I must be losing my mind, or strangely jealous of all the fun, fun comments Rose got in her circumcision post, because I’m going to opine about one of those fraught subjects that tends to be intensely emotional and controversial. Contemplating what I would write, several times the part of my brain in which my much-ignored common sense resides would remind me that I could spare myself the potential headache and just post about something else. But it seems cowardly to have an opinion about something and decline to state it because you’re afraid people will get mad at you. So here goes…
I’m going to write about home births, and why I am totally, utterly against them.
This article in the New York Times is what set me off. It’s about Ina May Gaskin, the matriarch of the contemporary home birth movement:
Gaskin, a longtime critic of American maternity care, is perhaps the most prominent figure in the crusade to expand access to, and to legalize, midwife-assisted homebirth. Although she practices without a medical license, she is invited to speak at major teaching hospitals and conferences around the world and has been awarded an honorary doctorate from Thames Valley University in England. She is the only midwife to have an obstetric procedure named for her. The Gaskin Maneuver is used for shoulder dystocia, when a baby’s head is born but her shoulders are stuck in the birth canal. [emphasis added here, and in all subsequent passages]
As the article goes on to say, Gaskin not only has no medical license, she has no medical training. None in obstetrics, and none in pediatrics. Zero.
Unmedicated home birth is being chosen by a growing minority of women. Between 2004 and 2009, giving birth at home increased 29 percent. Most of this rise is among white women. Recent pregnancy documentaries like “Pregnant in America,” “Orgasmic Birth” and “The Business of Being Born” — all of which feature Gaskin — present hospital birth as profoundly disempowering to women.
If the only person put at risk by a home delivery in pursuit of some kind of transcendent, orgasmic experience were the mother, I wouldn’t care about this all that much. I think that people should be free to take idiotic risks with their health. But it’s not just the woman, is it? There’s also a baby. But we’ll get to that in just a bit.
Of course, comparing the Farm to hospitals is of limited value. Many hospitals deliver at least as many babies in a year as the Farm midwives have delivered in three decades. Women who give birth at the Farm are self-selected, and midwives screen them further, eliminating, for instance, women with complicated medical histories. Hospitals would undoubtedly have better outcomes if all pregnant women arrived in excellent health.
And that, right there, is the only acknowledgment in this ridiculously biased article comparing the perinatal mortality figures for hospitals and home deliveries is a fool’s errand. Hospitals don’t have the luxury of sending premature deliveries or complicated cases elsewhere to make their numbers look better. They take all comers, and deliver orders of magnitude more babies.
Nonetheless, Gaskin’s outcomes are compelling. Is it actually safer for a low-risk woman to give birth outside of the medical establishment, as Gaskin claims? In 2011, ACOG acknowledged that “the absolute risk of planned home births is low” but cited a meta-analysis of 12 home- and hospital-birth studies, called the Wax Paper, which reported a two-to-three-times-higher risk of neonatal death in home births than in hospital births. But critics have raised questions about the Wax Paper’s methodology; the study included unplanned accidental home births, for instance. Natural-birth advocates point to studies in countries where home birth and midwifery are part of mainstream medical care — in the Netherlands, 30 percent of births take place at home — which show home birth to be equally safe for the baby.
You know what else happens in the Netherlands? Midwives are required to get four years of medical training. And as Dr. Amy Tuteur (an obstetrician who blogs at The Skeptical OB) also points out in that post, for most women in the densely populated Netherlands, getting to the hospital takes about as much time as it does for specialists to assemble. From rural Tennessee, where Ina May holes up? An hour to the nearest NICU.
…The birth of Ina May’s first child had been traumatic. She was strapped down and given an episiotomy and a forceps delivery, standard hospital protocol at the time. Other women also had bad birth experiences and wanted to avoid hospitals. They passed around a Mexican midwifery manual and agreed to support one another in labor. Gaskin attended her first birth in a bus parked at Northwestern University, where Stephen Gaskin was speaking. Her main method initially was to “just be nice to the women.” After a couple of months, an obstetrician outfitted Gaskin with syringes and clamps and taught her basic emergency techniques. During the five-month trip, there was one death: Ina May’s son, born prematurely.
It is not clear how premature that infant boy was. Perhaps he was too premature to live, and would have died wherever he had been delivered. A more skeptical reading certainly makes one wonder if that dead child would have lived had he been born surrounded by medical providers competent to save him.
Lawsuits aren’t an issue in Gaskin’s world. Her midwifery clinic has never purchased malpractice insurance or been sued. For years, when the commune was a true collective, she did not even accept payment for attending births. Farm midwives give intimate intensive prenatal care and have a high degree of trust with their patients. That’s why, Gaskin said, in 2006 when a breech baby she delivered became temporarily stuck and suffered permanent neurological problems, the parents did not sue. “We thoroughly discussed the issues, and they didn’t see a reason to be punishing,” Gaskin told me.
I am going to try very hard to keep the intensely vitriolic things I want to say about this terrible, stupid paragraph limited. Lawsuits “aren’t an issue” for Gaskin? She’s never been sued? She’s one hell of a lucky, lucky woman then, isn’t she? Because God knows she could well have been, what with that permanently disabled child whose disability is entirely her fault. Who, had he been delivered by C-section in a hospital, would not be disabled now. How nice for her that the parents didn’t sue her for all she’s worth. She sure had it coming.
For those of you keeping score, that’s one dead baby and one permanently damaged one.
When I visited the Farm, Gaskin was planning to travel to testify at the trial of a C.P.M., Karen Carr, who delivered a breech baby in a home in Virginia who died. Carr lived and practiced in Maryland, but Virginia requires a license in addition to certification, and because Carr didn’t have one, she was charged with involuntary manslaughter. (She pleaded guilty to lesser charges.) I pressed Gaskin about the case. Wouldn’t that particular baby have been better off in a hospital? She conceded that his life would have been saved but said that hospital birth comes with its own risks.
And we’re up to two dead babies.
Yes, hospital birth comes with risks. Birth comes with risks. That’s why treating as a beautiful, wonderful but potentially risky situation is appropriate.
The rest of the article is dedicated to the author’s own account of her negative experience giving birth in a hospital, whence comes the halo she gives Gaskin, I suppose. The number of obstetricians she interviewed for her six-page article about a highly controversial subject? Zip. Nice balance, New York Times.
And now, a concession from me. I am not an obstetrician, so I’m not in a position to comment with much authority on delivering babies. It is my observation that an awful lot of babies are delivered by C-section, and that it seems many OBs are quick to go with that choice. I suspect this is due in large part to fear of malpractice suits. One area in which I think medical tort reform makes sense is to offer additional protections for providers who agree to perform vaginal births after C-sections (VBACs), which carries more risk but nonetheless can be done safely much of the time. Hardly any OBs will agree to perform VBACs, and this contributes to a C-section rate that is higher than it ought to be.
I am not saying that there isn’t a lot of room for improvement in the delivery experience for women who deliver in hospitals. And I am wholly in favor of hospital-based midwifery programs, where access to skilled medical care is a phone call away. But home-based midwifery by people who have no meaningful medical training? No way.
I have been in blessedly few situations where I know my presence made the difference between a patient living or dying, or being permanently disabled. Those situations are 100% limited to being present at deliveries. In some cases, the infant had had a bowel movement (called “meconium” in neonates) during delivery, and the meconium needed to be suctioned from its airway. My being there meant the baby could breathe. Had I (or any other competent pediatrician) not been there, those babies could have suffered irreversible brain damage. Ditto for babies with difficult extractions who needed intensive resuscitation immediately after birth. I was there, and the babies did just fine. Had they not been in a hospital, they almost certainly would not have. These were in otherwise totally normal deliveries, ones where there was no sign of trouble up until those very moments. A midwife in a woman’s home would have had no reason to send those women to a hospital. Even a very short drive would have taken enough time to have dramatically altered the infant’s outcome.
If people have chosen to become parents, then they have implicitly agreed to take the welfare of their child seriously. I happen to believe that they are obligated to put their child’s welfare ahead of their own. And no matter how disempowering or non-transcendent that they may find the experience of hospital-based deliveries, that is the safest place for their newborn child to be delivered. It is their duty to put that child’s interests ahead of their own ideology. Home deliveries by medically incompetent providers does not respect the best interests of the child. Period.
And with that, I will hit “publish” and brace myself.
Update: Several commenters have made reference to home births in other countries, and have highlighted a legitimate flaw with the above post. My objection to homebirths is entirely limited to the United States. In countries like the Netherlands (and, presuming what commenters have said is true), Canada and the UK where midwives are required to have sound medical training, then my objection is much more muted. Similarly, if all homebirths in the United States were attended by well-trained nurse midwives, then I would have much less objection. What I object to is midwives like Gaskin who have no medical training attending deliveries where they are incompetent to take care of the infant should complications arise unexpectedly.