Doctors Vs. Midwives
02.07.14 10:45 AM ET
The Home-Birth Rebellion
There’s a war being fought over women’s reproductive rights, and this time it’s not about abortion. Doctors, midwives, and women’s health advocates are sparring—in academic papers, on blogs, through the media and even on Twitter—over just where pregnant women should actually have their babies.
Though a vocal group of medical professionals are saying it should never be at home, an increasing number of women aren’t listening. While the number is relatively small at 35,000—less than 1 percent—U.S. home births have grown by 59 percent from 2004 to 2012, according to data from the Centers for Disease Control and Prevention. The rapid rise is driven most by non-Hispanic white women, with about one out of every 74 having an at-home birth.
Women can’t easily turn to data to make an informed decision. Groups representing doctors and midwives are pushing statistics that advance their polar-opposite ideologies and confirm their own opinions. And as the war between the two intensifies, the pregnant women they both treat are left to sort through their contradictory findings.
Take, for instance, the two studies on home birth that came out this week.
The first, from the Midwives Alliance of North America(MANA) confirmed “the safety and overwhelmingly positive health benefits for low-risk mothers and babies who choose to birth at home with a midwife.”
The next came in the form of an abstract from researchers at New York-Presbyterian/Weill Cornell Medical Center. Doctors there reported that babies born at home to midwives have four times the risk of neonatal deaths than those delivered in the hospital by midwives. The risk jumps sevenfold for a first-time mother and tenfold in pregnancies over 41 weeks in duration.
Could both be true? Are the mothers who decide to have their babies at home making an irresponsible choice and risking the lives of their children, or is the tiny, but growing movement to avoid the hospital a relatively safe one, with benefits that outweigh the dangers?
A call for more information about these studies found both sides eager to point to flaws in the other’s research.
Melissa Cheyney, chief author of the pro-home-birth MANA study, calls the Cornell methodology “misleading.” But she says, “No one calls them on it. They submit it to these important journals and they go out for peer review and people say, ‘Great. Let’s publish it.’ And that is extremely problematic. I’m trying to wrap my head around how that can be possible.”
“We got incredibly low mortality rates, incredibly low C-section rates, incredibly low rates of intervention. There should be something that some physician, somewhere would say, ‘Maybe we should look just for a minute into what midwives are doing right rather than writing it off as completely untenable?’ Is there anything that they can learn? Why not critical self-reflection instead of midwife-blaming and mother-blaming?”
Weill Cornell’s Amos Grunebaum, who will be presenting the OB-GYN abstract at the Society for Maternal-Fetal Medicine’s conference today, says the MANA study was poorly designed and tilted toward better results. “It was a voluntary study. If somebody has a voluntary study, people with bad outcomes are less likely to fill it out,” he says. “They misrepresent the way the data is collected.”
Women are continuing to choose home birth, says Grunebaum (who was himself delivered by a midwife), because, “they are misled with misinformation about its safety.”
“Home-birth midwives published a horrible study last week, with horrible numbers, showed that more babies died, and they say it’s safe. It’s misleading and it’s important for us to inform women that it’s really not safe to deliver at home,” Grunebaum says.
Both sides seem unwilling to concede any ground. And like gridlocked politicians, it seems each side of the debate relies more on spin than facts to justify its positions.
The most liberal home-birth advocates sometimes paint the medical community as unable or unwilling to care for women, with language that puts the profession itself on the defense.
“Childbirth education really needs to include un-education of the mis-education that has been perpetuated for decades by the medical community,” doctor and former midwife Aviva Romm, who herself had four home births and advocates for more choices for women, recently posted on Facebook.
The doctors and advocates leading the crusade against home births are more heavy-handed with their accusations, even taking to social media to air them.
This week, Grunebaum responded to the midwives’ study via Twitter, making sure to tag Ricki Lake, the producer of the pro-home-birth film The Business of Being Born.
Not exactly a show of professional courtesy.
Grunebaum also retweets former OB-GYN Amy Tuteur, the most demagogic of home-birth critics, whose website serves as an echo chamber for the anti-home-birth crowd complete with horror stories of home births gone wrong. Despite her incendiary posts—she calls women who choose home births “ignorant,” “gullible,” and “selfish”—Tuteur is still touted as an expert in the media. “First and foremost, your websites are always so informative to women,” Nancy Redd recently gushed on a HuffPost Live segment on “Hidden Home Birth Deaths.”
The problem with this debate, fueled by constant studies and subsequent breathless media coverage, is this: America’s home-birth data are incomplete.
Most of the alarmist studies come from data pulled from vital-statistics data, from birth certificates and infant death certificates that are linked together. These administrative records “aren’t designed for research,” says Marian MacDorman, a statistician at the CDC who studies birth trends. “There are quite a few limitations in using that data for that kind of analysis.”
First, the researchers aren’t able to follow women who intend to deliver at home but later transfer to the hospital, which removes trauma patients from home-birth statistics. Then home-birth data fail to account for planned vs. unplanned births. Around 12 percent of births at home happen because of an unforeseen emergency, and many of them, MacDorman says, have negative outcomes—hence a higher mortality rate, tipping the scales against midwives.
These differences get very important when you’re talking about such a small data set to begin with, one that makes it hard to tell if the differences in settings are statistically significant.
The most recent Weill Cornell study found the risk of neonatal mortality to be about 1.2 per 1,000 births. That means that the chance women are taking is relatively riskier (maybe), but still generally safe. But “450 percent more deaths” sounds scarier, and cherry-picking the worst outcomes is more likely to make headlines.
“The use of relative risk is really misleading and alarming when the absolute risk is so incredibly low,” MacDorman said of these studies in general.
It is worth noting the Weill Cornell researchers’ view doesn’t necessarily reflect that of the wider medical community. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have come out with new positions on home birth recently. Each still name hospitals as the safest place for birth, but “respect the right of a woman to make a medically informed decision about delivery.”
Because of their growing number and the volume of their advocacy, it’s no longer possible to relegate homeward-bound soon-to-be mothers to the hippie or fundamentalist fringes. Women choose home births for a variety of reasons: comfort, cost, cultural or religious reasons, and to remain in control of a process of which they feel capable.
Rani MacNeal, a 37-year-old stay-at-home mom with a degree in marine biology, had all three of her children, now 2, 4, and 8, at her Boston home. After what she calls “an intensely deplorable” experience during a previous surgery, MacNeal decided not to go back for childbirth.
MacNeal describes the relationship with her midwife—who she says she researched thoroughly—as intimate, and her births, special. “I was taken care of really well. I was comfortable. I was in my own space. It was familiar and mine,” she says. “And coming from a science background, I know my baby was being born into a safe place.”
Many women actually say safety is a major factor in their decision, noting increased C-section rates and the risk of interventions that rise with hospital births. One out of three births in the U.S. is a Cesarean section and about a quarter of all labor is induced.
Studies outside the U.S. seem to support their opinion, finding home births can be as safe or nearly as safe as birth in a hospital.
The most recent U.K. data for planned place of birth shows no significant differences in negative outcomes between births at home, at birth centers, and obstetric units for mothers who have already had children. For first-time mothers, the risk is higher, though it is still relatively small. For low-risk pregnancies and births, women enjoyed better outcomes: reduced Caesarean sections, instrumental deliveries and episiotomies.
A large 2012 study from the Netherlands, where home births account for around 20 percent of all births, found planned home births to be actually safer than hospital births for low-risk women.
The study’s author noted (and anti-home-birth advocates are quick to point out) that the outcomes were a result of “a good risk-selection system, good transport in place, and well-trained midwives,” factors that are no doubt influenced by the collaboration of Dutch doctors and midwives and a national health system that support home births as a viable choice for women.
The common ground that other countries birth systems enjoy is within reach here.
Mainstream OB-GYNs Jeffrey Ecker and Howard Minkoff have asked for “dialogue rather than intractable opposition,” in the American Journal of Obstetricians and Gynecologists. “For those interested in encouraging hospital birth, dialogue and creating hospital practices appealing to those inclined to home birth are more appropriate than campaigning to restrict access to home delivery,” they wrote.
Since 2011, obstetricians and midwives have been meeting at home-birth “consensus summits” to try and find middle ground and work on issues like integration and the smooth transfer to a hospital when a problem arises.
But as with so many debates, the loudest voices, even when small in number, get the most attention.
“The irony of Chervenak and colleagues who are leading the anti-home birth crusade is that by polarizing the issue, no one can have a reasonable discussion to try and figure how to do this best,” says Eugene Declercq, a Boston University School of Public Health professor and a CDC statistician. “It’s either research that says it’s good or research that says it’s bad. And too few people ask, ‘How can we make it better?’”