So far this year women have learned that we can't have it all: We can't breast-feed past infancy without some idiot calling it pedophilia; we can't work a top political job in D.C. and raise a well-adjusted teenager in New Jersey. And we can't have a candle-lit home birth that isn't also dangerous, according to Michelle Goldberg at the Daily Beast.
For a long time home birth was too fringe to get caught in this parenting no-fly zone, but lately it’s been fitting quite nicely into the mommy war media narrative: There are the stories about women giving birth at home because it's fashionable, the idea that women are happy sacrificing their newborns for some “hedonistic” spa-like experience, or that moms-to-be (and their partners) are just dumb and gullible when it comes to risk management, making a decision that is “akin to not putting your child in a car seat because some layperson told you that car seats were unnecessary,” as blogger Amy Tuteur, M.D., put it.
I bring up Tuteur here because she is heavily quoted in Goldberg's piece, and. in fact, her point of view frames Goldberg's story, the gist of which is pretty well-summarized in its headline: "Home Birth: Increasingly Popular, but Dangerous."
For many parents, home birth is a transcendent experience. ... Yet as the number of such births grows, so does the number of tragedies—and those stories tend to be left out of soft-focus lifestyle features. Now a small but growing number of people whose home deliveries have gone horribly awry have started speaking out, some of them on a blog, Hurt by Homebirth, set up by former Harvard Medical School instructor Amy Tuteur. “These people are beating themselves up over this,” says Tuteur, perhaps the country’s fiercest critic of the home-birth subculture. “They did it because they thought it was safe, and it wasn’t safe.”
Goldberg's reliance on Tuteur is an interesting choice. Also known as “Dr. Amy,” Tuteur let her medical license lapse in 2003 and created the blog Home Birth Debate in 2006, which she used to advocate for her position, which is basically: Home birth kills babies. “Even the studies that claim to show that home birth is as safe as hospital birth actually show the opposite,” she'd frequently post in response to a challenge, smearing the researchers of those studies in dedicated blog posts and igniting flame wars in the comments section. On other sites, including Nature and RH Reality Check, her comments have been flagged and removed for being defamatory or basically spam.
In 2009 Tuteur moved over to her new blog, The Skeptical OB, the name of which is, on the one hand, misleading because she hasn't been in practice for more than a decade, but is ultimately more appropriate because her old site was never really about debate. She wrote briefly for Open Salon, where she took issue with Amnesty International's research on maternal mortality, and had a mutual parting with the blog Science Based Medicine (“mutual efforts between the editors and Dr. Tuteur to resolve our differences came to an impasse,” managing editor David Gorski wrote in the announcement). Her prose tends to be inflammatory. “It's hard to beat homebirth midwives when it comes to stupidity,” she recently blogged on her own site.
In January 2011, Tuteur added a new domain to her brand, Hurt by Home birth, in which she invites guest posts—“and please include pictures if you can”—from tragedy-stricken mothers.
Of course, there is nothing wrong with a site for parents who have lost their babies or had traumatic homebirth experiences. And there is nothing wrong with a one-sided advocacy blog. The problem is when a dogged journalist like Goldberg elevates Tuteur to expert. Tuteur is not a researcher, she's not currently affiliated with any medical institution, and more importantly, she's never published any of her kitchen-table calculations on the risks of home birth in any peer-reviewed journal. Yet she presents herself with the authority of a CDC epidemiologist when she writes, “Homebirth increases the risk of neonatal death. All the existing scientific evidence says so.”
Goldberg makes it clear in her piece that the research comparing home birth to hospital birth is difficult for nonscientists to parse. “One could spend days sorting through the claims and counterclaims,” Goldberg writes about the only recent study of American home births, which Tuteur has been beating up on for years and to which the authors, for better or worse, have been responding. Goldberg gives Tuteur a platform for her unpublished claims and number-crunching: “They sliced and diced the data to fool people who are not sophisticated,” Tuteur tells Goldberg, before going on to interpret Colorado state data as well.
“Ultimately, for those without medical expertise or statistical training, deciding whom to trust is as much a question of philosophy as of data, because the debate isn’t just about numbers,” Goldberg writes. “It’s also a metaphysical argument about the nature of childbirth.” Perhaps that's true for couples who are deciding what's best for them. But for a reporter trying to inform those decisions, it doesn’t seem very useful to throw up one's hands and say, hey, this is a metaphysical debate! What about the data? Why not call a scientist?
I could list several recent large prospective studies (this one out of Canada, this one out of the Netherlands, and this one out of the United Kingdom) all comparing where and with whom healthy women gave birth, which found similar rates of baby loss—around 2 per 1,000—no matter the place or attendant. We could pick through those studies’ respective strengths and weaknesses, talk about why we'll never have a “gold-standard” randomized controlled trial (because women will never participate in a study that makes birth choices for them), and I could quote a real epidemiologist on why determining the precise risk of home birth in the United States is nearly impossible. Actually, I will: “It's all but impossible, certainly in the United States,” says Eugene Declercq, an epidemiologist and professor of public health at Boston University, and coauthor of the CDC study that found the number of U.S. home births has risen slightly, to still less than 1 percent of all births. One of the challenges is that “the outcomes tend to be pretty good,” Declercq says. “So when Tuteur says no study anywhere has found this, it's a crock. There are studies that have found good results.” But to really nail it down here in the U.S., he says, we'd need to study tens of thousands of home births, "to be able to find a difference in those rare outcomes.” With a mere 30,000 planned home births happening each year nationwide, “We don't have enough cases.”
Declercq's statement makes Goldberg's only other source on safety also questionable. Martha Reilly, M.D., of Eugene, Ore., tells her that every OB at her hospital, McKenzie-Willamette Medical Center, has seen a baby dead or injured by a home birth: “The death rate we're looking at ... it's outrageous.” But how can this be? The Department of Health reports 102 planned home births in Lane County in 2010. Reilly's claim is improbable given that the odds are in the per-thousand range, though it's perhaps indicative of how polarized some providers are on this issue. A few years ago Melissa Cheyney, anthropologist at Oregon State, investigated a physician's claims that several babies had died in home births, but she could find none.* “What we found is that the animosity is so high between midwives and obstetricians that all kinds of rumors spread that are unsubstantiated,” she told me. UPDATE, July 6, 2012: This piece should have mentioned that, in addition to being an anthropologist, Melissa Cheyney is also a certified midwife and is chair of the research division of the Midwives Alliance of North America, though she did not have this Alliance role at the time of the Oregon investigation mentioned in the piece.
Deep into her piece, Goldberg repeats the Tuteur talking point that some midwives—nurse midwives—are fine and safe because they “have the same sort of training as midwives in countries like the Netherlands,” but not “the other kind,” i.e., the certified professional midwives, who attend home births in the United States but are not nurse practitioners. Actually, midwives in the Netherlands and other countries are not nurses. They don't go to nursing school, and they don't practice under the supervision of physicians like nurse-midwives do here. They're independent, autonomous pregnancy and childbirth-care providers who set their own standards just like any other profession. What's relevant is that, unlike the non-nurse midwives in the United States, European and Canadian midwives have hospital privileges and are integrated into the system, which everyone agrees is the safer protocol. But in the United States, medical groups oppose legislative efforts to license CPMs.
Like Tuteur’s new site, Goldberg builds her piece around two horrific home birth tragedies. Any reader would, and should, be moved by them. By these women's accounts, their midwives made terrible decisions and, worst of all, didn't get informed consent from their patients, which is central to midwives' practice standards. But is it responsible journalism to construct a story around the rare outcome? And is it logical for us, as readers, to take away from the anecdotes that home birth is dangerous?
“What we're talking about is felt risk rather than actual risk,” explains Barbara Katz-Rothman, professor of sociology at the City University of New York and author of much scholarship on birth, motherhood, and risk. Take our fear of flying. “Most people understand intellectually that on your standard vacation trip or business trip, the ride to and from the airport is more likely to result in your injury or death than the plane ride itself, but you never see anybody applaud when they reach the airport safely in the car.” The flight feels more risky. Similarly, we can look at data showing our risk of infection skyrockets the second we step in a hospital, “but there's something about the sight of all those gloves and masks that makes you feel safe.”
I'll venture that the reason most women don't choose home birth is because it doesn't feel safe, and that trumps data any day. What's unfortunate is that if we could get past the professional turf wars and the mommy shaming, women might have a clearer path to making informed decisions that both are safe and feel safe. It would almost be like having it all.
Correction, July 5, 2012: This article originally misspelled Melissa Cheyney's last name. (Return to the corrected sentence)