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.”

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!”

“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…Such is the pitch of the ‘home birth debate’ in the United States. And yet, the the research evidence suggests a more nuanced conversation.”

Read more on Babble.com.

Last time the New York Times reported on home birth it was in the “Home & Garden” section. Here’s another story, about the rise in birth video viewership on YouTube, in “Fashion & Style.” (Sigh. When will physiological birth get a page in the “Health” section??) Most of the thousands of birth videos are shot at home — as of today there are 10,900 results to the search terms “home birth” — because taping is rarely permitted in hospitals. It’s mindblowing to think that 30, 40 years ago, women didn’t have access to books or even photographs showing the normal birth process. Now you can spend a whole afternoon birth-surfing.

Here’s a favorite. Here’s encouragement for those carrying multiples. Here’s one of several women singing in labor. And check out this absolutely gorgeous birth shown in a Spanish ad for a bed! And look, a brand new video about midwives and health reform — perhaps the birth of a movement?

ADDENDUM: “The Birth of Amerlyn Grace” — a beautiful, intimate slide show shot in black and white by Austin photographer Lyndsay Stradtner.

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.

There’s no data yet on whether more women are staying home to give birth, but the New York Times reports evidence of a trend: NYC midwives swamped with calls, birth tub outfitters doubling sales, and DVDs of the cult hit Business of Being Born renting steady as ever. Perhaps an article about home birth does fit easily in the Home & Garden section of the Times. (We’d rather see it above the fold on page 1, but hey now…) Several paragraphs are devoted to logistic concerns specific to big apple residents: “the prospect of an inevitably messy process in a tight space invites delicate questions, like, What happens to the rug?” But nobody here laments any fabric stains; one mom says clean-up was just as the midwife said, “not a big deal, it’s like one garbage bag.” The neighbors don’t seem to mind either (at least when these moans and groans are over there’s a newborn to coo at!) Enjoy, and don’t miss the slide show.

 http://www.ipetitions.com/petition/birthathome/index.html

382 2,451 4,899 signatures and counting..

“Ladies, the physicians of America have issued their decree: they don’t want you having your babies at home with midwives. We can’t imagine why not…”


Click here to read the rest of this Huffington Post opinion co-authored by Jennifer Block, Ricki Lake & Abby Epstein

Missouri came tantalizingly close to licensing Certified Professional Midwives last week, with a bill passing the Senate and headed for a sure vote in the House, but was held up because “certain legislators buckled to a well-funded medical lobby,” said one consumer lobbyist. The St. Louis Dispatch reports that the Missouri State Medical Association “strongly opposed the bill over public health concerns,” but the data support the safety of planned, midwife-attended home birth — and history doesn’t support criminalizing healthcare providers.

In the past, the American College of Obstetricians and Gynecologists hasn’t said much publicly about home birth, except that the group “strongly opposes” it. Evidently the buzz over Ricki Lake’s provocative birth documentary and perhaps also the new nationwide “Big Push Campaign” for certified professional midwives has prompted the OB group to make itself clear. In an unusual statement released this week, ACOG denounces the research evidence on planned, midwife-attended home birth, saying that such studies “have not been scientifically rigorous.” ACOG goes further to accuse the woman who chooses home birth of putting “herself and her baby’s health and life at unnecessary risk,” and argues that “choosing to deliver a baby at home…is to place the process of giving birth over the goal of having a healthy baby.” Health-care decisions shouldn’t be based on “what’s fashionable, trendy, or the latest cause célèbre,” cautions the group, and goes on to blame the U.S.’s record-high cesarean rate on “maternal choice” and a “rising tide” of obesity and high-risk pregnancies.

There’s a lot to unpack here. The midwives’ campaign countered yesterday with its own statement, calling out ACOG for playing the “bad mother” card. Indeed, ACOG’s statement strikes at pregnant women twice, first implying that they’re selfish for valuing the “process of giving birth,” and second for being too posh — or too fat — to push.

Let’s look at the latter accusation first: nearly 1 in 3 American babies are born by cesarean section, major abdominal surgery, up 50% over the last decade. But according to CDC epidemiologists, this has little to do with women’s health status or their choices, and more to do with what’s trendy and fashionable for providers — the effective ban on VBAC (vaginal birth after cesarean) among many practices and hospitals, for one. While ACOG dismisses the studies on home birth as lacking in scientific rigor, there is not one peer-reviewed study to suggest that a significant number of women are demanding elective cesareans.

ACOG’s argument against home birth similarly relies on an unscientific premise. “Monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center is essential because complications can arise with little or no warning even among women with low-risk pregnancies.” Certified professional midwives would agree that monitoring is essential, and numerous studies suggest that for low-risk women, they do just as good a job of it at home births. Babies are born just as safely, and their mothers gain several health benefits: 95% have normal, vaginal births — optimal for both mother and baby — without drugs to induce or speed up labor, without episiotomies, and without major surgery. ACOG admonishes women for placing “the process of giving birth over the goal of having a healthy baby,” denying that one leads to the other, not to mention the goal of having a healthy mom.

Finally, there’s a double standard lurking here: elective, medically unnecessary cesarean has been considered en vogue for some time. We know that major abdominal surgery carries with it major risks for both mother and baby, but when it comes to that cause célèbre, ACOG has vocally supported a woman’s “right to choose.”