Archive for February, 2008 Helps Sort Out “Delivery Debate”

Kantrowitz and WingertIn their weekly “Her Body” column, Newsweek veterans Barbara Kantrowitz and Pat Wingert break down the who-what-where of childbirth options in the U.S.: in the hospital with an obstetrician, probably in the hospital with a certified nurse midwife, or at home or in a birth center with a certified professional midwife. They call this “delivery debate” increasingly “fraught.” “Between the controversy over elective cesarean sections and the debate about home births, it can be especially confusing these days for women trying to decide how and where to have their babies — and who will help them deliver.” The piece is brief but balanced and informative.


Parsing the ACOG Statement Against “Cause Célèbre,” Home Birth

In the past, the American College of Obstetricians and Gynecologists hasn’t said much publicly about home birth, except that the group “strongly opposes” it. Evidently the buzz over Ricki Lake’s provocative birth documentary and perhaps also the new nationwide “Big Push Campaign” for certified professional midwives has prompted the OB group to make itself clear. In an unusual statement released this week, ACOG denounces the research evidence on planned, midwife-attended home birth, saying that such studies “have not been scientifically rigorous.” ACOG goes further to accuse the woman who chooses home birth of putting “herself and her baby’s health and life at unnecessary risk,” and argues that “choosing to deliver a baby at home…is to place the process of giving birth over the goal of having a healthy baby.” Health-care decisions shouldn’t be based on “what’s fashionable, trendy, or the latest cause célèbre,” cautions the group, and goes on to blame the U.S.’s record-high cesarean rate on “maternal choice” and a “rising tide” of obesity and high-risk pregnancies.

There’s a lot to unpack here. The midwives’ campaign countered yesterday with its own statement, calling out ACOG for playing the “bad mother” card. Indeed, ACOG’s statement strikes at pregnant women twice, first implying that they’re selfish for valuing the “process of giving birth,” and second for being too posh — or too fat — to push.

Let’s look at the latter accusation first: nearly 1 in 3 American babies are born by cesarean section, major abdominal surgery, up 50% over the last decade. But according to CDC epidemiologists, this has little to do with women’s health status or their choices, and more to do with what’s trendy and fashionable for providers — the effective ban on VBAC (vaginal birth after cesarean) among many practices and hospitals, for one. While ACOG dismisses the studies on home birth as lacking in scientific rigor, there is not one peer-reviewed study to suggest that a significant number of women are demanding elective cesareans.

ACOG’s argument against home birth similarly relies on an unscientific premise. “Monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center is essential because complications can arise with little or no warning even among women with low-risk pregnancies.” Certified professional midwives would agree that monitoring is essential, and numerous studies suggest that for low-risk women, they do just as good a job of it at home births. Babies are born just as safely, and their mothers gain several health benefits: 95% have normal, vaginal births — optimal for both mother and baby — without drugs to induce or speed up labor, without episiotomies, and without major surgery. ACOG admonishes women for placing “the process of giving birth over the goal of having a healthy baby,” denying that one leads to the other, not to mention the goal of having a healthy mom.

Finally, there’s a double standard lurking here: elective, medically unnecessary cesarean has been considered en vogue for some time. We know that major abdominal surgery carries with it major risks for both mother and baby, but when it comes to that cause célèbre, ACOG has vocally supported a woman’s “right to choose.”

Pushing for Midwives in ’08

Time to Push

Nevermind that you haven’t heard the candidates debating a woman’s “right to choose” where, how, and with whom she gives birth. Activists are thrusting the issue onto the political agenda anyway, from all sides of the ideological spectrum. Last week in Chicago, a nonpartisan coalition of consumer advocates launched The Big Push for Midwives campaign to license certified professional midwives in every state. Currently these trained midwives, whose competency in caring for normal birth is supported by rigorous study, cannot obtain a license in several states, which forces them to practice underground, which isn’t good for anybody.

These activists are pushing against a strong, well-funded medical lobby that has a professional interest in keeping midwives marginalized — most recently this lobby flexed its muscle in Missouri, the only state where midwifery is a felony. But the research data, as well as other countries that are caring for women and babies better than we are, show that midwives should be supporting normal labor and deliveries (the majority), while MDs should be caring for the complications, emergencies, and women with risk factors. This “division of labor” also happens to be far more cost-effective than our current system, which bleeds more cash for less care than any other in the world. The bottom line from a public health perspective: home-birth midwives should be legitimate care providers, not criminals.

Kudos to RH Reality Check for calling on reproductive rights activists to support this initiative. “Part of our responsibility as advocates for women’s health and reproductive freedom is to… support and protect the practitioners who provide out-of-hospital birth, prenatal and postpartum services,” writes Erin Wilkins. “It is a valuable and necessary option that must be protected.”