Women in the World

06.25.12

Home Birth: Increasingly Popular, But Dangerous

A small but growing number of mothers are skipping hospitals to have their babies at home. Michelle Goldberg reports on what’s fueling the trend—and the hidden dangers at hand.

Mindy Bizzell decided to have her second son at home partly because of money and partly because of faith. She and her husband, who had recently moved to a remote town on the Washington state coast, lacked health insurance but earned too much to qualify for state aid. Delivering her baby in a hospital would cost upward of $10,000, compared with the roughly $3,000 it would cost to hire a home-birth midwife to take care of the entire pregnancy.

Besides, Bizzell, who grew up in what she calls a “pseudo-hippie household,” believed in home birth. During college, she’d considered becoming a midwife herself, and had spent a week at The Farm, the rural Tennessee community and midwifery center founded by the natural-childbirth guru Ina May Gaskin. Bizzell had attempted to have her first baby at home, though she was transferred to a hospital when her labor didn’t progress quickly enough. The experience left her feeling like a failure, and she wanted to try again. She figured that if something went wrong, she could go to the hospital like she had the first time.

She found a midwife she trusted, Tamra Roloff, a great admirer of Gaskin who owned the local health-food store, THC Organic Market. “She was just like, ‘Your birth is going to be amazing, it’s going to be so powerful,’” Bizzell recalls. “There was a lot of this earth goddess empowering stuff.”

All this resonated with Bizzell. The home-birth subculture, she says, draws “you in with the idea that this kind of birth will make you a powerful woman. It will make you spiritual. It will even make you a better mother.” She longed for all of that. “I wanted to make the best decisions for my baby,” she says. “And now he’s dead. It turns out I made the worst decision possible.”

A few decades ago, home birth in the United States was mostly limited to insular religious communities like the Amish and to dedicated members of the counterculture like Gaskin, whose husband founded The Farm as a commune in the 1970s. In recent years, though, it’s moved toward the mainstream, spurred by the rise of attachment parenting, a reaction against a dysfunctional medical system, and pro-midwife documentaries like The Business of Being Born, which featured producer Ricki Lake giving birth in her bathtub. Though still quite small, the number of home births is increasing—according to the Centers for Disease Control, it grew 29 percent between 2004 and 2009, to 29,650.

The practice is also increasingly chic. “Are midwives becoming trendy, like juice cleanses and Tom’s shoes?” asked a story in The New York Times style section earlier this month. “It seems that way, at least among certain well-dressed pockets of New York society, where midwifery is no longer seen as a weird, fringe practice favored by crunchy types, but as an enlightened, more natural choice for the famous and fashionable.” Some of the women in the Times piece had their midwife-assisted births in hospitals, but others, like the models Karolina Kurkova and Gisele Bündchen, delivered at home.

For many parents, home birth is a transcendent experience, and they’re profoundly grateful to have been able to have their babies on their own terms. Yet as the number of such births grows, so does the number of tragedies—and those stories tend to be left out of soft-focus lifestyle features. Now a small but growing number of people whose home deliveries have gone horribly awry have started speaking out, some of them on a blog, Hurt by Homebirth, set up by former Harvard Medical School instructor Amy Tuteur. “These people are beating themselves up over this,” says Tuteur, perhaps the country’s fiercest critic of the home-birth subculture. “They did it because they thought it was safe, and it wasn’t safe.”

Actually, hard numbers on the safety of home birth are surprisingly difficult to nail down. The American College of Obstetricians and Gynecologists says that home birth is several times more dangerous than hospital birth. But the group acknowledges that “high-quality evidence to inform this debate is limited.” There’s no central registry of home birth deaths, and the studies that exist are mired in controversy. It’s clear that some parents have lost babies during home births that could have been saved had they been in a hospital. Whether than means that the risk of home birth is significant depends on which experts you listen to.

Oregon doctor Martha Reilly’s hospital often receives home-birth transfers, and she says every OB there has treated a woman rushed in with a dead or severely injured baby.“The death rate that we’re looking at, in terms of preventable deaths, it’s outrageous,” she says.

A 2010 meta-analysis of the medical literature known as the Wax Paper, published in the American Journal of Obstetrics and Gynecology, found that planned home birth has a two to three times higher risk of neonatal mortality than hospital birth. Home-birth advocates, though, dispute the reliability of the underlying research. For them the gold standard is a 2005 study by Canadian epidemiologist Kenneth C. Johnson and his wife, Betty-Anne Daviss, a well-known home-birth midwife. Published in the British Medical Journal, it involved 5,418 North American women who planned home births in 2000. It found that they had similar perinatal mortality—meaning babies who died just before, during, or immediately after birth—as low-risk hospital births, along with lower rates of medical intervention.

But Tuteur points out that the figures Johnson and Daviss used for hospital deaths came from studies from the 1970s and 1980s. “They sliced and diced the data to fool people who are not sophisticated,” she says. When she compared Daviss and Johnson’s home-birth figures with data on hospital births in 2000 from the National Center for Health Statistics, she found that for women with comparable risks, the perinatal death rate was almost three times higher in home births. That, she says, “is in line with every single other study that’s ever been done of other home-birth statistics.”

She points to figures from Colorado, one of the few states that mandates the collection of data from licensed home-birth midwives. In 2009 midwives performed 637 deliveries and transferred another 160 patients to the hospital either before or during labor. Altogether, the midwives’ patients suffered nine perinatal deaths, almost double the perinatal mortality rate for the entire state, including high-risk and premature deliveries. Three of the nine babies died during labor, which is extremely rare in hospital births.

Johnson and Daviss reject Tuteur’s interpretation of their figures. In response to her criticism, they self-published an analysis with updated data that they say replicates their original results. Tuteur, in turn, critiqued their new methodology. One could spend days sorting through the claims and counterclaims. Ultimately, for those without medical expertise or statistical training, deciding whom to trust is as much a question of philosophy as of data, because the debate isn’t just about numbers. It’s also a metaphysical argument about the nature of childbirth.

“This is one of the most wonderful experiences in your life,” says Daviss, describing the concept of “orgasmic birth,” which is popular in parts of the home-birth community. “This is one of the times when you are going to be going into a labyrinth of ecstasy. You may not have an orgasm, but certainly you’re going to have to work and do something that is altogether internal and external at the same time and universally connects you with women around the world and with your family ... Somehow we need, in our culture, to help young women to understand that.”

Obstetricians tend to be less romantic about childbirth. “Reproduction is very dysfunctional,” says Martha Reilly, chief of Women's and Children's Services at McKenzie-Willamette Medical Center near Eugene, Ore., a place where home birth is particularly popular. Her hospital often receives home-birth transfers, and she says every OB there has treated a woman rushed in with a dead or severely injured baby. “The death rate that we’re looking at, in terms of preventable deaths, it’s outrageous,” she says. “And we have no idea how many babies are being harmed. Forget death—how about brain damage? We don’t know. Nobody’s keeping the data. All we know is what we see coming in.”

Parents who share the home-birth movement’s ideology may have no problem discounting voices like Reilly’s. After all, people take lots of calculated chances during pregnancy. The danger of a late miscarriage from amniocentesis, a prenatal test for genetic defects, is as high as one in 200, but many women opt for it anyway, with their doctor’s support. There are small but real hazards involved in C-sections and other procedures that women often feel pushed into in hospitals.

The problem is that as home birth becomes more popular, it’s attracting people who don’t fully understand the philosophy behind it and don’t realize that not all midwives accept standard medical protocols. When things go wrong, they feel duped and misled.

For Josh Jones and Tweeny Kau, a Santa Monica couple in their 30s, the journey toward home birth began when they saw The Business of Being Born, the 2007 film that has done an enormous amount to popularize contemporary midwifery. The movie is part exposé of the failings of modern obstetrics—particularly its overreliance on C-sections and other interventions—and part glowing look at the rapturous possibilities of natural birth at home. “That just sort of put it on the radar for us,” says Jones. “Oh, people do this and they’re fine. It’s as good an option as a hospital.”

Jones and Kau are in no way anti-science. He’s a cofounder of the Web hosting company Dream Host, and she has a Ph.D. in biology from Harvard, though she left the field to open a flower business. For them, home birth seemed like a luxury, a way to bring their baby into the world in a comfortable, calm environment. Jones compared it to choosing Whole Foods instead of Safeway, something rich people do that may or may not be better but is certainly no worse. Should something go wrong, they figured, they lived just 10 blocks from Santa Monica UCLA Medical Center, one of the best hospitals in Los Angeles. They found two midwives, both licensed by the state of California.

To be extra careful, Jones and Kau visited an OB practice several times during the pregnancy. At an early appointment, Kau tested positive for Group B Strep, a bacteria present in about a quarter of women. She took a course of antibiotics, and was to be retested later in her pregnancy. The midwives gave them a handout that “in retrospect was just terrible,” says Jones. “It had about a paragraph with real facts from the CDC, and then three and a half pages on the risk of antibiotics.” They suggested that Kau stave off the bacteria by putting a garlic clove in her vagina every night, which she did.

When Kau went into labor early at 36 weeks and 5 days, neither she nor her midwives had the results of her latest Group B Strep test. In the hospital, she would have automatically been given an antibiotic IV. But when one of the midwives arrived to perform the delivery, she didn’t bring it up, Jones says. It never occurred to Kau and Jones to ask.

Their son, Wren, was born on March 9, 2010, shortly after noon. He seemed healthy, and even began breastfeeding without difficulty. The midwife and her assistant cleaned up, and after three hours, they left. With every breath, Wren made a cooing noise, but Jones looked online and saw that lots of newborns make funny sounds. He thought it was cute; he even made an audio recording of it. He didn’t realize that it was because his son was struggling for oxygen.

But that evening, Wren stopped breathing. They called 911; the EMTs were there in three minutes. In the hospital, though, Jones and Kau learned that oxygen deprivation had left him brain dead, and so, as they held his hand, they let the doctors pull the plug. After an autopsy, the couple learned that Wren had died from pneumonia due to a Group B Strep infection contracted during delivery.

As they investigated what happened, they also learned more about how midwives are trained. They discovered that there are two categories of licensed midwives in the United States. Only one kind requires formal medical education. They had the other kind.

Certified nurse midwives, or CNMs, are, as their title implies, nurses, and many of them work in hospitals. They have the same sort of training as midwives in countries like the Netherlands, where a third of babies are delivered at home. It’s difficult to find a CNM who does home birth in the United States, though, because liability insurance usually doesn’t allow it.

Instead, the caregivers who preside over home births are typically CPMs, or certified professional midwives. They are accredited by a national midwifery organization, the North American Registry of Midwives. To qualify, an applicant must have at least a high school diploma, followed by either midwifery school or an apprenticeship under another midwife. Then they have to pass a 350-question multiple-choice exam. Twenty-seven states license CPMs to practice.

Jones and Kau’s midwives, who declined to comment on the record for this story, were CPMs. Jones and Kau thought of suing them, but lawyers weren’t interested because, like most home-birth midwives, they don’t carry liability insurance. “I do feel like they shouldn’t be able to be licensed,” Jones says of CPMs. “I’m scared that more states are allowing the licensing. On the one hand, people argue that in states where they don’t have licensing people just do it anyway, and they just do it illegally, and it’s almost worse. But the downside [of licensing] is that it just adds legitimacy to the whole thing.”

Right now, a national campaign, the Big Push for Midwives, is trying to expand licensing of CPMs nationwide. “There are about a dozen states with active legislation this year,” says Katie Prown, the Big Push’s campaign manager. Among them are Michigan, Indiana, and Iowa. Some states allow licensed midwives to be reimbursed by Medicaid, and because a home birth usually costs significantly less than a hospital birth, it saves the government money. That’s one reason that, in many states, the pro-midwife coalition has easily garnered bipartisan support. Indeed, the right-wing American Legislative Exchange Council, or ALEC, has endorsed legislation for licensing CPMs put forward by midwives’ groups.

Prown, a former professor of English and women’s studies at William and Mary College, sees licensing midwives as the solution to the problem of unqualified providers. When she had her first home birth in Virginia in 1992, midwifery was still illegal in that state, and finding a midwife to deliver her baby at home meant navigating a secretive underground market. She was determined not to give birth in a hospital, though, because her obstetrician, like many others at the time, almost always performed episiotomies—surgical incisions between the vagina and the anus—on first-time mothers. The procedure was thought to prevent vaginal tearing, but Prown, then working on her dissertation, started reading about it in the library and found little scientific basis for its routine use. (The medical consensus has since caught up with her.)

“For women who want to have a hands-off, low-tech birth, many of us just don’t want to negotiate that in the midst of labor,” she says. Many home-birth advocates are concerned about what they call the “cascade of interventions,” in which one procedure leads inexorably to another, often culminating in a C-section. A third of all births in this country are via C-section, a rate far higher than that in most other developing nations. (According to the World Health Organization, C-section rates shouldn’t go above 15 percent.) Experts debate why so many laboring women end up in the operating room. Some cite elevated rates of obesity and rising maternal age, which both increase the C-section risk. But it seems clear that at least some of the increase is due to doctors who fear lawsuits, or who simply lack the time or patience to attend to a vaginal birth that’s gone on too long.

“I would be the last person to defend the current medical system,” says Tuteur, who left obstetrics to write and raise her four children. “The whole culture of medicine has changed, and that’s one of the reasons I no longer practice … Almost every doctor I know is beside themselves with anguish because they feel they’re not providing good, respectful care. And there is no question that a home-birth midwife is going to be a lot nicer to you than the average obstetrician.”

Empathy, however, is not the same thing as expertise. If nothing else, people who’ve had disastrous experiences with home birth want fuller disclosure of what the CPM credential does and doesn’t entail. “I want people to understand the difference between medical care and midwifery care,” says Mindy Bizzell. “If everyone really understood the risks that they were taking, no one would ever do it.”

When Bizzell went into labor on Aug. 3, 2009, she had no idea that her baby was breech—with his feet, rather than his head, pointing down—because, she says, Roloff, her midwife, had warned her against ultrasounds, saying they can cause birth defects. “I assumed that she would know that,” Bizzell says of the baby’s position. “I’d been going constantly to her office, where she would palpate my stomach. She told me he was head down.”

The next morning, when Bizzell’s water broke, it was full of blackish meconium, a fetal bowel movement that signals distress. But Bizzell says Roloff didn’t seem alarmed. Basically, every medical doctor would tell you that means this is an emergency,” says Bizzell. “We didn’t know that. In fact, she told us it was fine.”

Soon Bizzell was dilating rapidly. Only then, she claims, did Roloff check her internally, feel the baby’s bottom, and realize what was happening. State regulations wouldn’t permit her to do a breech delivery, so they drove to a hospital in Astoria, Ore., 45 minutes away. The baby was coming quickly, but Bizzell says Roloff appeared sanguine about the possibility of simply delivering him en route.

Which is almost what happened. Bizzell’s son was partly born on the 4.5-mile bridge over the Columbia River. His head, though, was trapped in her pelvis, and remained there for 15 minutes until they reached the hospital, where a doctor rushed outside and used forceps to remove him while she lay in her car’s back seat. Bizzell was taken into surgery to repair a fourth-degree tear. Her son was resuscitated and then flown to a hospital in Portland, but he died of brain injuries.

Bizzell says she never took legal action against Roloff because she couldn’t stand to relive the whole ordeal. Someone at the hospital where Bizzell’s son was delivered, however, filed an anonymous compliant about Roloff’s behavior with the Washington State Department of Health. Because of the complaint, the health department launched a confidential inquiry into Bizzell’s case.

The records of that inquiry seem to support Bizzell’s story. At one point, the investigator wrote: “The Respondent’s statements and medical records do not appear to support that the patient was monitored or evaluated by the Respondent during her labor. Additionally, the determination of a breech presentation with the presence of thick meconium was not identified by the Respondent as an emergency.” (The case file includes an angry letter that the doctor who finally delivered Bizzell’s baby sent to Roloff. Noting his work on Indian reservations, in a migrant farm-worker clinic, and in Mali, Peru, and Afghanistan, he wrote, “I can see no reason to shun modern women’s healthcare by avoiding evidence-based medicine.”)

The investigation into Bizzell’s delivery was ultimately closed without charges being brought, but the health department wrote in a letter to Roloff, “This decision may be revisited if we receive new information or identify a pattern of similar complaints.” Soon more complaints came—according to the health department, seven have been filed since 2009. Now Roloff is facing disciplinary action in another case in which a client’s baby died. According to the department of health’s official Statement of Charges, the mother’s water broke on Feb. 27, 2010, and she was still laboring on March 1, with a fever and high blood pressure, when she had a seizure. Only then, according to the official state document, did Roloff call 911. Blake Maresh, executive director of the Washington State Health Department’s midwifery program, says she’s currently in settlement discussions with the state over that case.

The number for Roloff’s midwifery practice has been disconnected, and when reached at THC Market, she refused to comment before hanging up the phone. For now, she maintains her license. Her lawyer, Donna Moniz, also declined to talk about Bizzell’s case, except to point out that the investigation into Henry’s death was closed without charges being brought. “We have terrible things happen sometimes, despite the best care, in hospitals,” Moniz says. “Birth has its dangers, whenever it occurs.”

Bizzell blames Roloff and the culture of home birth for her son’s death, but she also can’t stop blaming herself. She started a blog, Dear Henry August, about her lost son, and its anguish is lacerating. “I feel like I killed you,” she wrote a few months after his death. “I really honestly believed I was doing the right thing for you, I wanted you to come into this world calmly and lovingly, I didn't want any drugs to affect you in anyway and I was prepared to endure any pain to ensure your health and well being. Henry, please forgive me.”