Field of Science

Do women matter in childbirth?

Image in public domain.
The news this past week was full of stories about home birth--they're on the rise in the US, even though rates remain comparatively tiny, and a home birth advocate in Australia died from unknown causes after giving birth at home. I pinned a piece I just wrote for Slate to the rise in home births, hoping in that piece to clarify that not all home births are created equal and one with an experienced, well-trained certified nurse midwife (CNM) with a hospital-based, backup OB and hospital access is the gold standard if home birth is your choice. I also argued that many women in the US don't have this choice or the choice of a hospital that offers an environment conducive to health and bonding between mother and child, which is, in fact, the case. A blogger over at Babble summed up this core argument better than I did in her post about my piece. 


The piece opened with a paragraph about my own experiences with the births of our first two children. In my original draft, I'd had that information at about paragraph three and written differently, but for reasons of narrative and word count limitations, it was moved to the top. It opens with a mention of fluorescent lights--not the way I'd originally described it, which was simply, "fluorescent lit"--and continues with a very brief description of that birth and the sequelae. The birth was no picnic--what birth is?--and my husband and I both were not thrilled with aspects like hospital visitors peering in through the open door as I laid there, spread eagled in stirrups, pushing and covered with the effluvia related to birth. But the aftermath was what left us so upset that to this day, we just don't talk about it with each other. 


I described this aftermath briefly in the article--it consisted of the hospital's forcing our son to have 12 blood draws for glucose testing for no medically indicated reason (he was full term, perfect Apgars, feeding well, all readings were normal, our pediatrician was appalled) against our will and without our informed consent. They also aggressively threatened us with separation from our healthy son and with dismissal from the hospital while they retained our son, unless we took him against medical advice. I was probably a hormonal mess--I had just given birth after three days of sleepless prodrome, we were first-time parents--but hearing the click as they ripped into his heel 12 times and listening to him shriek with pain every three hours (during which we anticipated each draw with growing dread) made me feel like I was feeling what he did, and that empathy between us has persisted to this day. When we finally did leave the hospital, within a day or two, I was fighting a raging hospital-acquired infection that required some powerful drugs to treat and interfered with my ability to breastfeed our boy.


It was these effects on my son--not me--that led us to pursue home birth for our second child, born in 2002. I was terrified of the prospect of a home birth, not because of safety issues--the literature I could find at that time indicated good safety profiles for CNM-attended births with an OB backup and hospital access nearby, which is what we had--I was terrified about the pain, about whether I could do it. But I forced myself to do it because I did not want our second son to go through what had happened to our first without medical indication. 


It wasn't because I had some nutty idea about a beautiful or lovely of fluffy birth experience. Birth isn't fluffy. It's hard as hell, and yes, emergencies can be sudden and fatal. We were fully aware of that. A hospital was blocks away. Had it not been, we'd've elected simply to be in a hospital because safety would have tipped the scale that way. When my water broke and I went into labor, I stood in my kitchen and ate some lasagna, then--dilated to about a 5--I went into my bathroom, looked at myself in the mirror, and said out loud to myself: You can do this. You're scared shitless, but you can do this because it is best for your son. That was our conclusion at the time, and that's what we did. Now, when someone asks me about the 1 to 10 pain scale, I know what my 10 is. Was I comfortable? No, not at all. Was he comfortable, peaceful, safe, and with me without separation from the moment he was born? Yes, he was. And only one heel prick, for the metabolic screen.


Our third child was born in 2006, in a different hospital, five years after our first hospital experience. This hospital was new, and they did labor, delivery, and recovery all in the same family-sized room, with family welcome at any time of day or night. They never once separated our son from us, they helped us with breastfeeding--it turned out that because of a motor deficit, he couldn't--and they did do two blood sugar draws, each carefully and clearly explained to us and done with our informed consent. I sent flowers to the staff after we left because they had done everything that was the right thing for our third and final son and they'd had a hard couple of days that had included a neonatal death on the L&D floor. This last birth of ours was the kind I'd choose again were I going to have any more children, which I am not.


The thing is, that last experience is not one that is widely available to women, women of any ethnicity or socioeconomic status. Many women I know have two widely different options where they live: birth in a hospital with a poor reputation for birthing women and childbirth, or childbirth with a direct-entry midwife who does not have the level of training of a certified nurse midwife (an RN) or the OB or hospital backup. To have a better option, you have to be living in just the right place and have just the right kind of insurance. Talk about white privilege. Speaking of which, does anyone really think that the hospital would have kept us there with our first son, against our will, had we not, at that time, had white-glove health insurance? 


In the Slate piece I wrote, I argued that women need a spectrum of choices that are best suited to their situations. Stress and anxiety and separation from the mother at birth are not optimal childbirth outcomes and rarely are necessary for a birth that proceeds normally. CNM-attended births are associated with specific benefits in this regard. In the piece, I argued that a national infrastructure of CNMs who are associated with OBs and have hospital access would be a boon to women everywhere, giving them the choices we didn't have in 2001 and that many still don't have today. Whether a woman chooses to birth at home--and increasing numbers of them are--or in a hospital or possibly best of all for low-risk pregnancies, a birthing center--there are safer and stress-reduced options that should be available. I also noted that a recent UK study found that home births with the gold standard I describe above are safe for low-risk women who have already had a child, but not for women giving birth for the first time. Birth in a birthing center, however, was safe for any woman who was low risk. I also cited studies about childbirth factors associated with post-traumatic stress disorder in mothers. This is not simply a theoretical exercise.


In this society, no one has a right to a personal and informed decision, yet everyone has a right to tell someone how to do things. After that piece appeared, some people read the central message--a need for choice so that mother and baby can be healthy, safe, with limited stress and with each other whenever possible--and some others read the first 157 words about our experiences among the 1302 words of the piece and began to attack me. They misread some of what I wrote and accused me of linking my first son's autism with the unnecessary and invasive interventions inflicted on him in his first 36 hours. I did exactly the opposite. They accused me of being a narcissistic princess who did a home birth only to make myself more comfortable and without consideration for my son, writing only for my own benefit (which is odd, as I'm all done with childbirth). Again, the opposite is the case. They accused me of being an entitled white woman with no idea of how poor people live and access medical care...and that one also is untrue. Maybe I am entitled now, although I feel that I've never lost touch with my roots. I've been poor. Very, very poor, very sick, with no access to medical care at all. I'll never forget the clinic doctor who did my lung X-rays for free--I had severe pneumonia--when I didn't have a quarter to my name. I'm not poor now, and I'm glad, but I have experienced it close up and personal. The midwives I've had have always had a sliding scale for their already relatively minimal charges and in some cases provided prenatal care to mothers for no money at all.


And some commenters can't let go of the fluorescent lights that open the piece. I'll admit--I am photophobic and I do avoid fluorescent lights. But our problems with the hospital--which, by the way, were not unique in our community--were not about the goddamned lights or even about our experience. It was about what happened to our son. Period. Those events were so powerfully embedded in my psyche that when I returned to that hospital five years later to have my thyroid removed, pulling into the parking garage and walking through the doors brought on, unexpectedly, a huge anxiety attack that I had to force my way through just to keep on walking. People can diminish what happened to us as not really traumatic in the grand scheme of things, but we are simply people with our own histories and own triggers and own experiences, and these--not other people's experiences--dictate our reaction to things and the decisions we make. That's so clear to me, that perspective taking--yet it seems to escape a whole lot of people.


The commentary on the Slate piece has been highly informative to me. I have a deep interest in how the Internet allows open discussion and how people take advantage of that discussion, for better and for worse. In this case, rather than address the core arguments of the article itself, many many of these comments have been personal--deeply personal--attacks on me, my white privilege, my (presumed) socioeconomic status and history, my "narcissism," my whining about fluorescent lights, my alleged linking of my son's autism to those earliest hours of his life. So very few of the comments talk about the core discussion at hand, which is that in this country, women--from every ethnicity and every socioeconomic background--deserve respect and dignity and consideration while they're giving birth and access to safe care that provides it. 


And many do not have it. That is the problem.


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ETA: And nothing new, of course. I blogged this previously on my parenting blog, as well.


Below are links to a couple of posts that address some of these issues of the complexity of choice and access. If more arise, I'll add to them here.


Meredith at A Mother Is Born has written a nice summary with bullet points of some of the main issues around birth choice. 


Ceridwen, at Babble, has also posted a piece that does a good job of summarizing some of these issues. I link to it in the above post, but wanted to feature it here, too.

42 comments:

  1. Well stated. There should be no need to justify your experience and you are right, it isn't particularly unusual. There are many women whose experience of child-birth is far from ideal and as my wife and I discovered, it's not really talked about much. I personally have met several women whose first births in hospitals led them to choose home for their seconds. The more I read and (as a husband and father) hear, it seems that more women need to make public their experiences and help shift many backwards policies regarding birthing.

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  2. Common sense ain't that common. Which is why I was thrilled to read your piece (and which is probably why you were attacked). I'd like to think that you are part of generation coming into their (our) own able to see shades of grey, not constrained to defending the old black and white positions, and that sees science as an outgrowth of curiosity, rather than a hammer with which to batter those with different opinions. At least there's two of us: I'm right there with you on this. Bravo on the piece.

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  3. Thank you so much for a great piece. I'm from the uk and we had our first child at home before moving to the states. I have been lucky to find a phenomenal midwife here and have had two subsequent home births in Colorado. Home birth is great when you are in the care of medically trained professionals with an OB back up at a hospital, should you need it. It is very frustrating to read constant attacks on home birth when in my experience it has been a very successful way to birth where I feel like I was accorded great respect and care from those attending me, which is not what I hear from so many women friends who have been through traumatic 'safe' hospital procedures.

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  4. I am so thankful that we are finally hearing some voices emerge from the home birth debate acknowledging that there are as many "right" choices about birth as there are women. Even if we had perfect evidence - which we do not - there are just so many contextual variations that can render the evidence meaningless for an individual woman. And there are such serious problems with our health care system in general and our maternity care system in particular. There are pockets of excellence but in many areas hospitals and hospital-based providers are failing women and babies. Miserably. The health consequences for the public are serious. Women face really difficult choices, usually with almost no information/data to go on, and in the context of a culture that judges mothers and fears birth.

    One nit to pick: I agree with your gold standard but I would caution the assumption that CNMs should provide the care. (I am a CNM who has practiced in home, birth center, and hospital and had two home births, one with CNMs and one with CPMs). I absolutely agree that the educational standards should be rigorous, and I know first hand that CNM education is rigorous. But few CNM programs are rigorous about teaching low-technology care or home birth skills such as how to perform risk screening for home birth, manage a transfer, etc. Much of the education has nothing to do with birth at all. CNMs are technically primary care providers, so we technically have an entire adult primary care curriculum packed in, along with gynecology. In our maternity rotations, we spend a lot of time learning about pitocin, epidurals, and electronic fetal monitoring because we have to know how to safely use these tools. We relish the natural, low-intervention births we get to attend, but they are not the norm. We learn to respond to complications with hospital-based treatments, instead of learning the hand-skills or low-tech strategies to stabilize or resolve a complication when it occurs remote from those resources.

    Of course, some CNMs are incredibly skilled and safe home birth midwives. This is usually something that comes with years of experience. Many of the exemplary home birth CNMs I know were direct entry midwives before they were CNMs.

    Hospital-based midwifery and home-based midwifery are overlapping skill-sets, but each also has a set of specialized skills. The midwifery profession must take seriously the task of preparing midwives - whatever national credential they have - who can practice safely in low-tech settings.

    Thanks again for a really great article.

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  5. Interesting insight--thanks for providing it. If I were the president or Bill Gates or something--which I'll never be--I'd try to have an infrastructure set up that specifically funds CNMs for these purposes with incentives for them to practice in underserved areas, etc. That's a dream, I know, but it would be ideal. From what I understand, nurse practitioners are headed toward taking on a large part of family practice healthcare...and it seems to me that CNMs could have a similar expanded role, except for pregnancy and childbirth.

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    1. Even if you had this system, many state laws make it nearly impossible for those with the qualifications who want to serve in underserved areas to do so. That is my frustration.

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    2. That is indeed a frustration, and I was thinking that as part of the system, regulations would make it possible for them to practice in those areas. It's a huge proposal and would require a legislative and educational sea change, but every change takes time and effort.

      Some MDs and nurses receive their medical training or have student loans cancelled in exchange for agreeing to work in historically underserved areas for at least a period of time (there's even a visa program that allows foreign students to do this). So the mechanisms are in place, and some regions may already incorporate CNMs into these programs http://nhsc.hrsa.gov/ --although it seems to be mostly for primary care, not specifically childbirth care (?). I actually know women who would be willing to do the RN+2 yr CNM training and engage in this practice; surely there are more than those whom I know? It would create jobs (for their training, for them, for their practices), serve underserved areas ("maldistribution" remains an issue http://depts.washington.edu/uwrhrc/uploads/CHWSWP70.pdf), and--I'm arguing--expand and improve birth choices for women in these areas.

      It's not a new idea and the nascent infrastructure for it exists. Is it a pipe dream? Every effort at cultural change starts out that way, right? --Signed, Emily (Don Quixote) Willingham

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  6. Hi Emily,
    The people who attacked you, did so because Amy Tuteur sicked them on you. She has a facebook page called Fed Up with Natural Childbirth..

    https://www.facebook.com/groups/199827500028384/

    Naturally, you can understand why your fair and balanced article was attacked; these women are on the hunt for anything that leans, even a little bit, to the more natural side of things.
    Don't take it personally, really. Anyone who obsesses day after day after day about another woman's decision to birth, probably is a little off kilter to begin with. It gets so tiresome. I'm sorry that you became a target.

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  7. Thanks for letting me know. I suspected a flying monkeys situation, as the antivaxx people are also prone to that tactic. Ironic, isn't it?

    Like I said, I knew it would happen and tried to steel myself for it, but didn't succeed 100% or anticipate how little otherwise articulate people would address the arguments of the article itself. What I do know is that someone researching home birth has something to read that gives them information to consider and that we cannot consider ourselves fully operational for pregnant and birthing women until we address these gaps.

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  8. Interesting Facebook page. "The woman who wrote the Slate article on homebirth is upset at the response she got." Not all of it, just the parts involving people's inability to read and stay on point.

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  9. OK...@skeptical mother...after going to your blog and looking at the screenshots on this post and this one, I would please like to have back the few minutes of my life I spent trying to carefully respond to Amy Tuteur's comments. Beck, Limbaugh, and Coulter? What a waste and so counterproductive.

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  10. Just for the record, I did not confuse the 12 blood draws for glucose screening for the metabolic testing that is done on all newborns. It was specifically for blood glucose readings, and we read every single value as it registered, and they were all well within normal range. That was the major reason for our immense frustration with the hospital. Normal reading after normal reading, they kept insisting on more readings. He was receiving supplemental feedings in addition to colostrum, and he never once had a reading out of normal range. Their rationale for the initial test was that he seemed "irritable." That was all--no eyerolling or lethargy or jitters, etc. That irritability remained throughout his infancy and into toddlerhood and was, we now realize, a part of his autism. At any rate, after one or two tests, the glucose measures made it clear that hypoglycemia wasn't the cause.

    As I've noted here and elsewhere, our pediatrician was appalled that the hospital had done this, so the judgment that it was medically unnecessary was not only my own. If it makes people feel better to pretend that these blood samplings were somehow necessary and that my husband and I are just medically naive and didn't understand...that alone would signify that these were done without our informed consent. The case is, however, that we were very well aware of exactly what they were doing, but they never provided a rationale for doing it. They just autocratically informed us that it was being done and told us that if we left without doing it, insurance might not pay for any of our hospital stay.

    My children have all had the appropriate newborn screenings, whether born at home or in the hospital. Our state actually required that two sequential metabolic screens be submitted, at a two-week interval (http://www.dshs.state.tx.us/lab/newbornscreening.shtm). These screens are distinctive in that the blood is applied into several circles on a blood spot card. The glucose testing is done with a strip and a glucose monitor. We did not conflate the two.

    FYI, the AAP has set guidelines (as of 2011) for glucose monitoring of neonates, and they state that it is not necessary except for high-risk infants. Our full-term, perfect Apgar, healthy son was not in that category (I had no GD or other risk factors, either), but guidelines didn't exist at the time for this "controversial area," so the hospital just did whatever it wanted. http://www.medscape.com/viewarticle/738204

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  11. If anyone would like to see a continuation of how people will focus on every single datum about the *person* without talking about the *issue*, Facebook page cited above is a perfect example. "Le sigh."

    If you're here from that page and reading, feel free to email me to ask me about my hospital-acquired infection or any other minutiae that seems of interest to you and that you are "distrustful of" in some way, instead of speculating about it on a Facebook page. ejwillingham at g ma il.

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  12. I apologize for speculating. I deleted my comments. I've seen so many comments about things "not being medically necessary" based on information received from woo advocates after the fact. I had assumed you were coming from a similar position and that wasn't a fair assumption.

    About your points -- I do think that homebirth would be safe enough with CNMs, with OB back up, standardized transfer procedure, and proximity to a hospital. I think there would probalby remain a slightly increased risk if a rare complication occurred. However, this isn't the scenario for most homebirths in the US. Many women I know who homebirth, and having had out of hospital births myself I know many, believe untruths about the relative safety of home and hospital, and aren't basing their decisions on objective information. I know I wasn't. I also think that no matter what, it is only a small minority of women who will want homebirth. A system of CNM run close to hospitals might be ideal. I still think the best bet is to push for better treatment in hospital than to encourage home births.

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  13. @becky...Thank you for coming here and posting and talking about the topic at hand. I can't say how much I appreciate it. One reason I wrote that article was so that if a woman were considering home birth, she might find this information and realize that not all home births are the same, that there's really a gold standard for it if you're going to do it. The other reason was to highlight how few choices so many women have--and I agree wholeheartedly that a system of CNM-run centers associated with/near/adjacent to a hospital would be, for many many women, the ideal.

    I get edgy about the emergency possibilities with a home birth, but my opinion about those or my own worries about it won't help a woman who's committed to having one or who's so put off by what's available in her local area for hospitals that she'll have a home birth instead under not-the-best circumstances. I agree that pushing for hospitals everywhere to offer better facilities for mother and child is ideal--and that takes me right back to what you say about a CNM system. I think we need that badly.

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  14. Every comment and person deserves dignity and respect - even if you don't agree with it.

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  15. Agreement is not the issue. I *welcome* disagreement that is on point. I do not, however, welcome anti-science cut-and-paste, which are endemic in the world of vaccine discussions, I don't welcome racist/sexist attacks, and I don't welcome personal attacks. For what it's worth, I've yet to delete a comment on this blog that wasn't just link spam. That comment warning is there to make clear what my standards are. The Web is an ugly enough anonymously driven scrum of personal abuse as it is without my allowing contributions to it here.

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  16. Anonymous- I wonder if you gave Emily the same dignity and respect, when you didn't think she was reading what you were saying behind her back..

    How often I have seen the crowd from the Fed Up with Natural Childbirth group, demand respect, compassion, kindness, understanding and more, but snicker when others ask for the same. You've got to give it, to get it. It's as simple as that.

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  17. I add that I also am not crazy about quid pro quo personal exchanges here, either. ...I'm personal-insult averse in general. I agree with TSM when she says that we all should both give and receive respect when we discuss these things, or we reduce the level of discourse to that of children on the playground.

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  18. Repost/link removed/ If anyone would like to come *here* and talk about the science and stats with me, they are welcome to do so. I have the training and education in biology to the postdoctoral level and the 31 scientific publications that qualify me to have that discussion, and I'm happy to have it.

    Because this is my personal blog, I expanded on the 157 personal-narrative words that began the 1302-word Slate piece, hoping to get *that* out of the way and then to move into...again...the main points of this article. It seemed to me that obsession with the finer points of my experience was distracting from the core questions at hand, so I tried to address all of the questions/assumptions people were making about that experience. The reason the first grafs of this post have a lot of "me" and "I" in them is because they were about us. Should I have told the story in the third person, instead?

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    1. "the 31 scientific publications that qualify me to have that discussion"

      All the more reason why you should have read the scientific publications on homebirth before presuming to lecture anyone else on what they show.

      If you'd like to learn about the scientific evidence on homebirth and to discuss it, feel free to come to my blog or to continue the discussion on Slate. There's no point in having a discussion on your blog when you are so quick to delete anyone who hurts your feelings.

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  19. Anyone interested in Tuteur's blog can find it at this URL: skepticalob.blogspot.com/

    Tuteur and I have already had a lengthy exchange about the science involved, in the comments on Slate, which you can find here by scrolling down a whole lot or searching her name: http://www.slate.com/articles/double_x/doublex/2012/02/home_birth_can_be_safe_for_mother_and_baby_.2.html

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  20. I wonder if a large part of the conflict has to do with the homebirthers one encounters. I'd doubt you'd agree with those in the Trust Birth initiative, for instance, who claim that "Birth is Safe, Intervention is Risky." Or with those that argue that breech is a "variation of normal" and doesn't risk one out of a homebirth, or those who deliver multiples at home. From what I can see, this is more of the norm for homebirth in the US than well trained midwives with prearranged back up. The midwives who ARE welltrained and have strict criteria for allowing a homebirth get labeled "medwives" and are criticized because they are part of the masculine medicine system. Your post on your parenting blog stated that "homebirth is not woo," yet so much of the movement is saturated with woo, even if the action itself might not qualify. I think that perhaps your experience with homebirth advocates may be very different to that of those with whom you're arguing. On the other hand, maybe they're just mentioning the worst offenders.

    I disagree with Dr. Amy as much as I agree with her, but getting irritated at her writing did send me back to the literature, where I discovered that so much of what I'd been taught in the natural childbirth movement misrepresented the evidence.

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  21. From my experience, if I mention "home birth" online--the Slate piece is an example--people instantly file me away into a woo file folder and equate me with everything else that has to do with woo, regardless of what I'm actually saying or who I actually am. That's one reason I wanted to write the Slate piece--to show that the population of people who have had a home birth or might be interested in it may be a little more complex than that.

    I wonder how many births that are done at home without CNMs would be done *with* CNMs if one were available. It's very hard to find them in many regions, and harder to find CNMs with OB backup, etc. Mine had strict criteria for home birth (never called them "medwives"; some people are just unreachable).

    Yes, I know that much of the home birth/natural birth sector is saturated with woo, and in the original draft of the Slate piece (this one didn't make it to editing), I had a line about how the article wasn't going to reach people at the extreme of the spectrum of this discussion--people who birth at home alone, etc.--but that's not the target of the piece. I had in mind women like I was in 2002 whose previous experiences, rather than a "philosophy," may have turned them toward home birth.

    Everyone will mention the worst offenders, and I think that strident and sneering commentary probably brings in the opposition true believers, rather than people who may have more modulated opinions. There are women who have a "birth philosophy" and insist that women who *want* an epidural, etc., are basically lesser women. I find fanaticism of all kinds repellent, frankly, and particularly detest dividing lines drawn based on litmus-test "philosophies" of that sort.

    I've not been a part of either movement, really, so I don't know what evidence the natural childbirth people misrepresented. I've read a lot of interpretations of the science and have determined (not surprisingly) that *everyone* picks and chooses data and rarely depicts the real equivocation present in most studies or groups of studies. It's so easy to use just the right terms or a half term, select results that confirm a bias, and construct an argument around it that fits your bias. My bias is toward women's having choices that are as safe as they can be, so I don't have to cherry pick anything to argue for that standard. The factors that add up to the safest kind of home birth for a woman who wants to have one are pretty clear cut.

    Where I have to fight bias is interpreting autism studies. I have to be very self critical and self questioning when I'm reading and interpreting those because I bring a clear bias to them. I just co-moderated a session at a conference about bias and what an awareness of it can do for your analysis of data; I think that if you use that awareness to challenge every conclusion you draw, you find that it takes you to interesting places and to discoveries of nuance and complexity you might otherwise have overlooked.

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  22. In terms of what is misrepresented, although I do agree that everyone tends to pick and choose, mostly I'm thinking of a complete exaggeration of the risks of interventions, especially pain medications. In the Bradley workbook that went with the classes I took while expecting my first, in discussing pain medication the book described "drugged babies" unable to bond or breastfeed. There was a strong current of what I now see as misogynism -- You will suffer whatever you need to suffer to *do the very best for your baby* because laboring and giving birth naturally is fulfilling your purpose as a woman -- doing what you were designed to do. Thus setting women up for lots of guilt if they decide to use pain medication, as they are no longer thinking of their babies first and themselves not at all.

    There are exaggerations of the risks of other kinds of interventions, like ultrasounds (might cause autism or other unknown problems!) and inductions and cesareans, and the minimizations of the risk inherent in birthing. Birth is natural, you know, and if you do everything right -- exercise, eat a good diet, abstain from any pharmaceuticals -- then the chance that anything will go wrong is so low that you don't even need to think about it. OBs only care about controlling women and their own egos, and nothing they do is evidence based. Afterall, the evidence confirms that pregnancy and birth is a safe, natural process, not a disease!

    Imagine going into hospital to birth with these sorts of attitudes towards the medical establishment! For so many women that I've known who were trained in the same methods at the same time that I was, the same pattern developed. Go into hospital distrustful of the staff and ready for a fight, any inconvenience is an offense, an offer of pain medication is a REAL offense, after fighting through labor and delivery and possibly postpartum (though all the hospitals in my area have standard mother/baby togetherness and NO nursery, even if you need a break) once or twice, you are ready for a different experience next time. Besides, everything went fine, so it is true that birth is safe! So next time you birth with a CPM, if you think that the only CNM run birth center is too far away, but that CPM is too medical for you and transfers too often, so next time you go with a lay midwife who has only been at a handful of births, but who at least "trusts the natural process" and doesn't encourage prenatal testing or any routine intervention in delivery, or you go for an unassisted birth, and after all you've had two or three perfectly smooth deliveries, so you've confirmed that pregnancy and birth is safe. It is what you were created for!

    In my experience, the deeper you get into the movement the deeper the woo gets. Medicine and science is masculine, and relying on it is denying your own power as a woman, which is intuitive and spiritual. A lot of the homebirth and natural birth movement is heavilly allied with the anti-vaccine movement. They're lying to us about birth, after all, so they're also probably lying to us about the vaccines. All of our bodies know what to do!

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  23. That IS my personal experience with the homebirth and natural childbirth movement. I know it isn't universal, but I've seen it repeated not just in my real life friends, but with numerous people I know online. Can you see how I'd then make assumptions about your article? I, and many others I know who read Natural Childbirth promoting books or take NCB classes, were set up to have problems with the hospital. We would have felt poorly treated even if every nurse and doctor had been perfectly respectful, professional and competent. So I take every report of ill treatment with a grain of salt, because *I* was encouraged to be offended by any offer of pain medication and every vital sign check postpartum. Moreover, most of the homebirthers I know take serious issue with much of routine medical care, not just birth, so saying "such and such wasn't medically necessary" often means that they went to a woo-filled website which assured them that X was not medically necessary, because they could have done Y homeopathic or chiropractic treatment, or assured them that their body "knows" how to do things, and the natural system is best. It is the interference that is risky, after all!

    Wow, this turned into a novel. Sorry about that. I'm still in the midst of deconversion, evidently, and it is hard for me to be fair or even admit to much good in such a system where the single underlying principle -- nature gets it right -- now seems false to me. I need to remind myself the people can come to the homebirthing decision from very different perspectives.

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  24. Loved your comment, Emily! I could not agree more. Similarly to you, I did not choose homebirth for the experience, to be a birth goddess, to prove a point, or any other shallow reason, and I have to admit that I have grown weary of being accused of it, over and over again. Before I knew anything about these natural childbirth online communities, I had never heard 'trust birth', 'breech is a variation of normal', etc, etc. The women I have known who have homebirthed, take it seriously. They understand, as do I, that birth comes with risks, and you must approach it cautiously.

    I chose homebirth, not because of a previously bad hospital birth, but because I had been sexually assaulted on two different occasions, one happened in my early teens and one happened in my late teens. I then suffered from anxiety and panic attacks that left me paralyzed for hours on end. It was the worst torture I have ever experienced and would not wish on my worst enemy. When I got pregnant years later, I was seeing an OB and planning a hospital birth, but I became more and more terrified as my birth approached and realized that I would be at the mercy of strangers. Some of the people on Amy's site, gave a really hard time when I explained where I was coming from and why I chose homebirth. Just like you, I cannot stand fanaticism, and when you can't take into consideration the many varied reasons why women choose homebirth and lump all homebirth women into the same category, then you have become a fanatic against it.

    I believe that the majority of women who homebirth have a balanced view of birth. When you choose to seek out the fanatics or only fixate on what the fanatics say, then yes, that's all that you will see. Even you, someone who put a lot of thought into homebirth and chose it for the right reasons, became a target and you were completely misunderstood. Almost everything that you wrote that was valid and balanced, was ignored. Instead, the trivial details of your post ( such as your dislike for florescent lighting-btw, I have the same disdain for them) became the only focus.

    I hope you continue writing about homebirth and letting people know that not all of us approach homebirth as a competition or game. And I also hope that the opponents of homebirth will come to realize that just as they are tired of being accused of not loving or caring about their babies because they take pain medication during labor, many of us are tired of being accused of choosing 'experience above everything else'.

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  25. Bradley. Don't get me started. Well...you already did. Our first midwife from the birthing center had us do a Bradley class, and it was the biggest waste of time and money I think I've ever experienced. My husband and I were both very irritated about it. And then they made these claims about the percentage of people who'd taken Bradley and then gone onto a "natural unmdedicated" birth...and I know they never followed up with any of us to gather those data. I agree with everything you say about Bradley. Huge ripoff for us, and another one of those "philosophy" things that tries to shame if you don't do something a certain way.

    Yes...I've seen those exaggerations about ultrasound, etc., definitely, looked into them, of course--we've had u/s for all of our children, autistic and not--and (biased definitely) found nothing to worry me. While I agree that pregnancy itself is not a disease, every transformative process in nature--and particularly in development, from my perspective--involves a risk with what seems like every cell division. I'm not someone who thinks nature is a kind mistress who just gets it right every time. In fact, nature doesn't give a shit and has built our species on existing tools (which can mean a lot of redundancy where it's not needed and not enough where it is), and as long as the math works out for a species (births pace deaths, at least), that's all that counts in nature's grand scheme.

    While I've run into a couple of doctors who were autocratic and dismissive (God complex), I've also known plenty of non-MDs who are like that, too. All the doctors--OBs, family practice, pediatricians--we've ever gone with have all been great people who treated us as people and as partners in health. I know not all MDs are like that, but from what I understand from research papers I edit, medical schools focus more on that partnership standard. I know that many journals (not NEJM yet!) require authors to use "participant" or "patient" or "volunteer" instead of "subject" and to use "adherence" instead of "compliance" as part of this sea change in attitude.

    I think that what you describe in your third paragraph is partly what we experienced our first time. Our birthing center referred us to the OB when I developed pre-eclampsia, and while we liked him a whole lot (we'd already met him as part of the birthing center process), we weren't fans of this hospital, which medicalized the crap out of everything (unlike the hospital where we had our third), and I think they took advantage of our good insurance to the fullest, based on my review of the bill. Anyway, while birth is certainly "natural"--it's how we all got here--there's nothing beneficent about nature itself, at all. But yes...I can see where a woman would start with a buildup from something like Bradley and snowball into other things, and I've known women who have. I've also known women who've done a home birth and hated it so chose hospital the next time. Choices!

    I can't really put myself in the shoes of someone who wants no prenatal testing, no monitoring, no detection of GD, etc., because I'm one of those people who doesn't like not knowing things I could know. But again...there's no way a discussion about what would constitute the safest possible kind of home birth is going to reach someone who rejects technology and science-based medical practices to that extent or births at home alone. In my mind, I put them in the same file as antivaxxers and people who practice homeopathy and insist on a litmus-test parenting and birth philosophy. That may not be fair, but that's where they start until new information comes in. I think that's exactly what people do with me when I mention or write about home birth.
    (continued)

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  26. Our bodies in general do "know" what to do, thanks to feedback pathways, but knowing and actually doing are two different things. As for the "masculinity" of medicine and science, it's true that up until recently, it was a very masculine practice, with clinical trials focused on men and erroneous information and assumptions about female physiology (my favorite has to do with something we taught for years in bio and developmental bio about the lack of nonrenewing cells in the ovaries). I think that when women--like my mother--starting fighting in the '70s for better representation and treatment in modern medicine, the dogma of their movement solidified into what you describe and has stayed that way in some circles, despite the changes that have happened and are happening in some places, like the hospital where we had our third. That kind of radical insistence in the '70s shifted the Overton window (http://en.wikipedia.org/wiki/Overton_window) for what was acceptable overall for women, which has contributed to the presence of hospitals like we had for our third. I am grateful for that, but can't subscribe to those ideas about nature as a beneficent goddess if you just put your trust in her. I do think that some of the interaction between extreme anxiety and labor can result in more negative outcomes (I found a couple of papers suggesting that, but it's sketchy) because anxiety can interfere with a lot of physiological pathways. Some of that "trust yourself" language could feed back physiologically and reduce anxiety (self talk can be a basis for cognitive-behavioral therapy that's been effective, for example), but it's not a basis for trying to ensure a safe birth.

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  27. @becky...no worries about the "novel." Conversations like these require a lot of words. Although it seems that our comment character limit is 4000, so anything over that requires another comment window.

    @TSM First of all, I am sorry for those experiences and can only imagine how hard it would be to expose yourself or your body to strangers after that.

    The rest of your comment resonates with me, especially this part: "when you can't take into consideration the many varied reasons why women choose homebirth and lump all homebirth women into the same category, then you have become a fanatic against it."

    "I believe that the majority of women who homebirth have a balanced view of birth." I wonder about the numbers on this. My circle is self selected, obviously, so any women in my personal experience who have done home birth are more similar to me. I don't personally know women who have birthed at home alone and that sort of thing...so I have no real idea of what the numbers are. The Lancet article made a reference to the percentage of US women who have well-attended home births, and it was a third, accompanied by "certified midwives," so not sure if they're CPM or CNM. If that's the case, it's a non-majority of women having home births with, at a minimum, a certified midwife. I infer from that that most women are having direct-entry midwife births, etc. Of course, involved in those numbers are communities and cultures that do only home birth, so teasing out women who aren't affiliated with such cultures, determining their rationales for choice of attendant, etc. isn't so easy. Also not known is how many women who don't use a CNM *would* do so if one were available to them, etc.

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  28. I'd like to hear your thoughts on the recent stats reported out of California, which don't seem to support the "homebirth is as safe" line. These weren't CNMs, but were homebirth midwives licensed by the state.
    You can compare the report: http://www.mbc.ca.gov/allied/midwives_2010_annual_report.pdf
    to California's overall numbers:
    http://www.ipodr.org/061/vs/mortality.html

    I've seen Dr. Amy's comment, but I'd really like to see something from someone experience with science and statistics (I'm not, sadly), but who is coming from a more objective position.

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  29. Hi, Becky...up to my ears with work and school (it's Monday, I homeschool two children--I know you can relate to that--you homeschool, yes?) today, but later this afternoon, if I have time, I will look at it. I'll probably do a post on it sometime this week.

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  30. Yes, we homeschool, I have three schoolaged kids, a toddler and an infant. So there are probably 1000 other things I need to be doing right now. If you could comment, that would be fantastic, take your time!

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  31. A Certified Midwife(CM) is actually a midwife who has a master's degree in midwifery, taken all the nursing prerequisite courses, and taken the AMCB midwifery exam (the same one that CNMs take), but they do not have an RN, so they are not CNMs. The certification is accepted for a license in New York, New Jersey, and Rhode Island, and you can get a permit to practice with it in Delaware.

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  32. The qualifications for "certified" vary from state to state. Certified is a very vague term, one that helps to confuse study intepretations, etc. In Texas, there are CPMs (certified professional midwives) and CNMs (certified nurse midwives), and the latter are RNs. To add to the confusion, a certified midwife is one thing to the American College of Nurse Midwives but can be something different for the states. MANA has a list of definitions here: http://mana.org/definitions.html

    Bottom line is, only CNM is the one that carries the requirement for the RN.

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    1. Yes, I realize that. I was just explaining that Certified Midwife is an actual designation, in addition to CPM and CNM. Per the ACNM, here is the chart describing the education and qualifications of the three: http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000001031/CNM%20CM%20CPM%20Comparison%20Chart%20March%202011.pdf

      FWIW, I agree with you that homebirth can be reasonably safe with a truly low risk women (i.e., not VBAC, multiples, breech, or any of the other "variations of normal" many homebirth supporters like to talk about), a CNM as an attendant, a reasonable transfer plan, and proximity to a hospital. However, that is not the situation with most American homebirths. The vast majority are attended by CPMs or some other version of direct-entry midwife.

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  33. I totally agree with Heather here!
    Florence

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  34. @heather...that comment wasn't intended for you. It was clarifying for anyone reading how confusing the term "certified" is.

    I noted in the Slate piece and in these comments that according to the Lancet editorial I linked, only a third of births are attended by a "certified midwife" and even in that phrase, it's unclear what "certified" really means. Given that the entire Slate piece focused on CNM+OB backup+hospital access as the gold standard if you're going to have a home birth, I'm not quite clear on what the purpose of your comments is. I get the feeling you're arguing something with me, but I can't tell what. Can you clarify?

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    1. Sorry if I came across as argumentative! The first time I commented I was just explaining that a certified midwife was an actual designation, and then when you replied, I thought you'd misunderstood what I was saying. I have no doubt that many people confuse the different terms. I believe that was intentional on the part of the people that created the Certified Professional Midwife (CPM) credential.

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    2. @heather... OK...phew. I felt like I was missing something and didn't want to overlook a discussion.

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  35. @Florence... And what she writes reflects what I've written.

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