stumbling through the home birth debate
My sister asked me some unexpectedly provocative questions recently: When it comes to giving birth, what do i think about “natural” techniques like water birth and involving fewer interventions? or of home deliveries as an alternative to hospital deliveries? or of midwifery?
I’ve learned to be skeptical of any medical product or procedure that presents itself as “natural”, or as an alternative to an established convention. To the extent that we can use products produced in ways that are less destabilizing to ecosystems or more compatible with our bodily configurations and processes, “natural” medicine sounds great. Unfortunately, “natural” products and procedures are typically better described as “unsubstantiated” or “unregulated”. Meanwhile, the hype around alternative medicine seems to be premised more on disillusionment with establishment medicine than on any successes by its challengers.
On midwifery generally, i had only limited exposure, but enough to make me cautious.
So, my biases acknowledged, i dove into the literature…and some of the conclusions i came to surprised me. So, let’s get to it.*
Disclaimer: These are my opinions. If you’re looking for advice, go somewhere else.
what are we talking about
The medical discipline/specialty of obstetrics concerns pregnancy, delivery, and the period following birth. So far as European history is concerned, midwifery and other roles were restricted to women up until the late 1600s. The infusion of experimental and historical scholarship into midwifery seems to have been facilitated by the emergence of wealthy, educated, and well-connected midwives (known as men-midwives), several generations of whom wrote classic texts and developed improved methods and instruments. Childbirth is now attended to by a variety of professional and lay attendants, and while obstetricians tend to attend to hospital deliveries, midwives are not infrequent primary or co-attendants and are ubiquitous in other settings.
Midwives in the United States fall within two basic categories. Certified nurse-midwives (CNMs) are registered nurses, with all the training that entails. They are trained and certified through the American Midwifery Certification Board (AMCB) and share this process with non-nurse certified midwives (CMs). Direct-entry midwives may have no training (lay midwives), have only state certification, or be certified professional midwives (CPMs), a status conferred by the Midwives Alliance of North America (MANA) through the North American Registry of Midwives (NARM).
Convention in the United States is to plan out a delivery in the hospital with one’s own obstetrician and other attendants. The medical establishment promotes hospital births, and CNMs attend to births almost exclusively at hospitals. Naturally alternatives are available, including birthing centers, which may be independent or affiliated with hospitals, and a growing home birth movement. While birthing centers may be staffed with CNMs or CPMs depending on affiliation, home births tend to be attended to by CPMs.
While home birth is a viable option and has been integrated into several other countries’ national health care programs, much of the American home birth movement is motivated by religion, individualism, and suspicion of “establishment medicine”. The likelihood of superstition and pseudoscience is high in light of the high emotional stakes, the high unpredictability, and the tradition of mysticism surrounding childbirth. Someone entering the conversation from a suspicious or superstitious perspective might begin with this decent reality check in Time by Amy Tuteur (whom we’ll hear from again). There will still be plenty of room for disagreement.
what questions are being asked
Studies that compare home deliveries to hospital deliveries (i’ll leave out birth centers) look at a variety of stats, but the lessons they’re trying to extract from those stats are few and straightforward: (1) What are the differences in the uses of interventions? (2) What are the differences in outcomes for the expectant parent? (3) What are the differences in outcomes for the fetus/newborn? I turns out that most of the controversy revolves around (3), so that’s where i’ll focus most of my discussion.
The important distinction, of course, is not between births that take place at home versus at a hospital, but between births planned for home versus those planned for the hospital. A meta-analysis (Wax et al, 2010) we’ll see in more detail next time found hospital transfer rates between a quarter and a third among people planning home births who had not given birth before. Other factors must also be taken into account, for instance the lower risk profiles of home than of hospital births.
The question (1) about interventions does not by itself establish that hospitals use more interventions than necessary. I’ll devote a separate post to this question, and to water births, since as topics they seem to be disentanglable from the intertwined issues of home birth and midwifery (though the issues certainly bear upon each other).
what can we agree on
Some differences appear to be in no (informed) dispute. Midwifery, for instance, is recognized as beneficial. The Cochrane Collaboration, widely viewed as the most reliable—though not infallible—source for medical research literature reviews, has recommended that expectant parents should be offered midwife support, provided their pregnancies are not at high risk of complications better-suited to an obstetrician. This recommendation followed a 2009 systematic review of trials in which expectant parents were randomly assigned to midwife-led or other models of care. These trials appear to have been strictly in-hospital; since planning a home birth without a midwife would obviously be unwise, midwifery seems like a good ideal all around.
Another essentially uncontentious claim is that deliveries planned for home less frequently involve much less use of a variety of interventions. The Wax paper, a recent meta-analysis of a dozen previous studies, concludes:
Planned home births experienced significantly fewer medical interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative vaginal and cesarean deliveries.
The different rates of use ranged from half (cesarean sections) to a tenth (fetal heart rate monitoring) as often, but most interventions (epidurals, epistiotomies, operative vaginal deliveries) occurred about a quarter of the time for home as for hospital planned deliveries.
Planned home deliveries also appear to have marginally better outcomes for the expectant parent: The Wax paper also concluded that “women intending home deliveries had fewer infections, ≥3-degree lacerations, perineal and vaginal lacerations, hemorrhages, and retained placentas”, while none of the other adverse outcomes measured was significantly more likely among those planning home birth.
what are the controversies
The major controversies seem to be (1) whether fetus/infant mortality rates are different between deliveries planned for home versus for hospital and (2) to what extent different sources of midwifery training and certification play a role. In the sequel to this post i’ll briefly review several studies that have received much attention in this debate, draw some provisional factual conclusions, and consider their context, interpretation, and implications for choosing a model of care. In the meantime, please clue me into any contentious topics i’ve missed or sources that should inform my opinion.
* This post is premised on the decision to produce children, with which i, for my own part, disagree.
The website of the American Pregnancy Association tends to top the Google returns for pregnancy-related queries, bested only by Wikipedia. Some reading through the cite reveals that they heavily favor alternatives to hospitalization and pretty overtly oppose caesarian sections and other interventions, perhaps unsurprising in light of their “nature”-oriented sponsorship. A skeptical inquiry then brought me to Heather Corinna’s discovery of the APA’s origin as a Crisis Pregnancy Center and exposure of many other inaccuracies, omissions, and biases that make it unreliable as a resource even for those who wish to carry a pregnancy to term. This is a site to avoid. (Corinna’s site Scarleteen, on the other hand, is one to celebrate.)