Archive for July, 2012

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”?