Midwifery Debate

07.05.12

Michelle Goldberg Answers a Critic’s Distortions of Her Home-Birth Argument

It’s often difficult to get hard facts on home birth, but inflammatory rhetoric and half-truths only makes things worse. Michelle Goldberg answers a critic.

In Jennifer Block’s pro-midwifery book Pushed: The Painful Truth About Childbirth and Modern Maternity Care, she quotes women who’ve written online about their traumatic experiences having babies in hospitals. “Many of the women who post to the … Yahoo group list are experiencing symptoms consistent with PTSD,” writes Block. “Some women call their experiences ‘birthrapes.’” She cites one woman’s description of her C-section: “I felt raped. Lying naked on a cold table, strangers sticking tubes up my body, pulling my innermost organs out to fondle … I could not bond to my child … This is not birth. I went in pregnant, and I came out a bleeding, empty woman.”

I have no doubt that such hellish experiences are real. But given the way Block uses them to indict all of modern obstetrics, I find it rich that she’s now criticizing me for quoting parents who’ve lost their babies after home births gone wrong. Earlier this week, Block published a piece in Slate, titled “How To Scare Women,” attacking my recent Daily Beast article about the dangers of home birth. “Goldberg builds her piece around two horrific home-birth tragedies,” she writes, and then asks, “But is it responsible journalism to construct a story around the rare outcome? And is it logical for us, as readers, to take away from the anecdotes that home birth is dangerous?”

Nevertheless, I’m grateful for Block’s piece, since it gives me a chance to wade into some of the disputes that I elided, for reasons for space and readability, in my original article. When writing about complicated controversies for a general audience, it can be hard to figure out how deep in the weeds to go. As my editor and I went back and forth on the piece, I said, more than once, that I wished I could write it at twice the length. In the end, though, I decided that I’d lose a lot of readers if I spent thousands of words dissecting every anticipated objection from home birth advocates, or loaded the piece up with sources saying the same thing over and over again. Instead, I relied on the shortcut of links. Now Block has given me the opportunity to take some pro-midwifery arguments on in more detail. (And, if you don’t want to follow me into a fairly recondite discussion, now is your opportunity to stop reading.)

Let’s start with her primary criticism—my use of Dr. Amy Tuteur, a figure anathema to the home-birth community, as a source. Now, I think Block overstates my reliance on Tuteur; there’s a difference between agreeing with her after doing my own research and repeating a “Tuteur talking point,” as Block accuses me of doing. But leave that aside, and let me explain why I’m not convinced by Block’s attempts to impeach Tuteur’s expertise.

Tuteur is a former obstetrician and Harvard Medical School instructor who, as I write in the piece, gave up practicing to devote herself to writing and raising her four children. 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. As Block wrote in 2009, Tuteur has taken on “mythical status among the home-birth community. Some activists believed she wasn’t real, that her picture and bio were fake, that she was a mere avatar for some sort of underground ACOG [American College of Obstetricians and Gynecologists] propaganda machine.” (The suspicion that American gynecologists would maintain a secret propaganda arm tells you something about this movement’s mindset.)

Block presents two arguments for why we shouldn’t take Tuteur seriously. The first is that she is no longer practicing, “she’s not currently affiliated with any medical institution, and more importantly, she’s never published any of her kitchen-table calculations on the risks of home birth in any peer-reviewed journal.” But Tuteur doesn’t claim to conduct independent research, and Block offers no evidence to dispute her interpretation of existing data. Nor does she explain why Tuteur’s retirement renders her impressive medical background irrelevant.

It was Tuteur who found serious flaws in a widely-cited study published by home-birth advocates Kenneth C. Johnson and his wife, Betty-Anne Daviss, in the British Medical Journal, that purported to show home birth’s safety. In response, Johnson and Daviss self-published a new analysis with updated data—a tacit admission that Tuteur’s criticisms were valid. (Tuteur, as I explained, disputes the methodology of their new, non-peer reviewed analysis as well.) She is an important voice in this debate, whether Block likes it or not.

Which leads us to Block’s second point about Tuteur—that she is obnoxious. Block notes that Tuteur’s prose about anything she regards as quackery tends towards the inflammatory. Her comments on various blogs have been “flagged or removed,” Block points out, and “she had a mutual parting with the blog Science-Based Medicine.” Perhaps Block thinks that I shouldn’t have quoted her without litigating her fights with various bloggers. I disagree.

In almost every story I’ve ever written about an arcane controversy, there is a person who has made fighting one side of it their life’s work. These people are, almost without exception, obsessed, irascible, and self-righteous. That doesn’t mean they’re wrong. The sharp edges of their personalities are often interesting, and in a longer piece, I would have devoted more space to fleshing out Tuteur as a character. I would have also quoted the parents who’ve suffered home-birth disasters who’ve told me how grateful they are to Tuteur for giving them an outlet.

The home-birth movement seems to be driven by a quasi-religious naturalist ideology that denies the danger that’s been inherent in childbirth for most of human history.

Charity Feb, for example, didn’t make it into my original piece for space reasons, but she was deeply traumatized after a midwife-assisted birth left her with urinary and fecal incontinence and a hysterectomy. Feb told me that Tuteur’s website, The Skeptical OB, “was a lifesaver for me when my marriage was tanking and no one in my life wanted to help or hear or be there.”

Of course, Tuteur isn’t the only expert I cite in my piece. I also quoted 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. Reilly told me that every ob-gyn she works with has treated a woman rushed in after a home birth gone awry, her baby dead or severely injured. Block essentially accuses her of lying, though according to Reilly she didn’t bother to call her. “The Department of Health reports 102 planned home births in Lane County in 2010,” writes Block. “Reilly’s claim is improbable given that the odds are in the per-thousand range, though it’s perhaps indicative of how polarized some providers are on this issue.” But Reilly didn’t claim that all these disasters happened in one year. Nor is there any reason to assume, as Block does, that none of them came from surrounding counties.

Block then does something particularly ironic, given that she’s attacked my reporting for not fully exploring Tuteur’s background. She quotes one “Melissa Cheney,” an “anthropologist at Oregon State,” who claims to have found that doctors spread unsubstantiated rumors about home-birth deaths. In fact, the anthropologist’s name is spelled Melissa Cheyney, and in addition to her post at Oregon State, she is a licensed midwife and head of the division of research at the Midwives Alliance of North America. Cheyney is a major figure in the pro-midwifery community, not an objective academic observer.

This omission is typical of Block’s bad-faith approach. So, too, is her treatment of the data on home birth safety. In my piece, I note that very little data about home-birth outcomes in the United States is available, that the existing studies are contradictory. Some show much higher death rates for babies born at home. Others, often conducted by home-birth advocates, do not. For those who aren’t qualified to adjudicate a debate over the construction of proper data sets, evaluating them requires, to some extent, understanding the philosophies of their authors. Thus I think it’s relevant that Johnson and Daviss, whose study on home-birth safety is constantly cited by the home-birth movement, are passionate partisans on its behalf. Daviss, particularly, has an almost spiritual stance towards natural childbirth—in my original piece, I quote her saying that it is “one of the times when you are going to be going into a labyrinth of ecstasy.” This doesn’t mean her numbers are wrong, but it shows us where she’s coming from.

Block objects to this approach. “[F]or a reporter … it doesn’t seem very useful to throw up one’s hands and say, hey, this is a metaphysical debate! What about the data?” she writes. “Why not call a scientist?” As if to rectify my sloppy reporting, Block proceeds to interview an epidemiologist, Boston University’s Eugene Declercq. He tells her that determining the precise risk of home birth “is all but impossible, certainly in the United States,” because there’s so little data. Somehow, Block doesn’t seem to realize that this proves my point.

Instead, she cites studies from Canada, the U.K., and the Netherlands, “all comparing where and with whom healthy women gave birth, which found similar rates of baby loss—around 2 per 1,000—no matter the place or attendant.” I explained, in my original piece, why it doesn’t make sense to compare home-birth midwifery in the United States, where training and regulation are incredibly lax, to the practice in countries where it’s deeply integrated into national health services. For the sake of brevity, I didn’t go into detail. Let me do so now, focusing on Holland, a country American home-birth advocates love to reference. (You may also want to read Lindsay Beyerstein of In These Times on the same subject.)

In Holland, around a third of babies are born at home. Some studies—though not all—have found that the perinatal mortality rate for home birth in that country is no higher than for hospital birth. In Holland, midwifery is part of the medical system, and doctors and midwives work in close collaboration. Unlike in the United States, Dutch midwives still get paid for a birth if they end up transferring a mother to the hospital due to complications, so they lack a financial incentive to proceed at home. One of the people I interviewed for my original story, but didn’t end up quoting, was Philippa Ribbink, a Dutch ob-gyn who now practices in Oregon. Having worked closely with Dutch midwives during a stint in Ethiopia, she emphasizes that they’re akin to the certified nurse midwives who work in American hospitals, whose training is much more rigorous and standardized than that of most home-birth midwives.

“The Dutch system overall works because there’s strict guidelines on who can deliver at home and who can deliver in a hospital, and because there’s communication between midwives and hospitals,” Ribbink says. In the United States, by contrast, some midwives, particularly those who are ideologically opposed to modern obstetrics, will attempt home deliveries with women who’ve had previous C-sections, or who are pregnant with breech babies or twins. Indeed, Block celebrates these midwives in her book. “We don’t have guidelines. It’s not the same health-care system,” says Ribbink.

Furthermore, it’s not entirely clear just how well the Dutch system really works. A 2010 study of Holland from the British Medical Journal found that the babies of low-risk mothers cared for by midwives had a higher death rate than the babies of high-risk women who delivered in hospitals. The study also pointed out that the Netherlands has one of the highest perinatal morality rates in Europe. “Whether the Dutch obstetric-care system contributes to this relatively high mortality remains unclear,” it says.

Part of the reason I wrote my home birth story in the first place is because women making potentially momentous decisions about where and how to deliver their babies are being bombarded with misinformation, some of it in the guise of feminist empowerment. The home-birth movement seems to be driven by a quasi-religious naturalist ideology that denies the danger that’s been inherent in childbirth for most of human history. It cherry-picks studies, distorts facts, and attacks its critics in a way that reminds me of my many years reporting on the Christian right.

Women have a right to adhere to the home birth movement’s ideology, and as far as I’m concerned they have a right to have their babies anywhere they choose. But they also have a right to know that giving birth at home has the potential for as much danger and trauma as anything in Block’s book about the horrors of hospitals.  They have a right to weigh the very real risk of an unnecessary C-section against the risk of a dead baby, which is much smaller but, to many mothers, much more grave.

That’s not trying to scare women. It’s being honest with them.