Is It Safe? Asking the Wrong Question in the Home Birth Debate


A recent heated dialogue between journalists Michelle Goldberg and Jennifer Block about the safety of home birth has been the latest in a recent media flurry about the rise in home births reported by the CDC in January. A New York Times Magazine profile of Ina May Gaskin, arguably our nation’s most famous home birth midwife, was just one of the most mainstream of the recent articles, and seems to have stirred up much scrutiny of the practice. 

I feel compelled to dip my toe into the conversation, if only to try and steer it in a different direction. The source of the back and forth between Goldberg and Block centers on this question: “Is home birth safe?” It’s not a new question; in fact it has been debated since the beginning of obstetrics and hospital birth at the turn of the 20th century. 

Unfortunately, though, it’s exactly the wrong question to which to be devoting so much air time. A scant share of all women giving birth in the United States do so at home. Despite the reported 29 percent increase in home births nationally between 2004 and 2009, fewer than one percent of births happen out of hospital. While home birth gets much scrutiny, particularly when wealthy white women are seen as forging a new trend by choosing it, the place where the majority of women give birth in the United States — the hospital — goes largely un-scrutinized. 

Hospital births do get a lot of attention in birth activist circles (where I spend significant time, as part of my work at Radical Doula). Midwives and doulas will quickly recite the problems with hospital birth, e.g., why high intervention rates (c-sections, inductions) are bad for mother and baby. But outside of that arena, where it’s arguably most needed, the conversation is stalled. 

Here is the reason this matters: we are in the midst of a maternity care crisis. I’ve said it before, but I’ll say it again: our maternity care system is broken. Why? Because our maternal and fetal mortality rates are worse than 40 other countries worldwide, despite the fact that we spend more money than anyone else on maternity care. And where is  almost all that care being delivered? In hospitals. 

More than thirty percent of all births in the United States are through c-section — a rate twice what the World Health Organization identifies as a dangerous level of c-sections. Maternal mortality is actually on the rise — more mothers are dying from childbirth-related causes now than thirty years ago. I could go on, but I’ve said this all before. 

I realize that things which are deemed “new trends” often get attention, despite the fact that we are only talking about a small minority of people. But there is another reason I think this crisis isn’t getting the air time it deserves — it disproportionately affects women of color. Black women are four times more likely to die in childbirth than white women. And remember, these are hospital births we’re talking about here. While CDC data showed an increase in home births from 2004 to 2009, non-Hispanic White women accounted for 90 percent of this increase. Women are dying from childbirth in our hospitals at alarming rates, under the care of obstetricians and nurse midwives. Something is wrong here.

I don’t hide the fact that I’m a supporter of the midwifery model of care. I do think home births can be a safe and viable option, given adequately trained providers and a relationship with emergency back up services if necessary (something that because of the history of hostility between midwifery and obstetrics is hard to come by). But I’m interested in seeing our energy and scrutiny focused on the vastly dominant portion of our maternity care system: hospitals. While some people know well what challenges arise in that environment, the stories of parents who’ve lost children or mothers in hospital aren’t often publicized in the same way as are those of that small share of home births. We know they happen — mothers and babies are dying from childbirth-related causes in our hospital system. Malpractice rates for OB-GYNs may be high, but the stories of what sometimes happens under their care doesn’t get the same level attention. Why? Because doctors practicing in hospitals have an army of institutional supporters that protect them legally, financially, and in the media.  

As I’ve said before, we desperately need innovation and new approaches to maternity care. Whether you think midwifery and home birth are viable alternatives or not, it’s hard to ignore the statistics that say what we’re currently doing isn’t working. We should be able to guarantee better (not perfect, but better) outcomes for parents and children. If I were to play the blame game, I’m going to look to where almost everyone is giving birth — the hospital. It’s likely that we’re not going to find just one solution that will reverse our rising maternal mortality rate, or our infant mortality rate (not to mention the less discussed, but also important, disability from childbirth-related causes); we will need a range of solutions.

I do think maternity care provided out of hospital by trained providers (yes, even midwives without nursing degrees) deserves our attention. I think evidence-based care should be the standard across maternity care disciplines, but right now it seems that the scrutiny spotlight is unfairly trained in only one direction. It’s the direction that affects very few people, and this imbalance undercuts efforts to do the work of improving birthing outcomes in all settings.

Midwifery, particularly Certified Professional Midwifery, the focus of Goldberg and Block’s conversation, is an under-resourced and extremely marginalized movement. It’s a movement with almost no institutional support, little lobbying power, and with a number of powerful groups (the American Medical Association, American College of Obstetrics and Gynecologists, even the American College of Nurse Midwives) working against it. It’s hard to imagine a movement so maligned being able to prove its worth in that kind of climate, even if Rikki Lake and the New York Times Magazine choose to promote it. 

Let’s focus our scrutiny on the system that is failing us, and figure out how we can make it better. A few things that would help greatly in this matter: transparency about c-section rates from hospitals, an independent body investigating deaths from pregnancy-related causes, and real pressure on the obstetrics community to follow their own advice on practicing evidence-based medicine. 

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  • alison-cummins

    Here is the reason this matters: we are in the midst of a maternity care crisis. I’ve said it before, but I’ll say it again: our maternity care system is broken. Why? Because our maternal and fetal mortality rates are worse than 40 other countries worldwide, despite the fact that we spend more money than anyone else on maternity care. And where is  almost all that care being delivered? In hospitals.

     

    The only way this statistic could possibly be interpreted to show that homebirth and CPMs could be a solution to your abysmal maternal and fetal mortality rates is if those 40 other countries where women do better rely primarily on untrained midwives for maternity care.

    You have this information, right?

  • elliebeline

    Alison, if you read the entire article, which it appears you did not, I don’t think she wrote or proposed ANYWHERE that homebirths with CPMs was the solution to our poor rates. I believe she wrote that improving maternity care IN THE HOSPITAL is what we should focus on. And in a large portion of the countries that have better rates than us, those countries are attended my midwives trained not unlike CPMs, who happen to be integrated into the hospital system. Maybe if women weren’t treated so poorly in the hospitals presently, they would be less inclined toward homebirth. Clearly our system is not working in their favor. Get your facts straight, or at least read the article properly.

  • louana

    If a physician needed to refer a patient to a specialist for, say Diabetes, that physican would not have any problem doing so, since there is collaboration between physicians.  It would be terrible if a Diabetic patient could not get the care he/she needed because the Endocrinologist decided that the regular physician didn’t ‘deserve’ to make the referral.  If a surgeon was faced with a complication in the surgical suite, all he/she needs to do is make a quick call and a group of nurses and phsycians will come to help take care of the patient to ensure that the patient gets the best care possible.  It would be terrible if support staff would not help that surgeon because he/she didn’t ‘deserve’ the help.  

    If a midwife makes an appropriate transfer from the home setting to the hospital she and her client are treated like dirt.  Many hospital staff members actually defer appropriate care because the client chose to have a (read dirty) midwife take care of her.  This is an unacceptable situation.  Midwives are legal in most states in this country.  Out-of-hospital birth is legal in most states in this country.  Yet, physicians and hospitals will not collaborate with midwives to ensure the best outcome for women due to some notion that midwives are witches and that women who choose midwifery care deserve a bad outcome for their (legal) choice.  What is needed is not a debate over ‘is it safe?’ but it needs to be about how this health care profession can accsess referral care when needed.  I call all physicans and hospitals to step-up-to-the-plate and start making collaborative agreements with all midwives in this country.

  • kalacirya

     I’ll say it again: our maternity care system is broken. Why? Because our maternal and fetal mortality rates are worse than 40 other countries worldwide

     

    Two points:

     

    1) Maternal mortality rates: The USA has a higher risk pool of women than many other industrialized countries.  Take higher risk women with an often inadequate health care system, and you will see higher maternal morality.  This is not necessarily an indictment of the maternity care system in particular, as many of the risk factors are present before pregnancy.  I would say that the Amnesty report makes this clearer than this article.

     

    2)Fetal mortality: On the topic of birthing choices, perinatal mortality is the proper statistic.  Neither fetal nor infant mortality are an accurate reflection of maternity care.  Additionally, some of these statistics are especially not useful in an inter-country analysis.  While the American infant mortality rate might be a useful statistic to look at from year to year, in comparison to itself, it is not appropriate to use across nations.  In the USA, premature babies are considered live births and thus when those high risk babies died more often, they are captured in the infant mortality statistic.  Premature babies are NOT counted in many other industrialized country, making our numbers inflated in comparison.

  • farah-diaztello

    Out-of-hospital birth is legal in most states in this country.

    The laws and regulations governing midwifery vary from state to state, but there is no law in any state that forces a woman to go to a hospital or any other location to give birth. Therefore, homebirth is legal-in-fact for birthing women in every state, and any law that did purport to force women to give birth in a particular location would violate their human and constitutional rights. Whether it is accessible is another matter entirely, of course, especially taking into consideration your excellent point about continuity of care.  As long as women are not allowed to be arrested for the benefit of a fetus–which people are attempting to change in a number of states–home birth remains legal.

  • cozycoleman

    I often hear women use phrases like “They let me/didn’t let me” in regards to their births. Who’s birth is it anyway?

    Until the consumer demands evidence-based care, the hospitals will continue to practice daylight obstetrics, which is a large contribution to our current system’s dysfunction.

    The question is, how do you get the consumer to care enough to become informed prior to their first negative experience? Sadly, for some, that first negative expereince is their last experience on earth.

    Shows like TLC’s Birth Story are wonderful for indoctrinating expectant mothers into believing that they have no choice in their births. Normal, natural births are boring. They make bad drama.  Homebirths are downright dull… bring your knitting.

    And yes, birthing outside of hospital must be legal. You can always say it was precipitous. But some states still deny midwives licensing, which makes the choice to birth at home on in which the parents must either chose to go unattended or the brave crusading midwives must risk punative fines or arrest.

     

     

  • evidencebasedbirth

    I agree with the author. As  much as I think home birth could be improved (with regard to back-up care, CPM licensure, etc.), the focus should really be on the quality of care that is provided to 99% of American women during childbirth– in hospitals. As a nursing professor in the cardiovascular field, I am appalled by the lack of evidence-based care that is provided to pregnant women in hospitals. In my personal experience, I have seen no other medical field that shows such a blatant disregard for evidence-based practice.

    So, let’s DO something about it. Let’s join together on Labor Day, September 3, 2012, to rally nationwide for improved birth in our hospital systems. Every woman deserves to receive evidence-based care. Let’s fight for it together.

    Check out http://www.improvingbirth.org/national-rally-for-change/ to find if there is going to be a rally in your area. And if there isn’t, there’s still time for you to coordinate one in your town.

  • clementinemec

    Certified Professional Midwives are not “untrained”.  Indeed, they are the only kind of provider that is required to be trained specifically in out-of-hospital birth settings.  Doctors, and even Certified Nurse-Midwives are not even required to receive this kind of training, and yet they are legal providers of home-birth in all states.  Further, midwives trained strictly in midwifery, known as direct-entry midwifery, ARE the norm in most countries that included midwives as part of their maternity care system.  Entering midwifery by way of the nursing route first is considered by many of these midwives as irrevelant and rather a waste of time.  The CPM credential was originally created to be the CNM equivalent of core-competencies for entry-level non-nurse (direct-entry) midwifery in the United States, Canada, and Mexico. Not all CPMs practice in strictly homebirth settings.  Many run free-standing birthing centers, and even enjoy collaboration with their local hospital for transports, in areas where such a relationship is allowed to flourish.  

  • clementinemec

    Obstetricians do not practice evidence-based maternity care.  They practice litigation-based maternity care.  

  • cnm3789

    I agree that the question we should be asking is not whether home birth is safe but why isn’t hospital birth safer?  But let’s not further inflame the midwife wars by putting CPMs on one side and nurse-midwives with obstetricians on the other.  We are all midwives.  We all endorse and practice by the midwifery model of care.  We have more commonalities than differences.  Far better to work on fixing the system that restricts practice of qualified and licensed midwives whatever their backgrounds (just to cite one example) than set up these false dichotomies that glorify one group and trash another.