to capture a large range (28 to 38 weeks gestation) where hospitals are incredibly good environments to give births and where home births are not a good option. Probably not a good metric in the context of comparisons to responsible home births or those with midwives in birth centers (which have very narrow windows – ~38 – 42wks gestation).”

    This.

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17. 17. Drug Monkey 10:11 am 08/25/2011

    Not “this” kclancy. Funny how when the going gets tough, statistically, for home birth you start conveniently narrowing your definition of what “homebirth” you are willing to include yet you focus on the worst case scenario for hospital birthing.

    It is intellectually dishonest to ignore the full sweep and influence of the home birth movement. Serious goalpost moving behavior to always insist the only thing worth discussing is the hospital-mimic socalled birthing center across te street from a real hospital that only takes near guaranteed safe cases.

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18. 18. kclancy 10:33 am 08/25/2011

    Brother Drug, I am trying to parse out the fact that there are plenty of people who do their best to understand the science behind pregnancy, labor and birth, and then to make intelligent, evidence-based decisions about where to do it. That they are not all about woo. That means that those of us who are interested in understanding when interventions are good and when they aren’t, WOULD want to tightly define those births safe enough for a home birth or a birth center birth. It would be stupid to try and give birth to a baby at home before 38 weeks; it would be taking an unnecessary risk. This is why I take issue with Dr. Tuteur trying to change the metrics for evaluating infant mortality to include those births that it would never, ever make sense to have at home or in a birth center.

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19. 19. AmyTuteurMD 10:34 am 08/25/2011

    “This.”

    No, it can’t be “this” because she’s wrong about the definition of perinatal mortality. Deaths from 28-38 weeks does NOT refer to deaths of premature babies, it refers to death in utero (stillbirths).

    The high death rate at the hands of homebirth midwives includes an unusually high stillbirth rate because homebirth midwives encourage women to ignore recommendations for induction to deliver the baby early and prevent death from causes such as postdates pregnancy.

    Please, please, please, before you start writing about homebirth, at least familiarize yourself with the definitions of terms.

    I understand that homebirth advocates have made a great effort to confound various types of mortality statistics, and therefore many people are confused, but it is impossible to discuss homebirth unless you know the meaning of the terms you are using.

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20. 20. Drug Monkey 10:55 am 08/25/2011

    You say evidence based decision, I say confirmation bias, kclancy.

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21. 21. Unbeliever 11:57 am 08/25/2011

    I’m a man, and other people make decisions about my body all the time too.

    They tell me to wear a seat belt if I drive. It seems that their interest in me not getting injured or killed is greater than my own.

    They tell me I cannot use certain drugs, under penalty of imprisonment. It seems that me obtaining pleasure from using certain substances is repellant to them. Sinful even.

    They tell me I’d better report to the recruitment office should I be drafted. This is something no woman need worry about.

    Should I go into my backyard and urinate, and my neighbor sees me, I’m going to be arrested and fined.
    My body, my yard… my bad, apparently.

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22. 22. Unbeliever 12:03 pm 08/25/2011

    A woman giving birth at home is being the ultimate feminist.
    She is doing something she’s designed for, under circumstances controlled by herself.
    She’s surrounded by trusted family and friends.
    Typically, she’ll feed her infant with her own milk direct from her own mammary glands.
    A woman behaving as such is behaving as any normal female mammal – designed by Nature to be impregnated, give birth and lactate nourishing milk to her offspring.

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23. 23. ejwillingham 12:10 pm 08/25/2011

    “The high death rate at the hands of homebirth midwives includes an unusually high stillbirth rate because homebirth midwives encourage women to ignore recommendations for induction to deliver the baby early and prevent death from causes such as postdates pregnancy.”

    I had two midwives…both CNMs…refer me immediately to the backup OB when my blood pressure went to 145/90 in the third trimester of my first and third full-term pregnancies. They offered no other option. All three midwives I have had have stated from the beginning that they would not deliver past 42 weeks or before 38 weeks if a home birth were the goal. I’ve never had a midwife “encourage” anything like what is described above. The “very narrow windows” described by other commenters are also legal windows where our midwives practiced.

    Urinating the backyard and the consequences thereof are not comparable to pregnancy or childbirth. What an odd example.

    “It is intellectually dishonest to ignore the full sweep and influence of the home birth movement.”
    One of the consequences of that movement is the hospital environment in which we had our third child. It is intellectually dishonest to ignore the influence of women’s demands for an appropriate and respectful birthing environment on the development of these much-improved circumstances, which include rooms that accommodate both L&D and recovery for the mother, baby, and family.

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24. 24. Unbeliever 12:17 pm 08/25/2011

    Women performing as nature intended do not need complex man-built industries, infrastructure developed over centuries as those desiring to assume traditional male roles.

    Natural females do not require that men be psychologically imprinted and brainwashed by others employing bizarre and unproven ideas and methods in order to cause men to treat women as men.

    Complex cultures do fail. There’s no rational reason to expect ours is immune from failure and regression.
    Who do you suppose will perform best after such a fall?

    I’ll make a wild stab and guess it would be those who can hunt, use their hands to build stuff, give birth and raise children.
    I’m pretty sure it won’t be men who act like girls and women who refuse to give birth at home.

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25. 25. mgmcewen 12:17 pm 08/25/2011

    For a skeptical scientific woman it can be a hard choice to make. Home birth has some statistical risks, but hospitals have been very slow to embrace the latest science on birth. For example, scientists have concluded that it’s best for women to give birth in an upright position and to have uninterrupted contact with the baby after birth, but hospitals continue to reject these practices. I would honestly prefer to be in a hospital and be guided by doctors that make decisions based on science rather than whether or not things are “feminist” or “natural,” but I also would prefer to go to a hospital where they embrace the latest in biology. It seems like they don’t exist.

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26. 26. kclancy 12:19 pm 08/25/2011

    Just remember folks, that when you are commenting on my blog it’s like having a conversation with me while sitting on my living room couch. Which means, disagree all you want, but don’t pee on the furniture.

    And again, Dr. Tuteur, I wish you would actually engage with the home birth advocates, and just lowered intervention advocates, who are effectively in my living room trying to talk to you. Because you keep ignoring what they are saying, and claiming that the home birth movement does not include them, that it is only a woo, flower essence, be empowerful in your femininity at all costs movement. These woman are describing experiences with their midwives that directly contradict what you claim ALL midwives do.

    I’d also like to understand why the perinatal stats are calculated the way you say they are. So what stats, then, include deaths that aren’t stillborn from 28-38 weeks? And again, given that the midwives I know would never, EVER allow a woman to give birth at home if the baby were anything but 38-42 weeks, how can you continue to make such vast assumptions about that profession?

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27. 27. kclancy 12:21 pm 08/25/2011

    mgmcewen, you are describing exactly the rock and hard place many women feel they are in.

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28. 28. Unbeliever 12:21 pm 08/25/2011

    So-called Feminists are totally dependent on a complex, centuries developed infrastructure built by Men.

    As Camille Paglia said, had human culture been matriarchal from the start, we’d all be living in grass huts.

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29. 29. Anony 12:22 pm 08/25/2011

    Apparently many of us have forgotten what this post was all about. It is about understanding context. Lets keep this in mind and I think we all will have a more civil and intellectually honest argument. Dr. Amy – it is intellectually dishonest to group together wide ranges of people/conditions to make a sweeping generalization to support an inflammatory point. As an apples-to-oranges analogy, Dr. Clancy was trying to make a nuanced point about differences in types of apples and you start yelling ‘Oranges are evil!’ This post was not to decide whether people interest in home birth should burn in hell. It was to try to unpack the multiple, interrelated variables that may contribute to different people making different decisions about the birth of their child. If you really just want to rant and rave, then do it in front of a mirror because I’m certain that will makes you happy.

    Unbeliever – you almost have the right analogy, but here is what is closer to what is going on here: People tell you to wear a bike helmet when you’re biking, but then yell ‘YOU’RE A HORRIBLE, IRRESPONSIBLE, REPREHENSIBLE PERSON’ at you when you ride by without one. That’s a bit closer to the tenor of the argument going on around home birth.

    The sooner people stop being inflammatory the better we’ll all be doing.

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30. 30. Unbeliever 12:23 pm 08/25/2011

    A natural woman is not “between a rock and a hard place”.
    Only women who are influenced by Feminism find themselves there.

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31. 31. Qaoileann 12:39 pm 08/25/2011

    There seems to be a few commenters who are talking about different ideas of what kind of ‘homebirth’ we’re talking about. Homebirth in the USA only, with the different degrees of regulations and professionalism required? Homebirth in the UK, which is integrated into the NHS? Homebirth historically? Homebirth in developing countries? Homebirth *in principle*?

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32. 32. AmyTuteurMD 12:40 pm 08/25/2011

    “So what stats, then, include deaths that aren’t stillborn from 28-38 weeks?”

    Infant mortality, neonatal mortality and perinatal mortality. In the US, all of these metrics include premature babies who are born alive but subsequently die.

    Interestingly, in some countries like The Netherlands, the government tries to make mortality statistics look better by classifying live born early premature infants as stillborns so they won’t have to include them in their mortality statistics. That’s why The WHO considers perinatal mortality the most accurate measure of obstetric care. Since it includes stillbirths is prevents countries from artificially improving infant and neonatal mortality rates by pretending that premature babies who die after birth were born dead even though they were born alive.

    “These women are describing experiences with their midwives that directly contradict what you claim ALL midwives do.”

    That’s what’s known as the “fallacy of the lonely fact.” You know as well as I do that if you want to rebut an assertion about scientific evidence, you need to provide different scientific evidence, not anecdotes.

    If we are speaking honestly, as if we were in your living room, I will tell you that you and those who are supplying anecdotes have no idea of the depth and breadth of the lies propagated by homebirth midwives. I know that you said that you don’t want to discuss the scientific evidence, but it is impossible to discuss homebirth without discussing the scientific evidence, and most of what homebirth advocates think is “scientific evidence” if flat out false.

    For example, the author of comment 25 claims “scientists have concluded” that it is best for women for women to give birth in the upright position. Scientists have concluded no such thing. There is no scientific evidence that position has anything to do with the rate of C-sections, operative deliveries or the length of labor. NCB advocates have simply lied and claimed that what they believe (that upright labor is better) is supported by scientific evidence.

    Homebirth midwifery in the US is a form of quackery. It is about a bunch of women who didn’t even bother to go to college awarding themselves a phony degree and charging women to “attend” them in labor.

    The Midwives Alliance of North America, the organization that represents homebirth midwives is HIDING their own death rates. Even MANA knows that homebirth leads to an appallingly high number of preventable neonatal deaths. They just don’t want you to find out.

    You know and I know that if their statistics were good, they’d be shouting them from the rooftops. The fact that they spent hundreds of thousands of dollars to collect, collate and analyze those statistics for the publicly stated purpose of “proving” that homebirth is safe and then refused to release the death rates is a massive red flag.

    Call them up. Ask them how many of those 23,000 babies in their database died at the hands of a homebirth midwife. They won’t tell you. If they won’t disclose that, how can you believe anything they say about the safety of homebirth?

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33. 33. Qaoileann 12:50 pm 08/25/2011

    Also, demonising people who make what you perceive to be bad choices is rarely the best way to change their minds.

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34. 34. mgmcewen 1:06 pm 08/25/2011

    Wow, Amy, you seem incredibly narrow-minded. A simple search on Google Scholar shows many peer-reviewed studies showing an upright position is best, such as “Women’s position during labour: influence on maternal and neonatal outcome” and “Randomised trial comparing the upright and supine positions for the second stage of labour” . I have trouble taking you seriously because you seem more interested in condemning than looking at science.

    On a more practical note, does anyone know anything about birthing centers? Could they represent a “middle way?”

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35. 35. mgmcewen 1:12 pm 08/25/2011

    “The ability to move and change positions during labor has been known for centuries to help facilitate labor progress and decrease pain (Atwood, 1976; Engelmann, 1977; Johnson, Johnson, & Gupta, 1991). Because of routine use of technology, women today are often confined to bed from a very early point in the labor process, thus decreasing the baby’s ability to flex, engage into the pelvis, find the best fit, rotate, and descend.

    Fenwick and Simkin (1987) discussed six physiological mechanisms that are important to facilitating labor progress and preventing dystocia, through the use of walking, sitting, kneeling, leaning, and squatting. However, in the Listening to Mothers II survey, 76% of women reported being unable to walk after admission to the hospital (Declercq et al., 2006).

    It has been suggested that the maternal immobility that results after epidural administration may contribute to midpelvic arrest and failure to descend, with the resulting need for either forceps, vacuum extraction, or cesarean delivery (Fenwick & Simkin, 1987). However, a Cochrane Collaborative review of 21 studies (Anim-Somuah, Smyth, & Howell, 2007) found that although epidural anesthesia resulted in an increased risk of instrumental delivery, it had no significant impact on the risk of cesarean delivery. Because epidural anesthesia is used for the majority of women today, it is important that movement (in a rocking chair, on a birthing ball, or with ambulation or slow dancing) be encouraged prior to its administration and that the mother’s position be changed in the birthing bed at regular intervals after administration (Simkin & Ancheta, 2005).” (Zwelling, E. (2008), The Emergence of High-Tech Birthing. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37: 85–93. doi: 10.1111/j.1552-6909.2007.00211.x)

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36. 36. AmyTuteurMD 1:15 pm 08/25/2011

    mgmcewen,

    A Google search is NOT a review of the scientific literature.

    In order to know what a study says and whether it is valid, you have to read the whole study, not just the abstract, and you must analyze the data. When you do that, you will find that those studies LOOK at whether position affects labor, but the data does NOT support the conclusion that position affects labor.

    One of the things that homebirth advocates do, in an attempt to mislead lay people, is give citations to scientific studies and imply that the studies support homebirth claims. They rely on the fact that no one will read the actual study or have the statistical background to analyze the claims. It impresses lay people, but it is no way proof of anything.

    Please read the actual studies and get back to me. I’ll be happy to analyze them with you.

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37. 37. Anony 1:18 pm 08/25/2011

    Dr. Amy – here’s the interesting thing about even lonely facts. It is all about perspective. When you make a sweeping generalization about a topic and someone provides even anecdotal evidence that refutes your point, you’re right that it doesn’t make their perspective scientific fact. It does, however, make your statement of absolute fact wrong. You can’t then turn around and *just* say their point isn’t science because they don’t have data with statistics. You have to also say, ‘Woops, my bad. Perhaps things are more complicated then I wished everyone to believe in my statement too.’

    You seemed to have lost perspective on what people are actually saying here. No one is arguing to dive pell-mell into only home births, but your arguments are all set up to rail against some evil, nebulous force that will convert us all to unthinking robots. The whole point is that the shades of gray that exist in this problem are important to understand.

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38. 38. mgmcewen 1:37 pm 08/25/2011

    Dr. Amy, I read the actual studies and quoted directly from the fulltext one of them. What more do you ask for? I am certainly no advocate of homebirth. Every article I’ve read has come to the conclusion that movement is important during birth and women should be allowed to chose their own position.

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39. 39. The Dude 1:55 pm 08/25/2011

    It took 130 stitches to sew up my wife after our unexpectedly big-headed daughter was born. The cord was around her neck and her heart rate was fluctuating greatly. After unsuccessful suction (which made her look like Marge Simpson), the department head yanked the baby out with a violence that I had never seen before, while I used all my strength to hold my wife in place. He told the resident that he was supervising that it would be the hardest extraction of his career. Fortunately my wife had an epidural so that she didn’t have to experience the pain. The puddle of blood on the floor covered about 10 square feet. This happened 13 years ago.

    The odds of all these things happening at the same time are very low. But at the time that I was born any one of these circumstances may have killed both mother and daughter. For anyone to label homebirth as “feminist” means that they are putting their own needs higher than the baby’s. For anyone to risk the life of their baby, no matter how low the odds are, is narcicistic at best, criminal at worst.

    In addition, anyone who says that parenting is hard is also putting their own needs higher than the child’s. It is always easy to make the right parenting/birthing decisions when you take yourself out of the equation and think only of the child’s best interest.

    And thank you, Dr. Clancy. It is outstanding to see the author of an article have so much interaction with the readers. And your article has prompted a very informative discussion.

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40. 40. mgmcewen 1:59 pm 08/25/2011

    Nevertheless, neither I nor Dr. Clancy seem to be advocating for homebirth. I think we are both interested in what drives women to seek homebirth. Is it ideology? Perhaps, but there also seem to be economic factors in place. Hospitals are businesses and they are obviously not appealing to certain women. We should think about whether some of the factors that make hospitals unappealing at legitimate or not. And why hospitals are reluctant to offer these services. That said, hospitals vary and women shouldn’t be reluctant to shop around.

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41. 41. The Dude 2:03 pm 08/25/2011

    I might add that an easy and complication-free birth can happen in the forest, in a taxi, or at home. Complications during birth are really what this discussion is all about. Unless all the risks can be eliminated, the hospital is the best place.

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42. 42. jgrosay 2:24 pm 08/25/2011

    Some deliveries have problems, and some delivery-related problems cannot be diagnosed or even suspected until delivery begins. A home environment lacks the means and trained personnel an hospital has, and thus the rate of complications can be expected to be higher at home than at the hospital. Home delivery poses a higher risk for both woman and child, and although one may discuss if a woman has a right to risk her own health or even her own life, for sure she hasn’t at all a right to expose the baby to potentially life-long diseases, disabilities or even death. Voluntary home delivery must be actively banned and prosecuted

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43. 43. jgrosay 2:26 pm 08/25/2011

    Other unsafe at all speeds delivery way is pool delivery, or underwater delivery. Just one case of drowning will justify banning it, but it seems that there have been several cases of baby drowning connected to pool or underwater delivery. Run away from this !

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44. 44. kclancy 2:42 pm 08/25/2011

    I really appreciate when folks try to address the crux of this particular post — the nuances of those who make different decisions about where to labor and birth, the politics, and the trade-offs.

    And The Dude, thanks for your kind words. I do think it’s possible to disagree and be civil, to try to tackle one specific aspect of this issue (around why women make home birth decisions), and to avoid being condescending. I think a lot of commenters are working hard to exemplify this.

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45. 45. The Dude 5:26 pm 08/25/2011

    Exactly right jgrosay. My wife had a completely normal pregnancy and did all the right things. Issues started to arise only when she was almost totally dilated. Without the doctors, nurses and equipment present, I am sure there would have been a tragedy.

    On the issue of financial interest of the hospital, in big cities many get care through an HMO, which has an interest in lessening care.

    On the issue of constant contact between mother and child, I might add that I spoke to the baby many times every day while she was in the womb. I used a very low and deep voice, not the baby talk that parents seem compelled to use. While the ordeal was going on, I spoke to my wife’s belly. The birth was also very traumatic for my daughter. As soon as I was sure that my wife would be ok, I went to my daughter and spoke in that deep voice and it quieted her immediately. She knew me. The nurses were amazed. So I do know about the importance of close contact, before, during and immediately after birth. This is an issue that hospitals should always address, and that parents should be assertive of.

    Her first word wasn’t “dada” or “mama”…it was “Dude”. Hence, my nickname. She called me Dude until she went to school and thought that other kids wouldn’t know that I was her real Dad.

    I think that an important point is that homebirth has nothing to do with a close connection between parent and child. The connection can be created even before birth.

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46. 46. ejwillingham 6:02 pm 08/25/2011

    “Homebirth midwifery in the US is a form of quackery. It is about a bunch of women who didn’t even bother to go to college awarding themselves a phony degree and charging women to “attend” them in labor.”

    My midwives all had RN degrees for which, I’m pretty sure, they had to attend college. *All* of the midwives in our area of which I was aware had nursing degrees. That is not a “lonely fact.” It was a universal consistent factor in our not inconsiderable metropolitan area.

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47. 47. DirtyOldTown 6:59 pm 08/25/2011

    Dr. Clancy, I think it’s disingenuous to start this post with: “I don’t necessarily advocate home birth. I advocate better information about the impact of hospital interventions on maternal and infant morbidity and mortality, their impact on breastfeeding success, and their impact on maternal-infant bonding and postpartum depression” and then back out with “I’m happy to debate the evidence-based reasons another time,” leaving commenters unable to challenge your veiled implications that hospital interventions have a negative impact on these things.

    Also, I find the line “I also think it’s important to question the motivations of hospitals, who have a lot of money at stake were women to start choosing birth centers or home births at a higher rate” very telling of your own personal biases in this area. Do midwives work for free? Do lactation consultants and doulas have no financial stake in the choices women make?

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48. 48. AmyTuteurMD 7:37 pm 08/25/2011

    “My midwives all had RN degrees for which, I’m pretty sure, they had to attend college”.”

    Those are certified nurse midwives and only a tiny fraction of them do homebirths.

    The vast majority of homebirths are attended by homebirth midwives, known as direct entry midwives, lay midwives, certified professional midwives (CPM, any confusion with CNM is intentional) or licensed midwife (LM).

    These midwives do not have nursing degrees and most do not have college degrees. In some states, like Oregon, you can call yourself a midwife even if you have no degree, no credentials, no experience, AND, by state law, you cannot be prosecuted for it.

    Homebirth advocates like to sow confusion and the biggest source of confusion is that they are not the same as certified nurse midwives and they are not the same as midwives in Europe, Canada or Australia. They have less education and training than ANY midwives in the industrialized world. Some have no education or training at all.

    There are thousands of certified nurse midwives in the US working in hospitals, birth centers and some at home. Homebirth midwives are something else entirely.

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49. 49. ejwillingham 9:23 pm 08/25/2011

    If there are “thousands of CNMs in the US working in hospitals, birth centers and some at home,” –some at home–then…evidently, sweeping indictments of all homebirth-attending midwives as untrained charlatans are a little overboard. You cite Oregon, which is notoriously lax. What are the laws in other states?

    “Homebirth advocates like to sow confusion, and the biggest source of confusion is that they are not the same as CNMs…”–but in my cases, all of them, they were, so there wasn’t any confusion sown. By the way, I’d hazard that in spite of the low opinion you seem to harbor for the target population of your profession, many women are fully capable of telling the difference between CNM and CPM and understanding what they mean.

    Of course, none of this addresses the actual point of the original post, which was not about whether or not women can understand the facts surrounding homebirth but the factors that drive women to consider or choose homebirth in the first place. I asked a related question in an earlier comment to which I have not received an answer: “What is required to provide quality obstetric care?” I do not see much discussion here at all about the factors that create this divide or any attempt at bridging it.

    If women were robots, perhaps one could enter a slew of facts into their decision-making machinery and have the presumably desired decision emerge. However, women are not robots. Obviously, it takes more than a fact hammer to provide quality obstetric care. So, what factors constitute quality obstetric care–outside of adherence to clinical guidelines? If homebirth is so outre, so dangerous, so undesirable, what can OBs and hospitals/the medical industry bring to the table that will lead women toward them and away from birthing at home?

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50. 50. nthmost 4:17 pm 08/26/2011

    As ejwillingham just pointed out, the conversation hasn’t been directed at the real issue:

    “what factors constitute quality obstetric care–outside of adherence to clinical guidelines? If homebirth is so outre, so dangerous, so undesirable, what can OBs and hospitals/the medical industry bring to the table that will lead women toward them and away from birthing at home?”

    Indeed.

    My decision to do a homebirth was, like for so many others, based on my evaluation of the medical system turning women into “patients”, which creates a cultural context in which mothers are *waiting* (pun intended) for doctors and nurses to deliver their babies FOR them.

    The birth stories I heard and continued to hear from my friends and acquaintances who planned to go to the hospital were mostly something like this:

    “Yeah, I wanted to do an all-natural birth if I COULD. But at [some point, different for all of them], they recommended an epidural and I was ready for it.”

    To my mind, that narrative arises from a cultural context in which:

    * women aren’t taking themselves seriously, because
    * doctors and nurses aren’t taking women seriously, and
    * no one EXPECTS a natural birth to take place.

    It seems to take a truly mule-headed sort of personality with single-minded devotion to the idea of natural birth to arrive in hospital for labor and go through the gauntlet of medical culture to come out having done a fully natural birth.

    Does it seem right that the only women who CAN deliver naturally are, by some strange evolutionary coincidence, extremely stubborn and single-minded? (On the contrary, really: it’s women who are relaxed and flexible who have the easiest time delivering naturally.)

    To get back on track:

    If homebirth is to be eschewed due to unacceptable risk, then we need to create a medical environment that sees natural birth as default, as EXPECTED, rather than to be “tried” and scrapped upon the slightest note of difficulty. Because it seems to be the unnecessary interventions (e.g. pitocin, leading to too-fast labor, leading to epidural and/or episiotomy) that cascade into a host of totally avoidable complications after the baby is born.

    (When you’ve got pitocin, every problem looks like a “failure to progress”…?)

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51. 51. da bahstid 1:25 pm 08/27/2011

    Given that human birth has happened for tens of thousands of years without the supervision of trained professionals, it shouldn’t be too much a surprise that completely uneducated people can sit next to a woman giving birth and have nothing go wrong most of the time. “It’s alright, ma’am, if anything goes wrong I’ll dial 911.” The fad probably hasn’t existed long enough for the safety hazards to be exposed.

    That said, human birth is broken compared to other mammals. Our upright posture imposes very tight mechanical constraints on the morphology of the pelvis that conflict with easy childbirth, and this is only compounded by modern multi-ethnic culture where people of all sizes are coupled. Other mammals don’t have anywhere near the mortality associated with childbirth humans do, and as there’s no easy evolutionary path to reroute the human vagina out our bellies instead of through the pelvis as we’ve inherited from our mammalian precursors, we’re just kind of stuck.

    Point of all that is, there are good reasons people should continue to seek qualified medical care for childbirth. I find myself siding with Amy in this discussion, though perhaps less ferociously…i think homebirth actually SHOULD be alright, but that the people engaging in midwifery should actually be required to earn substantial qualification to practice and bill women for care. The trend for unqualified quacks to practice in settings that should require trained professionals isn’t just a problem in childbirth, but all over healthcare. The fact that childbirth may be the most dangerous among them though, perhaps reflects that women’s care is again relatively neglected by healthcare in general. If this is the case, then there is no responsible way to rationalize that “home-birthing” with sketchy witchdoctors can be associated with feminism.

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