Home birth is hotly controversial, so you can bet that when any study about it is released it gets thoroughly dissected (or torn to pieces) by the side bound to clash with its conclusions. That’s exactly what’s happening to the new study being fast-tracked by the American Journal of Obstetrics and Gynecology.

The meta-analysis, led by Joseph Wax, MD, of Maine Medical Center, pools data from several studies and is making headlines that home birth triples the risk of infant death. It is also being widely criticized as “deeply flawed.” “We are puzzled by the authors’ inclusion of older studies and studies that have been discredited because they did not sufficiently distinguish between planned and unplanned home births — a critical factor in predicting outcomes,” says a press release by the American College of Nurse Midwives. “A meta-anlysis is only as good as the articles you put into it,” explains Michael Klein, MD, a professor and researcher based at the University of British Columbia. If you put “garbage in,” he says, you get “garbage out.”

But Klein is not only calling the Wax study garbage, he says the garbage stinks. Klein told CBC News that it is “a politically motivated study.” Klein’s colleague Patricia Janssen, who led a study out of British Columbia that was included in Wax’s paper, called it “sensationalist.” The grassroots Big Push for Midwives campaign charges: “Their ultimate goal is obviously to defeat legislation that would both increase access to out-of-hospital maternity care for women and their families and increase competition for obstetricians,” says Susan Jenkins, legal counsel for the campaign. (Bills are currently on the governor’s desk in New York and in the Massachusetts’ senate.)

There is of course no way to know for sure if politics is influencing science, but the Journal’s own July 1 press release announcing the article (named an “Editor’s Choice” two months before its pub date) quotes the journal’s editors stating, “This topic deserves more attention from public health officials at state and national levels.” At the very least, we can say that the editors believe the study has political implications.

Here’s what’s particularly curious: Wax and coauthors acknowledge that some of the included studies were not powered to report mortality rates, and when they analyzed the data for mortality and excluded those studies, they found “no significant differences between planned home and planned hospital births,” to quote the study verbatim. But this is not the study’s banner finding. Instead, the authors include the very studies they had excluded and report as their conclusion that “less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.”

The ACNM calls this conjecture. “This conclusion cannot be drawn from the data presented in this meta-analysis. In fact, a number of credible studies have shown that the increased use of technology and interventions in childbirth for low risk women…do not improve birth outcomes.” The National Association of Certified Professional Midwives accuses, “the authors of this study are obscuring important information about the safety of home birth and neonatal outcomes.” The daggers are coming from all directions, including Canada and the UK, where 4 in 10 women are now offered the option of home birth.

If politics are at play here, what’s most troubling is that they are deaf to patients’ rights. The reality is that some women choose home birth, and several large, well-designed cohort studies (of actual women planning home births) have found comparable safety and significant benefits over hospital birth. Those studies (out of Canada, the Netherlands, and the U.S.) suggest that part of what makes home birth safe is the presence of an attendant trained to handle emergencies who has the ability to transfer to obstetric care if needed. Why does the (newly renamed) American Congress of OB/GYNs continue to oppose legislation that licenses and regulates home birth midwives as it prohibits its members from collaborating with them?

*UPDATE 7/10 — For a great break down of the science, look to Amy Romano’s Science & Sensibility. She asks why the authors did not graphically display their results using the customary “forest plot,” which usually accompanies meta-analyses (perhaps because it would have shown “a confidence interval you could drive a truck through”?). But she also questions whether meta-analysis is even appropriate for studying the safety of home birth. “We need to continue to study home birth using all of the tools in the research toolbox, qualitative and quantitative, to determine under what circumstances home birth is safe and how to optimize care and outcomes in all birth settings. And we need to stop pushing home birth underground in the United States where it remains a fringe alternative, poorly integrated with the maternity care system,” she writes. “Shame on the American Journal of Obstetrics and Gynecologists for making this task even more difficult than it already was, by publishing and publicizing a junk meta-analysis.”

In today’s New York Times, Section A, a story about a tiny, impoverished Navajo hospital in Tuba City, AZ, doing birth better than anyone: “this small hospital in a dusty desert town on an Indian reservation, showing its age and struggling to make ends meet, somehow manages to outperform richer, more prestigious institutions when it comes to keeping Caesarean rates down, which saves money and is better for many mothers and infants.”

How do they do it? Midwives attend the majority of births; obstetricians are available if needed. All the providers are on salary, so the profit motive is gone. And the hospital is federally insured, so it hasn’t been bullied into banning VBAC like so many others around the country. Even though the patient population has risk factors like hypertension and diabetes, the cesarean rate is a mere 13.5%.

“Tuba City…could probably teach the rest of the country a few things about obstetrical care,” writes the Times. “But matching its success would require sweeping, fundamental changes in medical practice, like allowing midwives to handle more deliveries and removing the profit motive for performing surgery.”

Investigative journalism lives at California Watch, which published this article about maternal mortality. An independent task force investigating the problem found “the most significant spike in pregnancy-related deaths since the 1930s…it’s more dangerous to give birth in California than it is in Kuwait or Bosnia.” But the state has yet to release a report.

This investigation is not the first to reveal higher than officially reported numbers of deaths, but it appears to have gone deeper than previous reviews in Virginia, New York, and Florida. “The group’s initial findings provide the first strong evidence that there is a true increase in deaths — not just the number of reported deaths.” And unlike previous reviews, it sought to determine causes, which are usually attributed to women: obesity, older mothers, and fertility treatments. The data, however, suggest otherwise, according to Elliot Main, MD, the task force’s lead investigator: “What I call the usual suspects are certainly there,” he told California Watch. “However, when we looked at those factors and the data analyzed so far, those only account for a modest amount of the increase.” What then is to blame for the increase?

Main said scientists have started to ask what doctors are doing differently. And, he added, it’s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.

While the findings appear to be languishing with the state department of public health, the Joint Commission, which certifies and accredits hospitals, is taking action. On January 26 it issued an alert, stating: “Unfortunately, current trends and evidence suggest that maternal mortality rates may be increasing in the U.S.”  After receiving the CA task force’s report, the Commission “issued incentives for hospitals to reduce inductions and fight what it called ‘the cesarean section epidemic.’”

Women denied health insurance because they’ve been raped, because of domestic violence, because they’ve had a C-section… Insurers telling women who’ve given birth by cesarean, “Alright, we’ll cover you–but only if you get sterilized.” Parents denied coverage for their children because they’re too big, too small, because they hold their breath …(?!?) It sounds too outrageous/absurd/illegal to believe, but listen to the testimony of Peggy Robertson (courtesy of the Service Employees International Union’s campaign for healthcare reform):







Here Robertson illustrates the awful bind so many women are in: No hospital will take her for VBAC, she doesn’t want another cesarean, she feels she has no choice but to have one, yet she can’t afford it. Her health insurer’s answer to this? Don’t have any more children. So much for reproductive choice.

RH Reality Check’s Jodi Jacobson has a novel idea: “I say the insurance industry as currently constructed is too sick to function and should be declared a national ‘pre-existing’ condition of which we should rid ourselves permanently.”

With the historic news that a majority of the U.S. workforce is now female, it’s clear that American women have more power than ever before, says OB/GYN and bestselling author Christiane Northrup, MD. But is that power reflected in the healthcare available to women? No, she writes in an essay for Huffington Post, especially when it comes to childbirth:

“Our so-called healthcare system, which is a direct reflection of the beliefs of our culture, sees the female body and its processes (like labor) as an accident waiting to happen…The truth is that labor and birth need not be the emergencies we think they are. And the medicalization of birth actually does more harm than good.”

Northrup criticizes the rising rates of cesarean section and labor induction, and cites the rising maternal death rate. “Studies have repeatedly shown that in healthy mothers with no risk factors, home birth is as safe as hospital birth. Increasingly, savvy women who trust their ability to birth normally [and, we should add, who have the resources] are opting to avoid the hospital altogether.”

Northrup concludes the essay with a call to action: “When it comes to pregnancy and birth, we as a culture and as individuals need to wake up and claim our right to literally birth right!”

In the latest example of a woman reclaiming her birth rights, Joy Szabo (left) of Page, Arizona, is refusing to have the cesarean section that Page Hospital is ordering. Szabo had her 1st child vaginally. Her 2nd child was delivered via emergency cesarean at Page — and she was very thankful for it. She had her 3rd vaginally (VBAC) on the same L&D ward. But now, because the hospital has changed its “policy,” it has told Szabo that VBAC is no longer allowed, and that her only option is a cesarean. Page Hospital’s CEO Sandy Haryasz (sandy.haryasz@bannerhealth.com, 928-645-2424) even threatened legal action. “I asked Sandy what would happen if I just showed up refusing a C-section and she said they would obtain a court order,” Szabo told the Lake Powell Chronicle. “They don’t want to allow VBACs because she said they aren’t equipped for emergency C-sections, but if they can’t do emergency C-sections, they shouldn’t be having labor and delivery at all. That’s why women go to the hospital to have their babies — in case there is an emergency.”

Since coverage in the Chronicle and on CNN, the hospital has backed off the court bullying, but it is still deferring to its “No VBAC” policy. Szabo’s doctor supports VBAC, in theory, but told her he’s powerless. “He was wringing his hands, and said he would have to do [a cesarean] if the hospital told him he had to,” Szabo wrote in an ICAN blog post. “He told me he would lose his licence if he didn’t. I have looked into it and have yet to find where doctors lose their licence for having ethics. But it was clear to me that I was not safe in this hospital, and if I step foot in the building, I would have a cesarean, and my doctor would do it while I scream in protest.”

The closest hospital Szabo can find to support her choice is in Phoenix, 350 miles away. In order to avoid surgery, she will leave her family in mid-November and rent an apartment in Phoenix until she goes into labor. Her husband probably won’t make the birth. In the United States, it is illegal, unconstitutional, and medically unethical to force a competent adult to have surgery for any reason. And yet, some 800 hospitals officially “ban” VBAC and another 600 don’t have a single provider willing to attend, forcing hundreds of thousands of women into this situation every year.

The Big Push for Midwives campaign — 10,000 Facebook members strong — is taking their message to Congress this week with a Capitol Hill Issue briefing “on how out-of-hospital maternity care reduces costs and improves outcomes,” writes the group. “Studies show low-risk women who plan their births with out-of-hospital midwives have outcomes equal to low-risk women who deliver in the hospital, but with far fewer costly and preventable interventions.” Not to mention unnecessary and harmful interventions! Increasing women’s access to midwives and birth centers should be a no-brainer, but so far, nobody at the healm of health care reform is talking about the need for maternity care reform, which could save the country billions of dollars a year. (Read more about the potential cost savings in the L.A. Times.)

You can help out the Big Push by spreading the word about the briefing, scheduled for this Thursday, May 21, and urging your representatives to attend.

You’d think that between Erykah Badu’s home-birth twitter and Ricki Lake’s film success and the New York Times coverage that we’d moved beyond dissing home birth as fringe — “extreme.” Apparently not. The current New York magazine titles a feature about it “Extreme Birth.” The piece, by Andrew Goldman, tries to be a character study of Cara Muhlhahn, the home-birth midwife and now memoirist featured in Lake’s film The Business of Being Born. But after raising her to a teetering pedestal, crowning her “the fearless — some say too fearless — new leader of the home-birth movement,” Goldman shoots her down. It feels more like a character assassination — of both her and the movement.

This is unfortunate for many reasons. As Goldman himself admits, routine maternity ward monitoring, inducing, and anesthetizing have added up to millions of unnecessary cesarean sections (latest CDC rate: 31.8%) — a “hospital childbirth system gone insane.” Midwives who attend home birth provide a much needed, safe alternative. But Goldman can’t quite buy that (or manage to cite any research one way or another). He claims that Lake’s movie “de-radicalized home birth, conflating it with garden-variety natural childbirth and allowing Muhlhahn, largely unchallenged, to argue for its safety.”

Here’s the deal on safety: The American College of Obstetricians and Gynecologists claims that it isn’t safe; the American College of Nurse Midwives and the American Public Health Association claim that it is. The research evidence clearly demonstrates that birth outside the hospital with a trained midwife is not only as safe for the baby, but safer for the mother, provided she is considered “low risk” — a healthy woman carrying one full-term, head-down baby.

What does Goldman mean by “garden variety natural birth” and where can you get one? The “painful truth” is that it’s an uphill battle to avoid unnecessary intervention once you check yourself into a garden variety U.S. maternity ward (these “pushed births” are epidemic). In many places, like NYC, there is very little gray area between the extremes, if you will, of home and hospital. And freestanding birth centers are great if you can find one, but there’s no real clinical difference between there and at home: every piece of equipment at a birth center a midwife can bring to a home birth. If labor isn’t progressing normally or a complication develops in either location, you transfer care to the hospital.

This concept of transporting a birth from home to hospital is a toughy, especially for reporters — it looks like failure. The anonymous OBs quoted in New York magazine call transports “dumps” and “train wrecks.” In reality, transports are normal and appropriate. These are the women who actually need advanced medical intervention; most just need pain relief or antibiotics (the C-section rate for planned home birthers is under 5%). The option of transport to a fully equipped hospital is what keeps home birth safe. Supportive physicians embrace the role of providing appropriate medical intervention and emergency care, rather than demanding that every woman give birth in the hospital and be treated as if she’s an emergency.

Several times in the NY piece, Goldman thinks he’s catching Muhlhahn in flagrant malpractice, but this is because midwifery standards and obstetric standards differ so, and because Goldman is relying on a cultural bias that obstetrics is more scientific. But it’s not.

Yes, hospitals and physicians restrict women to 24 hours of labor after their waters have broken (many providers want you induced with Pitocin immediately after membrane rupture), but that’s just standard protocol, not science. The best, largest study actually showed that a woman can labor four days without risk to the baby. Goldman also sanctions Muhlhahn for underestimating a baby’s weight, and quotes an OB who claims she should have known the baby was “too big.” But again, the evidence shows that even the highest-tech ultrasounds can be off by two pounds, and that it’s impossible to predict which babies’ shoulders will get stuck. Even ACOG doesn’t recommend inducing or sectioning based on size guesstimates.

The truth is, standard maternity care is not evidence-based care (see this recent report.) And this is why more women are interested in giving birth at home. Not just so they can have candles and music and a better “experience,” but because they know that checking into a hospital means exposure to preventable risks.

Which is really the shame in all this. Because most Americans are skittish about home birth, and no woman should feel it is her only option for that garden variety, supported, physiological birth.

As for the higher-risk births (twins and breeches for instance), the ideal setting is a hospital in theory, but some midwives agree to attend them at home because they know that their clients have zero chance of a vaginal birth otherwise. They feel an obligation to support women’s choices and help them avoid unnecessary surgery. And they have the skills to do it (the current obstetric training for breech delivery is a cesarean section!). The system is shameful to an extreme.

Woah, Florida dept. of health officials really need a childbirth ed. class. Twenty — yes, 20 — state and federal law enforcement and government agents RAIDED the Miami Maternity Center on December 24, Christmas Eve, based on allegations that the center was baking their clients’ placentas together in a single batch and grinding them up into pills for distribution. The midwives deny any wrongdoing. ”They charged in here as if I were making crack cocaine,” said one midwife. Or maybe a witch’s brew…. Read more about it in the Miami Herald.