Who’s really winning the homebirth debate?
By Jennifer Block
Originally published on Babble.com, August 3rd, 2009
Mention that you are planning a home birth and it might be as if you had just brought up Sarah Palin or Palestine: brace for family feuds, public denunciations, and offhand remarks that imply you are selfish and stupid, your midwife is a quack, and your unborn child is a victim already in need of social services.
If you’ve made a documentary that is critical of standard American hospital maternity wards and portrays home birth in a decidedly more flattering light, you might be likened to Nazi propagandists by an obstetrician, as Abby Epstein and Ricki Lake were after they screened their film The Business of Being Born at St. Luke’s Roosevelt hospital in New York City. Or if you appear as a pro-home birth guest on a TV show hosted and produced by doctors, perhaps called The Doctors, get ready for opprobrium of this sort: “You don’t want to be responsible for the death of your baby or the death of your wife!”
That’s also the bad-parent card played by the American College of Obstetricians and Gynecologists, the standard-setting professional organization of doctors for women: a woman who chooses a home birth “puts herself and her baby’s health and life at unnecessary risk,” says a 2007 statement on the subject. “Choosing to deliver a baby at home . . . is to place the process of giving birth over the goal of having a healthy baby.” Ouch.
Such is the pitch of the “home birth debate” in the United States. And yet, the research evidence suggests a more nuanced conversation. Home birth by choice among healthy women in industrialized countries has been studied for four decades. There have been dozens of studies published. The largest to date, published in April in the British Journal of Obstetrics and Gynecology, looked at more than 500,000 births to healthy women in the Netherlands and found that no more babies died among those who planned to give birth at home than those who chose the hospital. “The opinion that a hospital birth is the best option for every woman is increasingly being challenged,” write the study’s authors. “These results should strengthen the policies that encourage low-risk women . . . to choose their own place of birth.”
A 2005 study of 5,000 planned home births in North America, published in the British Medical Journal, also found that babies were born just as safely at home, and that the mothers did much better than compared to similarly low-risk women who had intended a typical hospital birth – with a C-section rate five times less (4% v. 20%) and with hardly any inductions, episiotomies, epidurals, vacuum extractions, or forceps. (A proportion of women who plan home births transport and deliver in the hospital, mostly for non-emergency reasons, depending on how integrated the system is. In the States the rate is around 12%, in the Netherlands around 30%.) In a 2007 review of twenty-eight studies of planned home birth, The American College of Nurse Midwives found such optimal outcomes and safety among home births to be true across countries, health systems, and midwife credentialing systems. In other words, the available body of research suggests that for healthy women with access to care, home birth is a low-risk, high-benefit choice.
This body of research evidence has been enough to convince the American Public Health Association: “Recognizing the evidence that births to healthy mothers . . . can occur safely in various settings, including out-of-hospital birth centers and homes,” the organization ” . . . supports efforts to increase access to out-of-hospital maternity care services.” The international consensus is that women should have the option. The Royal College of Obstetricians and Gynecologists, together with the Royal College of Midwives, says that there is “ample evidence” to “support home birth for women with uncomplicated pregnancies.” The 2007 joint statement continues: “There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families.” The British government, in fact, is now nudging healthy women to stay home. ACOG, meanwhile, likes to pass out a bumper sticker to its members: “Home Deliveries are for Pizza.”
Melissa Cheney is an assistant professor of medical anthropology at Oregon State University. Last year, she got a call from a physician from a county in Southern Oregon with a higher-than-average rate of poor baby outcomes and deaths. “He was trying to explore the hypothesis that midwives and home birth were what was driving deaths in their county,” says Cheney. He told her he knew of three deaths related to home births. Cheney got institutional review board approval from the university to investigate his hypothesis. She was given access to the county’s vital records and hospital databases, and followed this with interviews of medical staff where a death was believed to occur. An independent statistician reviewed the findings. But she could find no deaths. “The physicians were saying that there was a ‘stream of dead babies.’ My question was, where are they? There were no vital records, no death certificates, no statistical evidence of them.”
Cheney asked the physician who had called her if he personally knew of the three deaths. “It was, ‘Such and such doctor told me . . . ‘,” she says. Basically, it was a rumor mill: stories of women and midwives who had transported in labor from home to hospital that had become stories of dead babies. But it hadn’t happened. “We found zero deaths,” says Cheney.
Her findings didn’t go over so well with the task force of 15 physicians that had chosen her – nor did the fact that she is a certified professional midwife (she got the credential so that she could have access to the midwives she wanted to study for her dissertation). “There was a lot of disbelief among the obstetricians of our findings,” she says. “They called me a baby murderer, they accused me of pseudoscience. I thought, these people are not going to be convinced by the data.” Which led her to do a qualitative study of providers from the community. “What we found is that the animosity is so high between midwives and obstetricians that all kinds of rumors spread that are unsubstantiated. A woman and her midwife would transport for something relatively benign, and three or four OBs away, the story was that the baby came in half-dead. You know that game Telephone? That’s the folklore, that’s what becomes the institutional memory.”
When she asked the physicians if they were familiar with the large studies suggesting that home birth is safe, that an emergency transport is the exception to the rule, they admitted that the research evidence did not match up with their lived experience. (After all, they only see the transports, not the 88% of women who give birth uneventfully in their living rooms.) It doesn’t help, says Cheney, that our vital records are threadbare and that we have no standardized surveillance of infant or maternal death in the United States. This enables medical staff to operate on anecdotal data, which are the transports. “They’re using these to judge the entire home birth movement,” says Cheney. This is a natural human tendency, to base knowledge on anecdotal experience, “and we have science to help us get around it. But for this topic it’s not happening.”
“What’s interesting is why these twenty-nine studies have not swayed public opinion and not been integrated into the medical establishment,” she says. “People deeply, deeply believe that a baby cannot be born without massive amounts of medical intervention, and it’s nearly impossible to overturn that cultural norm. There’s something blocking people from operating on the basis of the balance of evidence. There’s much more evidence on the safety of home birth than there is for elective cesarean section or so many of the other things that we do as a matter of course. So why is that? That’s my work.”
In the case of Amy Tuteur, MD, Cheney has her work cut out for her. For several years, Tuteur, better known online as “Dr. Amy,” ran the web site Homebirthdebate.com, whose tag line was “countering the misinformation of homebirth advocacy.” From 2006 to early this year, she posted to this site almost every day, entries titled like “Another Homebirth; Another Baby Dies a Preventable Death,” and “How to Tell if a Homebirth Midwife is a Quack.” But she also ventures off-turf, to the Chicago Tribune, to Slate, to Lamaze’s blog, to Huffington Post and Babble – to anywhere a story about home birth pops up. And there in the comments section she tries to whack it down.
“The most important piece of information that every woman should know about homebirth is that all the existing scientific evidence to date shows that it has an increased risk of preventable neonatal death,” she wrote on Slate.com. “Even the studies that claim to show that homebirth is as safe as hospital birth, actually show the opposite.” This is a typical Tuteur declarative. She has read the data and done her own calculations, and she believes a different number than the one that was peer-reviewed. This is usually challenged by several readers or activists, some of whom have been summoned like a volunteer fire department to respond. A “debate” then ensues, in which Tuteur charges that the study’s authors are, simply, wrong. Then there’s the name-calling. The researchers, which she often names, are “biased,” pulling a “bait-and-switch,” and women are falling for it. “I have written repeatedly about the fact that while homebirth advocates claim to be educated . . . they are easily duped because they lack the most basic knowledge about science, statistics and childbirth itself,” she writes.
So omnipresent has Dr. Amy been on the boards that she began to take on a 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 propaganda machine (rumors live on all sides).
But “Dr. Amy” is real. I sat with her, face to face, for nearly three hours at a Starbucks off Route 1 south of Boston a couple years ago. She is not a researcher, not an epidemiologist, and probably not on anyone’s payroll; she is an obstetrician-gynecologist who left private practice more than a decade ago because, she told me, she’d had it with HMOs and wanted to spend more time with her four kids (she let her license lapse in 2003, according to the Massachusetts Board of Medicine). And for some reason, which I never quite got to the bottom of, she believes in every cell that Home Birth Kills Babies (that’s in fact the title of her most recent post on her new site, The Skeptical OB), and no amount of research evidence will convince her otherwise.
Though the American medical establishment doesn’t go as far as Tuteur in denouncing the evidence base, it also won’t be convinced: “Studies comparing the safety and outcome of births in hospitals with those occurring in other settings in the US are limited and have not been scientifically rigorous,” states ACOG in a press release that renews their “longstanding opposition” to home birth. ACOG’s statements are generally made without reference to any studies, and after I emailed the organization asking for references and clarification on what “rigorous” entailed, they still did not provide any citations. “The highest level of evidence come [sic] from randomized, controlled trials,” they wrote back, adding, “As a health/medical writer, one would expect you to know what qualifies as ‘rigorous.’”
The randomized controlled trial provides the evidence base for “evidence-based medicine,” the movement toward employing only those treatments that have passed rigorous clinical study. Considered to be the gold standard, the highest quality research evidence obtainable, the RCT is basically the classic high school science experiment: divide two groups of subjects with the same characteristics, assign one to treatment A and one to placebo, and observe the outcomes. ACOG’s response is doubly ironic because obstetrics has arguably been the slowest specialty to adopt the philosophy of evidence-based care – indeed, most labor interventions became routine without any study whatsoever, and several, like continuous electronic fetal monitoring and episiotomy, continue to be used even though copious evidence has proved them unnecessary and potentially harmful.
These policies may increase the risk to women and babies. They do have a point about there being no RCTs on home birth, which is often the same point Tuteur makes when she criticizes a study for not comparing apples to apples. But there’s a good reason for it: how many women would agree to be randomly assigned to where they will give birth? Not many, researchers have found. “It has been shown that conducting a randomized controlled trial is not possible,” write the authors of the Dutch home birth study. “Good quality observational studies are therefore the only source of evidence on this subject.” In evidence-based medicine, observational studies are second-tier (because the characteristics of groups A and B are not tightly controlled), but with home birth – and breastfeeding, and other large questions about childbirth for which women will not be subjected to random assignation to answer – they are best evidence possible.
Which brings the debate over safety to a bit of an impasse: if the only research that will satisfy those with authority and power is research that is unfeasible, the controversy will never be resolved. There could be 20 more large, observational studies that come to the same conclusion as those that already exist, but they still wouldn’t be randomized controlled trials. The home birth advocates would continue to say “The research proves it’s safe!” and the American medical establishment would continue to say “The research isn’t good enough!”
The physicians are of course entitled to their opinion, but this opinion is often presented as fact, with the weight of medical authority. An American Medical Association resolution passed last year states without qualification that ” . . . the safest setting for labor, delivery, and the immediate post-partum period is in the hospital” or accredited birth center, and promises legislative action to discourage birth outside it. Again, there is no research cited to back up this claim – because there isn’t any. “We don’t have evidence that home is safer than hospital, or that hospital is safer than home,” says Soo Downe, a researcher with the Cochrane Collaboration, the international authority on evidence-based medicine. “There’s absolutely no evidence either way at the level of randomized controlled trials.”
One of the reasons the medical side has a hard time accepting home birth is that they forget that there are risks to being in the hospital. “It appears that being in a big and busy place with the attitude that birth is dangerous until proven otherwise may bring risks to women,” says Downe, like higher rates of unnecessary surgery and invasive procedures, separation of mother and baby, and emotional trauma. Melissa Cheney calls this phenomenon “multiple interpretations of risk.” “The physicians are talking about dangers to baby, while the mother might be talking about the dangers to her own body, or the danger of feeling victimized by an unnecessary cesarean, and having to go on and parent from a position of victimization. Her definition of risk tends to be much broader.”
Cheney would like medical staff to see the home birth population as a cultural group, with its own language and value system, and for the staff to have a degree of cultural competency. The lack of cross-cultural understanding breeds hostility in the community and in the delivery room during a transport. “There can be a lot of mother blaming or midwife blaming,” says Cheney. “This can produce a very very hostile environment, just at a time when it is crucial that the doctor and midwife communicate across that divide. The outcome is very dependent upon that communication.”
Meanwhile, more and more American women want to give birth outside the hospital setting – and economists have shown huge potential cost savings in terms of health reform – yet physicians’ groups are fighting to keep certified professional midwives marginalized, and in some states, criminalized. The ACOG and the AMA policies prohibit physicians from collaborating with CPMs, which contributes to the hostility, and which may in fact contribute to a birth outcome that’s worse than if a woman’s choice had been supported and the midwife and physician had been encouraged to collaborate. In other words, these policies may increase the risk to women and babies.
Many physicians do support home birth midwives, and they are furious that their professional organization would not only try to dictate what women should do, but also how they should practice. In an open letter castigating ACOG and AMA, Canadian obstetrician Andrew Kostaska, MD, urged the American obstetric establishment to “join the 21st century.” “Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, randomized controlled trial,” he wrote. “Science supports home birth as a reasonably safe option. Even if it didn’t, it still would be a woman’s choice . . . As scientific evidence supporting its safety mounts, however, [ACOG and AMA] will be forced to accede or get left behind.”