Separating Evidence from Ideology in the Home Birth “Debate”

Background: Last week, Michelle Goldberg published a story on the Daily Beast, the gist of which is well captured by the headline: “Home Birth: Increasingly Popular, But Dangerous.” It relied heavily on the views of former obstetrician and blogger Amy Tuteur. I wrote a response in Slate, fitting Goldberg’s treatment into the mommy-war narrative and questioning her main source’s credibility. Goldberg volleyed back with this. Here’s my return:

First, I want to respond to Goldberg’s charge that my book, Pushed, uses the “rare” outcome “to indict all of modern obstetrics.” There are more than 4 million births a year in the U.S., roughly one-third are now by cesarean. Of course some of those surgeries are needed and most women recover, and nobody is arguing that we don’t need obstetric care. But the reason Amnesty International, March of Dimes, and now even ACOG are concerned is because that rate of major abdominal surgery is putting women’s health and lives at risk — and babies, too. Our maternal mortality rate is rising. We know a portion of preterm births are caused by scheduled inductions and repeat cesareans (and preterm birth is the most frequent cause of infant death). And a not insignificant minority of women are emotionally traumatized — one study pegged it as high as 9 percent. They have symptoms consistent with PTSD, which affects their ability to function, parent, etc.

Pushed was an indictment of a maternity system that rewards the overuse of risky medical intervention and discourages physiological support. I have been very clear in my reporting that well functioning systems incorporate both midwives as front-line providers and obstetricians providing high risk and emergency care. That is the division of labor that countries with the best outcomes employ.

So why does Goldberg accuse me of reporting “in bad faith”? This is also Tuteur’s accusation, by the way. I just peeked in on the comments section at Slate and saw these words at the top: “Jennifer Block, Melissa Cheyney and Gene Declercq all KNOW that almost all the existing scientific evidence, state, national and international data shows that homebirth increases the risk of neonatal death. …They just don’t want you to find out and if you do find out, as you did in Michelle Goldberg’s piece, they want to convince that it doesn’t matter.”

Well, I would never accuse Goldberg of trying to deceive her readers — I believe her when she says she came to “agreeing with [Tuteur] after doing my own research.” I, too, came to this topic as a curious, childless, feminist journalist. And after doing my own research, I tend to agree with the American Public Health Association, which “supports efforts to increase access to out-of-hospital maternity care services and increase the range of quality maternity care choices available to consumers.”

I’m still surprised that Goldberg is defending Tuteur as a credible source on the data. “She is by far the most prominent critic of home birth in the country, and it would be absurd to write about this controversy without citing her.” Definitely, which is why I, too, wrote about her in 2009 when I covered this debate for Babble. But as an authority on the research? In my experience, an MD is not a credential in epidemiology, or even the latest research in one’s field. If I were writing a story about the controversy in treatment of appendicitis in older people, for instance, I wouldn’t call the local surgeon for a read on the evidence base. Sure, the surgeon could talk about her sphere of experience — how her patients respond, how her practice has changed over the years, whether there’s liability pressure to treat one way or the other, etc. But for the big picture — the data on whether surgery or antibiotics are more appropriate in the elderly — I want to talk to the people who are doing big picture analysis. Those are published physician-researchers and epidemiologists. Amy Tuteur is neither.

Goldberg writes: “But Tuteur doesn’t claim to conduct independent research, and Block offers no evidence to dispute her interpretation of existing data.” I’m not sure what to call it other than independent research. Tuteur takes the raw data available on the CDC web site and state health department sites, runs her own calculations, and posts them on her blog. But it’s my understanding that we do not have reliable data gathering on home birth — those raw data include unplanned, backseat-of-the-car, EMT delivered births (which we know tend to have poorer outcomes). The raw data don’t control for fetal anomalies or fetuses that die in utero in car accidents or other deaths that are clearly independent of the intended place of birth. And, as Eugene Declercq pointed out to me, they also wouldn’t reflect home births that transported to the hospital in which the baby died. Those would be coded as hospital births.

Typically, researchers take that raw data, run their analysis, control for things like anomalies, report their methodology and conclusions, and submit for peer review. And they hardly ever work alone. That’s why publishing is so important for credibility, and why Tuteur’s rogue calculations are not worthy of citation. We agree she’s a character alright, which Goldberg writes that many activists are: “obsessed, irascible, and self-righteous. That doesn’t mean they’re wrong.” It also doesn’t mean they’re right.

How has maternity care become as politicized as abortion? Melissa Cheyney and Declercq both said that just by virtue of researching home birth, they are seen as having an agenda. Whereas, an OB who researches birth is not. “There’s this idea out there that researchers are supposed to be completely unbiased, objective,” said Cheyney. “But most social scientists are moving toward applied science. So we research a topic, and we try to move policy forward that is evidence based.”

Cheyney’s research into the rumored home-birth deaths led Oregon to change its birth certificate, so that now there’s a check box for “planned home birth.” This will enable useful data collection, which has begun. Which brings us again to Goldberg’s other source, also a private physician, not a researcher, who is sure the home-birth death rate is “outrageous.” “Without knowing the denominator, it’s impossible to make a scientific assessment,” said Cheyney. “You need to know how many planned home births are occurring versus how many poor outcomes. And that data will not be available until 2013.”

I should have identified Cheyney as not only an anthropologist but also a midwife — she got her CPM while she was doing her dissertation research on midwives because her advisor encouraged her to gain access to the hidden population she was studying (this was in a state where midwives are underground). I just learned that she became chair of the division of research for the Midwives Alliance of North America in 2010, three years after the investigation, and also now serves as chair of the board of direct entry midwifery for the state of Oregon. OSU, meanwhile, has just awarded her tenure for bringing her research to bear outside the ivory tower. “It is political when your research starts affecting change,” she said. “In my world, that’s a good thing.”

If we’re doing a public service with our reporting, separating evidence from ideology, then we’re being honest about risk on all sides. Goldberg is presenting a false choice — and again feeding into the shame-on-you-mom narrative — when she writes that women “have a right to weigh the very real risk of an unnecessary C-section against the risk of a dead baby.” The fact is, no provider can guarantee any woman a healthy baby. Very rarely they don’t make it, even in hospitals. I’ll quote the epidemiologist again: “What people don’t want to talk about is that there’s a balance of risks,” Declercq told me. “You’re facing risks in both settings. It’s a trade off…But that’s a level of understanding that we’re nowhere near.”

This research “debate” is hardly over. As we collect better data in the U.S., perhaps we’ll be able to know better how our midwives are doing, whether having a license or being a nurse makes a difference, how risky it is to plan a home birth in communities hostile to it. In the meantime, there are many studies that show where the U.S. should be headed in terms of care. There’s also the matter of rights. Don’t we as feminists want women to get through pregnancy and childbirth with the least trauma necessary? Don’t we want this conversation to be as much about healthy women as it is about “having a healthy baby”?

 

Brazilian author-activists talk “parto humanizado” over pie in Brooklyn

Luciana Benatti and husband Marcelo Min, who together published the lovely book Parto Com Amor (Portuguese for “Birth With Love” — she wrote the text, he took the photos) visited NYC this week and suggested we meet. I was thrilled to hear from them, two emissaries from the land of many C-sections — Brazil’s national rate just hit 52%, but in private hospitals it’s as high as 90%.

I suggested they get a taste of “artisanal Brooklyn” while they were here, so we met at a favorite pie shop. They ordered very respectable savory lunch items while I downed an entire slice of lemon chess.

 

Naturally, the food got us talking about “orgasmic” birth, which led to a story that suggests the universality of media gatekeepers: they had originally wanted to call the book “Birth With Pleasure,” (Prazer, I think is the word in Portuguese) but the editor balked. “Oh no, we can’t have that! Birth and pleasure? Too confusing!” mocked Benatti.

The couple are now part of a continental movement for “Parto Humanizado” — humanized childbirth.  They mark their entry into this movement in 2007, when Benatti was 36 weeks pregnant and decided to ditch her OB.  He wouldn’t reveal his C-section rate and told them, “You don’t need to concern yourselves with the birth, I’ll take care of that. You just worry about what the baby will wear.” Benatti got the name of a “humanized doctor” through a journalist friend who had written on the topic, and she had a lovely birth in the hospital. For their next baby, the doctor attended them at home.

Benatti and Min are from Sao Paulo, a “megacity” of roughly 11 million people. “I know of only four midwives, and about five humanized doctors” Benatti told me. Meanwhile, her doctor is no longer allowed to attend home births. “The physicians organization is against midwives, against water birth, against home birth,” she said. “They are so powerful. The media won’t cover this.”

Maybe I gave them some hope. I told them that ACOG is also against all those things, but they are finally acknowledging that the cesarean rate is a problem. I also told them the media can shift quite rapidly: everywhere I turn another newspaper or magazine is running a story about home water birth or doulas, whereas ten years ago editors were completely uninterested.

Benatti returned the favor with a great anecdote about the impact her book is having: a woman told her that she found Parto Com Amor at the last possible moment in her pregnancy. She was past her due date and her doctor was pressuring her to have a cesarean. Upset and unsure of what to do, the woman went to a shopping mall to calm down, walked into a bookstore, found the rose-colored book, and sat down. “She read the whole thing in one sitting,” said Benatti, “and started having contractions.” She gave birth, naturally, that afternoon.

Maternal Health Care Crisis by the Numbers

Amnesty International shines a light on U.S. maternity care

GPS for L&D?

Where in the world is the baby?Some intriguing promotional materials arrived this week for a device called LaborPro, which combines global positioning technology (GPS) with ultrasound to help childbirth care providers, er, better pinpoint the baby’s global position (?) and how much the woman’s cervix has dilated. (Is there a pleasant-sounding female voice directing the baby, “At the pelvic outlet, go straight, then twist right”?? Or does the GPS talk to the doctor?)

I asked around to see if any hospitals had been seduced into purchasing this latest high-tech (and likely inferior, if history is any guide) substitute for skilled hands and brains, and so far haven’t found one. But I did learn that the device was unveiled at this year’s ACOG conference, and the manufacturer’s web site notes that, “LaborPro automatically displays and stores all labor progression parameters, as well as FHR [fetal heart rate] and uterine contractions. This data can be used as a decision support tool, and is also archived for offline review.” In plain English, this means that the data can be used in court, which means this labor Garmin is poised to be yet another agent of defensive medicine.

Quebec’s Creepy Post-Birth Vaginal Inspection Policy

Heather Mattingsly “will not have to show her vagina to anyone to prove the 5-month-old infant is hers,” begins the Montreal Gazette’s story about one of the most creepy, abusive, nonsensical policies a new mother could imagine:  Quebec’s new requirement that women who give birth without a doctor or licensed midwife have to submit to a vaginal examination to “prove the biological link between mother and child” in order to get a birth certificate. After a barrage of calls from the media, the director of the vital records agency called Mattingsly personally and told her she could pass on the exam.

But the requirement apparently still stands for other women who give birth with unlicensed midwives at home, which some do because the provincial health system doesn’t employ enough midwives to meet demand — women who want a midwife only have a 1 in 5 chance of having one attend their birth. That’s quite a punishment/deterrence policy for going outside the system. One wonders what (or who) prompted the change. Women’s rights groups are calling it “another abuse of women’s bodies” and want the policy reversed.

Twitter Phenom “Feminist Hulk” Revealed, Had Home Birth!

Congratulations to Jessica Lawson, the brains behind Twitter superhero “Feminist Hulk.” (Sample tweet, in all CAPS, natch: “HULK APPROACH SMASHING PATRIARCHY LIKE JUDITH BUTLER APPROACH WRITING SENTENCES: AS LONG AS IT TAKES TO GET JOB DONE!”) Lawson revealed Hulk’s alterego in a Q&A  with the Ms. blog: she is a 28-year-old English Lit PhD candidate at the University of Iowa, a supporter of midwives, and a new mom!

Ms. asked: “Why did you decide to have a home birth? What were some of the challenges you faced in making that happen?”

Lawson answered:

While I value the ways that obstetrical science has made birth safer for women with high-risk pregnancies, mine was a low-risk pregnancy and I was compelled by the many studies that show the midwifery model of care is as safe as hospital birth, often with fewer interventions and post-birth complications. Unfortunately, though Certified Nurse-Midwives legally practice in all 50 states, I gave birth in one of the handful of states which still does not license Certified Professional Midwives. I am active in attempts to push midwifery licensure through our state legislature. I still chose home birth, though, and am so lucky to have labored in an environment that made me feel relaxed and safe, with a birth team that gave me tons of love and support. And for anyone who asks, “What if something goes wrong?” all I have to say is, “Something did go wrong.” I suffered a postpartum hemorrhage and lost about a quart of blood. My birth team responded with speed and skill to stop the bleeding (and they would have transferred me to a hospital without hesitation if they encountered a complication that required additional resources). I owe them my life, and I have nothing but faith in the quality of their care.

Home Births On the Rise

The Feminist Breeder with her home-born babe

It’s official: more women are planning home births attended by midwives — 20% more — according to the Centers for Disease Control and Prevention. “One mother chose home birth because it was cheaper than going to a hospital. Another gave birth at home because she has multiple sclerosis and feared unnecessary medical intervention. And some choose home births after cesarean sections with their first babies,” reports the Associated Press. Physician groups are still opposed, but individual obstetricians are speaking out: “Dr. Joel Evans, the rare board-certified OB-GYN who supports home birth, said the medical establishment has become ‘resistant to change, resistant to dialogue, resistant to flexibility.’”

Update: Check out The Week‘s five theories for the trend, including, “Women are taking charge!”

 

Best for Babes Foundation Features PUSHED

It's You Babe!

What’s not to love about Best for Babes, fearlessly naming and shaming the “booby traps” that keep moms from breastfeeding (rather than shaming women!). “Women are being pressured to breastfeed but set up to fail” says the group. Check out their site, featuring celeb “champions for moms” like Laila Ali, Jenna Elfman, and Kelly Rutherford, and a new Q&A with yours truly about the booby trap of early elective birth.

Pregnancy-Related Heart Disease Silent Killer

courtesy Daily Beast

As we know, pregnancy-related deaths are on the rise in the U.S. for many reasons, including the rising cesarean rate, rising obesity, and more health problems in general. A new study out of California sheds light on another factor: heart disease that goes undiagnosed  and untreated: “A few days after Michelle MacDonald gave birth, she felt alarmingly short of breath—like someone was holding her head under water, then yanking it up every few seconds for her to steal a few gasps of air. But when the first-time mother complained from her hospital bed, the postpartum nurses in Fredericton, New Brunswick, were unconcerned. ‘Everyone just kind of brushed it off,’ she told The Daily Beast. ‘I think they thought I had new-mom anxiety.’” Read more at The Daily Beast.

“If Birth Matters, Midwives Matter,” says Ina May Gaskin

courtesy Guardian UK

From Time.com: “Ina May Gaskin started delivering babies in 1970 while on a hippie cross-country trip known as the caravan. She had no medical training, just a master’s degree in English and a gut feeling that women deserved kinder, gentler births. When the hundreds of caravaners settled in Tennessee on what they called the Farm, Gaskin and several other women began delivering the community’s babies at home and also opened one of the first, nonhospital birthing centers in the country. Word got around when Gaskin wrote about her successes in Spiritual Midwifery, and a movement was born.

“Today, women still travel far and wide to give birth on the Farm, and Gaskin’s methods have the respect of clinicians around the world (there is even an obstetric maneuver named after her). Now 71, she is credited with reviving what was essentially a dead profession in the U.S., inspiring scores of women to enter the field and helping found the Midwives Alliance of North America. But even while midwives attend more births in the U.S. — about 7.5% in 2008 — they’re finding it increasingly hard to get practice agreements with doctors and hospitals. In her latest book, Birth Matters: A Midwife’s Manifesta (Seven Stories, April 2011), Gaskin argues that America needs midwives more than ever.” Read my interview with Gaskin in Time.

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