Wednesday, June 02, 2010

What explains physicians' beliefs about home birth?

I've been corresponding with Lara Freidenfelds, author of The Modern Period: Menstruation in Twentieth-Century America. She posed me the following question about the dissonance between obstetricians' perceptions of the safety of home birth, versus the research evidence. She wrote:
As I've been teaching about the controversies over maternity care, students have asked me some crucial questions I have not, so far, been able to answer. I'm wondering if you might be able to help, since you know the literature so well. Basically, my students (and I) want to know why the doctors' concerns about sudden extreme complications do not seem to show up in the morbidity and mortality numbers for home births. Are they simply mistaken about what can go wrong, and how much of an emergency it constitutes (i.e., do home birth midwives get these patients to the hospital anyway)? Are physicians/hospitals not actually very good at addressing emergencies either (i.e., all the monitoring in the world doesn't actually catch the impending stillbirths; hemorrhages are not noticed and addressed quickly enough)? Are the causes of maternal and infant mortality and severe morbidity in home and hospital births the same, or different (i.e., is home birth maternal mortality/morbidity the result of hemorrhage, while in the hospital it's the result of c-section complications)?

I tell my students that my guess is that a well-staffed and equipped birthing center would likely be the safest option, since women could have low-intervention, midwife-supported care with emergency backup immediately available. But the one study you cite which included birthing centers did not seem to support this theory. Would it be reasonable to argue that the various kinds of support offered by home birth actually reduce risks for drastic emergencies by a big enough margin to offset the dire results when a drastic emergency actually does happen out-of-hospital?

Basically, I want to understand why physicians' intuitions seem to be so far wrong. While I think the physicians' organizations are quite self-serving, the individual doctors I've talked to seem quite earnest, not at all cynical, in their concerns about home birth, and they always call up examples of times when they believe they were able to save a mother's or baby's life only because they had a physician's skills and hospital equipment at the ready. Are they wrong because many of these emergencies were iatrogenic? Or because they are wrong to write off other cases of mortality and severe morbidity that they do not realize were iatrogenic (or at least avoidable in a home setting)? What, besides self-interest, might explain the divergence between physician's experience-based intuitions and the large-scale studies?

I'm guessing these aren't easy questions, or I'd have seen them answered somewhere. If you'd be willing to hazard a guess, or outline the limits of the data so far available, I'd appreciate it tremendously.
I'm particularly interested in hearing from my blog readers, especially those who work in a hospital environment: OBs and family physicians in particular, as well as CNMs and nurses. Could you please chime in too? Correct me if I'm wrong, add to what I have to say, offer new perspectives I haven't thought of, etc. I know I have OBs and family practice physicians reading this blog. If you're one of those, please take a minute to answer Lara's questions from an insiders' perspective!

Here's my reply--or rather, a preliminary attempt at tackling this large, complex question.

Let me first mention the research or published material that already addresses this. The first resource that comes to mind is chapter 7 ("Obstetric Training as a Rite of Passage") in Robbie Davis-Floyd's book Birth as an American Rite of Passage. I'm in France, so I don't have my book to refer to directly. But I remember that she discusses how obstetricians' first-hand experience, especially in scary/dangerous/traumatic situations, often supersedes their numerous encounters with "normal" birth. In other words, one bad hemorrhage impresses itself far more vividly upon their minds than the hundreds of births with no excessive bleeding. This translates into a tendency to act (react?) with the worst possible situation in mind, even when the current situation does not warrant that specific reaction. For example, imagine a physician who, after experiencing a uterine rupture, will no longer attend VBACs at all. Never mind that most VBACs occur without serious complications and that there is the possibility of something going wrong in a cesarean--that one bad experience governs thoughts and actions far more than the hundreds/thousands of good outcomes. Not too surprising, really. This kind of thinking is part of human nature.

Probably the only research specifically examining obstetricians' perceptions of home birth (midwives) is by Melissa Cheyney. I referenced her work in my recent article "Attitudes Towards Home Birth in the USA," so I won't repeat it here, except to say that it's a great resource.

I also did some original research of my own into what physicianss think about home birth (quoted from my article):
To discover additional physician perspectives on home birth, we read through five years (Jan 2005-Oct 2009) of discussions about home birth in the OB-GYN-L archives, a list serve for OB/GYNs and maternal-fetal-medicine specialists and the occasional family physician or midwife. Although this discussion group is not a representative sample of obstetricians, the themes serve as a starting point for future research about physicians’ attitudes towards home birth.

First, legal and political constraints played a significant role on limiting physician involvement with home birth, either direct (attending home births) or indirect (providing collaboration, consultation, or backup to home birth families and midwives). Several physicians wanted to provide backup and/or collaboration with home birth midwives, but their hospitals or malpractice carriers specifically forbade these actions. In addition, many physicians on this list could not move beyond an adversarial view of all patients as potential litigants. Besides having to protect themselves against (real or potential) lawsuits, physicians dealing with home birth transfers often faced the brunt of the families’ anger, disappointment, and hostility. They did not enjoy being seen as the “bad guy” in situations they sometimes described as “train wrecks.” And, since home birth midwives often do not carry malpractice insurance, physicians are more likely to be sued for a negative outcome in a home birth transfer. In sum, physicians often characterized themselves as victims of out-of-control legal and bureaucratic systems, forced to adhere to regulations that benefit hospital administrators and trial lawyers at the expense of patients’ wellbeing. In addition, some OBs on this discussion list suggested that the ACOG’s and AMA’s disavowal of home birth was motivated less by safety concerns and more by licensure and professional recognition issues.

Second, physicians held a wide range of opinions about the safety of home birth. Some physicians adhered strongly to the ACOG position that birth outside of a hospital setting can never be as safe, because of the unpredictable nature of birth complications and the access to monitoring and emergency treatments that a hospital can offer. Some characterized home birth as an inherently risky and selfish behavior, on par with smoking, drug abuse, or other dangerous lifestyle choices. Other physicians questioned these definitions of safety, turning instead to research on home birth and discussing the strengths and weaknesses of various studies. Other list members suggested that physicians could benefit from interacting with home birth midwives, who consistently achieve high rates of spontaneous, unmedicated vaginal births. They also noted that improved communication between physicians and home birth midwives would make home birth safer. Others proposed revising certain hospital practices that currently drive some women towards out-of-hospital births.
Another place to discover, indirectly, why physicians feel the way they do about home birth is to look at legislative testimony about direct-entry midwifery. One thing to keep in mind, though, is that physicians' public testimony might not accurately reflect their real concerns about home birth. For example, in the mid-1990s, Dr. Marsden Wagner gave a speech in Des Moines about scientific literature on the safety of midwife-attended out-of-hospital births. He wrote this in a letter to the Iowa Scope of Practice Review Committee on June 6, 1999:
After my speech two Des Moines obstetricians took me aside and chatted with me in the extraordinarily frank manner often found when physicians talk privately with each other. They told me that while they were aware of the research I had quoted proving out of hospital birth to be a safe alternative, they nevertheless frequently use lack of safety as an issue in order to frighten politicians and the public in order to maintain their monopoly over perinatal services. They then explained that the real issue for them is not safety but economic. They do not like the economic threat that midwives and out of hospital birth represent. As they put it to me: “We will not have these midwives taking money out of our pockets!”
I'm sure that many physicians are sincere in their beliefs and perceptions about home birth--however accurate or misguided--but we cannot forget the factors that influence how physicians portray home birth in a public setting.

Now that I've mentioned what little research exists explaining the dissonance between physicians' beliefs and research evidence on home birth, let me leave the safety of citations and delve a little further.

Robbie Davis-Floyd's research already touched on the power of anecdote and personal experience. I want to reiterate how tremendously important this is in framing how we perceive the world around us. Think, for example, of the multiple factors that influence how pregnant women make decisions about their care. I don't think any pregnant women makes her decisions entirely--or even mostly--upon the statistics from randomized controlled trials. Her family and friends' birth experiences, her personal beliefs and values, her birth culture, and her relationship with her care provider are all powerful forces shaping which choices she will or will not make. The same is true with physicians. Evidence-based medicine play only a small role in clinical decision-making. Experience, personal judgment, anecdote, fears of litigation or failure or of a bad outcome...all of these influence how a physician perceives home birth.

Most physicians form their beliefs about home birth without ever having attended one. On the other hand, almost all midwives, doulas, birth advocates, childbirth educators, etc have witnessed both home and hospital births, either first-hand when they were giving birth, or in the role of doulas, friends, etc attending other women. This gives "home birth advocates"--how I hate that term, since it's a gross generalization and easily turns into caricature--much more ground to stand upon than physicians when discussing the relative merits or disadvantages of home and hospital birth.

Physicians who have been fortunate enough to attend home births usually come away transformed from the experience. This happened to Dr. Marsden Wagner (who, to be fair, is dismissed as a kook/raving lunatic/etc by his detractors). Upon the invitation of a Danish midwife who worked primarily in a hospital setting but who also attended births at home, Dr. Wagner began attending home birth. He wrote:
It would be impossible for me to exaggerate the influence of my experience with homebirth on my opinion of obstetrical authoritative knowledge and practice. Home birth is as different from hospital birth as night is from day. Trying to describe home birth is like trying to describe sexual intercourse - you can give the outlines, but you can never adequately describe the personal dynamics, feelings, ambience. (Childbirth and Authoritative Knowledge, p. 370)
In Carol Leonard's memoir Lady's Hands, Lion's Heart, this same transformative experience happened to her OB husband, Dr. Ken McKinney when he attended a home birth for the first time. (At this point, she and Ken were not yet in a relationship.) Here is Carol's account:
Jessie's labor goes without a hitch. She paces up and down her crate [Jessie lives in a converted shipping crate] like a caged tigress, stopping only to pick dead leaves off her houseplants. During the hard time of transition, she lies on her side, panting heavily like a great cat. I sit beside her, rubbing her back and giving her sincere words of praise and encouragement. Out of the corner of my eye, I watch Ken as he sits in a chair, nervously flipping through magazines, pretending to be nonchalant about the whole thing.

A slight smile creeps across my face. I really am fond of this man. I know he is worried that all hell is going to break loose, and he will have to bail me out. As Chief of Obstetrical Services at MVH, what would be the consequences of his being caught attending a crate-birth with a maverick, lunatic-fringe midwife? His credibility within the medical community would be shot. This really is a huge risk for him. I admire his courage. I look at him, studiously engrossed in Woman's Day, and I feel a rush of tenderness...

When it comes time for Jessie to push her baby out, she spontaneously gets up into a huge, old, overstuffed armchair and drapes her legs over each arm. She says this feels the best to her. It is great for me; I can see clearly without doing the usual gymnastics. This position seems to bring the head down quickly. Soon, I am oblivious to Ken and anything else in the room. I ask Jessie to slow her efforts down, to blow out through her mouth instead of blocking her breath.

I say, "Beautiful. Gentle, Easy now. Nice!" over and over as the babe's head slowly stretches Jessie's skin taut. As always happens at this point, my focus becomes so complete on the crowning head, that when Jessie's baby girl slides into my hands, there is a stillness behind all motion. I hold my breath until she takes her first, as if my very will can coax the living spirit into her glistening body. Her color changes rapidly, going through a rainbow of hues until it is a healthy rose. I quietly hand her up to her skunk-haired mother.

It is only now that I become aware of Ken's watching intently over my shoulder. I turn to grin at him. He gives me a triumphant thumb-up....Ken is excited and energized by the experience. He talks the entire way back.

He says that this has really been an eye-opener for him. He has been on the verge of quitting obstetrics because it is so impersonal and dehumanizing; the routine of women, drugged and unconscious and unable to push, often requiring forceps. He calls it the "knock 'em out, haul 'em out" school of obstetrics. He's been getting bored and disgusted; he knows there is more to it than that. This is the way it is meant to be, with women in their power, in control of their experience.

We sit on a rock, warming ourselves in the spring sunshine. He allows as how he still wouldn't feel comfortable attending births at home. His training makes him feel most secure with an operating room, fully equipped for an emergency cesarean, just down the hall. But why couldn't women have a similar experience, even if they have to be in the hospital? Why couldn't changes be made in standard hospital procedures that would allow women to dictate how they want their births to be? His all fired up now. He turns to me and asks if I would help him identify the routines that are archaic and unnecessary, changes that will make hospital births more human. I agree, knowing that I can come up with that list in about two seconds flat.
This lack of first-hand exposure to home birth, in combination with only seeing "failed" home births (i.e., home birth transfers for reasons ranging from exhaustion to needing pharmaceutical pain relief to fetal distress or hemorrhage), lead to a very skewed perception of home birth. Many physicians probably cannot imagine any of the benefits of a home birth because it is so far beyond their realm of experience. So in their minds, home birth is simply hospital birth minus all of the technology--a scary thought indeed. What physicians likely do not understand is that home birth is not simply the subtraction of medical technology from birth, but the addition of an entirely new process that has subtantial benefits for mother and baby. Home birth really is a world away from industrialized, institutionalized birth. As such, I understand how impossible it would be for a hospital-based practitioner to grasp what home birth is like if they have never actually witnessed one in person.

What else might explain physicians' perceptions of home birth safety? Well, there are some who firmly believe that the research evidence on home birth is wrong, plain and simple. Some have argued that every study claiming to find similar safety outcomes between home and hospital birth is either deeply flawed, or that the conclusions are totally wrong, or both. This outright rejection of the evidence is not too common--usually the evidence is simply ignored.

And I've already referred to the role of litigation, both above and in an earlier post Litigation and the Obstetric Mindet.

This post is already far too long, so I will end without tackling Lara's question about birth centers and leave that to my readers. I am really curious to learn the reasons for ACOG's dramatic about-face in its position on freestanding birth centers. As recently a 2006, ACOG disapproved of home birth and freestanding birth centers for the exact same reasons. Then, in 2008, the ACOG and AMA both approved accredited freestanding birth centers--the first ever endorsement of out-of-hospital birth. Why this sudden change? Why for birth centers and not home birth (it's not as though the outcomes of birth centers are significantly better than home birth, at least that I'm aware of)? Is there anyone who knows more about the motivations for this change in policy?

Please take the time to respond to Lara's questions. I'd love to hear from you!

Replies to this post:
Jenna at Descent into Motherhood asks Do birth workers know what mothers are reading?


  1. i dont know the reason for the about face but Im sure we can guess- better to concede a bit than to lose the whole argument. they may be seeing the beginnings of the writing on the wall?

  2. Amazing post, Rixa. Definitely a lot of stuff to think about, and lots of good information as well.

    As for the birth centers, I don't actually know, but I'd venture a guess that it's because birth centers can be regulated better than someone's private residence. I thought that they specifically only accredited NON-freestanding centers, though, which would make more sense - attach it to a hospital and it has to play by the hospital rules. At any rate, I know many birth centers can't recieve funding unless they follow strict guidelines: no VBACs, no twins, no breech, etc.

  3. Marsden Wagner's comparison to explanations of sex is right on target. If a doctor has seen a few thousand hospital births, he assumes he knows about birth and its variations. The idea that the hospital itself is limiting what he sees of birth -- it doesn't seem to occur to most doctors.

    Amy Tuteur has posted more than once about orgasmic birth as an utter fabrication, and her commenters dutifully chime in to say "Oh, yes, so ridiculous." It just doesn't seem to compute for her that there are tremendous qualitative differences between birth at home and birth in the hospital, and that these differences can have real effects on birth. Better to assume that women are lying than to assume that she has something to learn about birth, I guess.

  4. I've been mentally tackling some of these very same issues. After attending the American Association of Birth Centers workshop on how to start a birth center, I recently starting writing about it on my blog as well. I'm only at the tip of the proverbial iceberg.

    Having only ever witnessed hospital births as an L&D nurse, I can only imagine how different a home birth or birth center birth would be. Yes, maybe I'm idealistic in some of my thinking, but women need more options than just the hospital birth!

  5. What explains it? The scientific evidence of course.

    Every scientific paper on home birth with a US direct entry nidwife and all the US statistics show that homebirth increases the risk of neonatal death.

    A more interesting question is what explains home birth advocates lack of knowledge of the scientific evidence. The reason is that they only read and quote each other, just like you've done in your post Rixa. They don't read the scientific evidence and are entirely unaware of what it really shows.

    The ONLY people who believe homebirth with a US direct entry midwife is safe are home birth advocates themselves. Everyone else knows better.

  6. Dr Amy is usually banned from commenting--and she know this but continues to post anyway. If everyone can refrain from hurling comments/insults her way, I might just leave this comment up, to illustrate my comment regarding "some OBs who firmly believe that the research evidence on home birth is wrong, plain and simple."

    If there is any loss of civility, I'll take her comment down.

  7. I think you hit most of the reasons on the head--but one hesitation that seems to come up more often when I hear it discussed at my hospital, is not necessarily issues with mom, but issues with resuscitating a newborn. Since this is something that most OBs and hospital based midwives have little to no experience in, the idea of being responsible for the baby once it is out of the mother is a complete game changer for them.

    When I did get into the conversation with hospital staff about my own choice to birth at home, they were much more comfortable with the idea once they knew my particular midwife works as a team, so there was one midwife for baby and one for mom.

  8. I am curious to see what others say. My gut feeling is that what you said about hospital-based medical personnel seeing home birth being "minus" all the technology being a big part of it - because they imagine it minus EVERYTHING. This is discussed a bit in "Business of Being Born" - the idea that the midwife just shows up with a towel to bite on, and everybody believes that nothing will go wrong. There's not an understanding that midwives do carry much of the equipment they use in the hospital.

  9. "Why do Ob's feel home birth is unsafe?" Is that the question?

    With a research question like this you would have to do qualatative research. Qualatative research usually has a strong theory for a frame work in which to INVESTIGATE the question. So we don't just hazard a guess. So in this question the only people who we should be investigating, is Obstetricians who believe home birth is unsafe.

    So if this person really wants to answer the question, "Why do Ob's feel that homebirth is unsafe?" I would suggest she do a qualitative study and get back to us.

    If she does not want to do the study, she could look it up in numerous search engines.

  10. Why do you care what Obs think about home birth? Do you want permission, acceptance, cooperation? Are you insecure about your choices? FYI: Marsden Wagner is not an obsetrician. According to his bio, he did his residency in pediatrics and his masters in public health in pediatric epidemiology. Many people think he is an Ob/Gyn and he doesn't do anything to disabuse that idea. He calls himself a "perinatologist," but I think this is incorrect. (A perinatologist is an Ob/Gyn who does a two to three year fellowship after residency in high-risk obstetrics.)

  11. tina--I wrote this quickly and I should have written "physicians" (which was Lara's original question) rather than "obstetricians" specifically. I know that Dr. Wagner isn't an OB but the way I wrote this, it definitely seems like he is. I'll go back and fix that when I have time.

    re: your first question--I'm not sure who it's directed at. Me? Other commenters? Lara? Lara seems to want to know out of a spirit of academic inquiry, since this is something she and her students find puzzling.

  12. The College of Physicians & Surgeons of B.C. (a very conservative group who have been vehemently opposed to homebirth and made the lives of mws a living hell) recently did an about face and pub'd a statement saying "homebirth is safe". I was astounded. It came out of the blue with no fanfare, no publicity, just up on their website.

    I can only speculate on what is happening.
    1. more young women drs are graduating and they want to do midwifery
    2. more drs are reading midwifery related info on the internet
    3. some drs may want to open private birth centres
    4. the science (esp the Marjorie Tew giant study in Britain)has overwhelmed them.
    5. the risk of going into hospital has become so obvious (35% c section) that even the dinosaurs can not maintain their stance.

    I think it will be interesting to watch what happens in this province in the next 5 years.
    Gloria Lemay, Vancouver BC

  13. Here's the link to the B.C. physician's policy statement:

    Gloria Lemay, Vancouver BC

  14. Not to over-simplify, or come across as an extremist, but the first answer, of course, is money. What do I mean by "Money"? Money as in doctors are money mongers who can get thousands of dollars more than midwives for doing so so much less? Money as in defensive medicine being at its pinnacle when we are dealing with the potential life and death of someones child?

    This and so much more.
    I have no idea how many doctors actually believe homebirth is dangerous, or how many of them just cant imagine any women ever 'surviving' without their machinery. they see the mothers suffering in the hospital beds with thte blip blips and the sudden decels and they picture it all at home and they cant even imagine.

    We've all read that "most" of them have never attended even one homebirth/out of hospotal birth. that right there just shows you what we are up against.

    There is so much involved here, and I am a homebirth supporter, homebirth mother, who has had 4 hospital births and one homebirth. I am profoundly aware of the differences in it all. I am just rambling, but its all about the lawsuits and the lawsuit prevention and the training and the education and the experience and the mind set.

    Its NOT about the facts.

  15. I am a family physician very interested in OB and here's my take. I think there are two main reasons why most physicians are uncomfortable with homebirth.

    The first has to do with the larger issue of why many physicians struggle to reconcile evidence based medicine, which is population based, with their individually based experiences. For instance I was involved in a delivery recently where a low risk woman was delivering vaginally in a hospital setting. Her labor was uneventful until she was 2+ and pushing, when she began to have deep variable decels (which we often see while a woman is pushing and are not too concerning) and then the baby's heart rate stayed in the 40's. A vacuum was used to deliver the baby, who came out gray and floppy. The baby needed CPAP and intensive intervention. Although I know the evidence (that low risk women do well with home deliveries) and I agree that a homebirth is optimal in many ways, experiences like the one I had recently make me uncomfortable with home birth. It is difficult for many physicians, including myself, to reconcile the fact that our population will generally do well with a certain medicine, procedure, etc when we have had potentially devastating experiences with individuals which were the small minority and are the exception to the rule. In the case of homebirth these exceptions are deliveries which we feel would not have turned out as well in a home birth setting. (as a side note I know that midwives are trained in NRP but there is some convincing evidence that early CPAP use significantly shortens NICU stay and decreases intubations and there are quite simply some instances where baby needs intensive therapy right away, and having to wait for a hospital transfer is less than ideal).

    The second issue is that way that physicians are treated on many of the homebirth websites and blogs. This attitude is typified in the previous individual's comments. I know that there are "evil" doctors out there who are all about the money or their own convenience but the majority of physicians that I work with work incredibly long hours with increasingly high debt burdens out of a desire to work with women to have the best possible outcome of their pregnancy. As soon as physicians are vilified in this debate, the possibility for helpful conversation ends. I consider myself an advocate for women who would more often side with women who desire less intervention and I often find myself furious after reading the comments directed towards my profession on this and other similar blogs. If I get hot under the collar I can only imagine how the older and more traditional of my colleges would feel.

    I understand that this is an emotional topic but hopefully my thoughts can help explain in some small way how us evil and money hungry doctors think. (this from someone currently working 80+ hour weeks and paying a quarter of my take home salary in loan repayment all in an effort to torture hapless women who end up in my clutches at the hospital! :) )

  16. ps before it comes up I know the evidence is not there for continuous fetal monitoring, however this baby's distress was real and long lasting and would have been picked up as well on intermittent monitoring. . .

  17. Dr B,

    Thank you so much for that insight. It was one of the most frustrating things of my last pregnancy to hear my doctor say that the evidence doesn't mean much when you've seen all the bad outcomes. I didn't understand what he meant, but you have shed some light on it and I think I can start to see it from your point of view.

    I guess I now find myself asking...midwives also see normal birth going pear shaped, yet most of the ones I have met seem to be able to learn what is needed from the experience but not take that fear or concern into the next birth. Is it because what they do (or don't do) means that there are less iatrogenic complications or is it someting else? Do people who feel unable to leave the last birth at that birth self-select out of the process or is it something in the way we are training midwives versus doctors.

    Dr B, this is not an ad hominen attack. I'm trying hard to find "non-judgey' words and phrases, so if I've failed to do so, please be assured of my intent to be kind!

  18. Maybe I'm oversimplifying, but to me it boils down to 2 different mindsets. Most doctors (and virtually all OBs) view birth as a pathology. That belief was the very basis for the rise of the specialty and the very nearly totally successful campaign to eliminate midwifery in this country (see this excellent post at The Unecesarean: Amy Tuteur (I refuse to call her Dr., she does not fit the definition in any way and is not licensed to practice medicine) epitomizes this viewpoint; she is a firm believer that birth is inherently dangerous for mother and baby. When you truly believe this, the mind is closed: no evidence will sway you, and home birth can only be viewed as insanity.

    On the other side of the coin you have birth advocates: a handful of enlightened and progressive physicians, doulas, many women who have given birth (by many different methods, including medicated and unmedicated, spontaneously and operatively, vaginally and surgically), some women who have not (though in the far minority), and of course the majority of midwives (those who practice the midwifery model of care, which can't always be ascertained by the letters after the midwife's name). All of these people believe that birth is a natural process, a function of our physiology, which operates best when educated, supported, and otherwise not messed with, in most cases. Not every birth advocate is a home birth advocate or would choose home birth for herself or his/her loved ones, but we are much more open to the idea, can evaluate the information with an open mind, and trust women to make their own choices.

    Thanks for a thought-provoking post.

  19. (I apologize for any typos in advance, writing this while trying to care for my 15month old)

    In response to Dr. B
    From your post I can see how the hostile "Evil Dr." attitude of many homebirthers would make many Doctors feel negatively towards homebirth. I would like to make a comment about why this attitude even exists.

    I had a homebirth that ended in a transfer due to a hemorrhage. My perception of doctors before my transfer was very negative. After my transfer I met a wonderful nurse who encouraged me so much. She was the opposite of what I thought went on in hospitals. When I met the OB, he was so kind and even gave us tips on how to prevent tearing for our next homebirth.

    Sadly, everything went downhill from there. The other nurses where trying to get me to use formula, The pediatricians where lying to me about what would happen if I did not consent to newborn shots, and the OB who had been so kind previously, did an unconsecrated D&C while I was incapacitated from a spinal, and sutured 3 tears that had been open for 24 hours.I kept asking him what he was doing but no one in the room would answer me.
    I was so traumatized from that hospital experience that I ended up with vaginismus, an infection, and extensive internal scarring.

    The fact is that many women are hostile towards Ob because they have had horrible experiences with them or have heard of the horrible experiences that others have had. I find this ironic in a sense because you feel negatively towards homebirth due to your experiences while I feel negatively towards OBs because of my experience.

    What it really should come down to is evidence based medicine. What do the facts say. The facts say that homebirth is safe.

  20. One more thing. More on topic this time.
    Concerning the situation Dr B explained. One thing that would make Drs more wary of midwifery is that they do not understand that the midwife has an entirely different arsenal of techniques to use when problems arise.
    In this incident, if the decels were due to cord compression the midwife would have probably told the woman to change positions. The women probably would have changed positions before the decels were serious. She may also have never had decels at all because she would have been able to move all throughout labor.
    If the decels were due to an epidural or pitocin induced contractions, these drugs would have never been used in a normal homebirth.
    I believe this is what the original post is referring to when it says that some of the negative outcomes that Drs see are due to interventions.
    This may be the reason why homebirths, although statistically low in interventions, are still low in complications. The entire mindset is completely different.
    I would propose that trying to use your hospital experiences to judge homebirth is in the end unfruitful due to the drastic differences in techniques.

  21. I think Rosemary's hit on such a key question. I'd love to see some writing and research on that (the different long term reactions of midwives/drs/L&D nurses/etc to a difficult or traumatic birth).

  22. Great post, Rixa, and great discussion here. I really felt for Dr. B talking about being villainized in birth blogs. And yet, I also totally can relate to the countless number of women who have been mistreated by OB's or the hospital system in general.

    I began to have slightly more faith in OB's during my last pregnancy, since I now live in city where CNM's don't have birth priveleges. (My previous birth was in another state with a CNM.) My OB was so different in so many ways. I ended up actually kind of having a friendship-type connection with him and even still stay in touch occasionally with him, on a professional level (sharing links to interesting websites, etc). Through this, I felt like I got a bit of a picture of the amount of pressure that OB's are under (and not that this justifies the damaging behaviors of some OBs).

    For example, this OB is a fairly young guy, at age 32. He is really trying to be that doc that honors his patients wishes, breaks down the barriers of the traditional dr/patient relationship, etc. And yet, he also want to earn the respect of his older and more experienced colleagues. This must be quite a fine line to tread, I imagine, especially when you're an OB who wants to practice medicine more holistically.

    And I guess I didn't really add any discussion to the original questions from this post, did I?! :) Thanks again for continuing to write thought-provoking pieces.

  23. Would the freestanding birth centres have OBs and anesthetists on premises to do any emergency procedures, or would they be exclusively CNM run?

    For low-risk women, small birth centres with more personalized care and less volume of births, with the added bonus of having surgical back-up would be ideal.

  24. Freestanding birth centers do not have anesthesia or surgical capability. Some physicians are thinking of creating "freestanding maternity centers" (my term) that would have in-house OB and anesthesia, allowing women to have a midwifery style of care, but with surgical and obstetrical backup. So far, I don't think anyone has actually created one of these. You'd need a really high volume of patients to be able to fund such a center (even small hospitals can't afford to provide round-the-clock OB and anesthesia coverage).

  25. Yes (bolded mine): "the power of anecdote and personal experience [...] I don't think any pregnant women makes her decisions entirely--or even mostly--upon the statistics from randomized controlled trials. Her family and friends' birth experiences, her personal beliefs and values, her birth culture, and her relationship with her care provider are all powerful forces shaping which choices she will or will not make. The same is true with physicians."

    It occurs to me also that people in the "saving" professions have more to lose than money -- they have personal pride. If you're a good person, how hard must it be to acknowledge error and harm done when your identity is tied up in being a savior? Some people (and oh how I admire them) are able to do that and move beyond it to better things, but I'm guessing that for the vast majority there are huge psychological barriers to doing so.

  26. I think that it is not only doctors but many people in society in general who view home birth as "hospital birth minus all of the technology". I run a home birth support group in the UK where our government and health service supports the option of home birth and quote it as being "as safe as hospital birth" provided there have been no complications during pregnancy. However, I often hear parents saying "well, I'd rather birth in hospital just in case something goes wrong". So many people fail to consider that "home birth is not simply the subtraction of medical technology from birth, but the addition of an entirely new process that has substantial benefits for mother and baby." Perhaps it comes down to requiring trust in the process of birth and the ability of women to safely birth their babies in the absence of fear. This trust is not easily quantified and so the scientifically-trained person in particular may find it hard to acquire, particularly if they have learned in detail about, and perhaps even witnessed first hand, all the terrible ways in which the birthing process can go wrong. But supposing many of these cases could have been avoided simply by trusting in the birth process initially? Unfortunately it may be that the very thought in a woman's mind that there may be a sudden extreme complication during birth increases the likelihood of one occurring. And in a doctor's mind this may lead to interventions that perhaps lead to the very events he/she was hoping to avoid...

  27. "I tell my students that my guess is that a well-staffed and equipped birthing center would likely be the safest option, since women could have low-intervention, midwife-supported care with emergency backup immediately available."

    I disagree with this presumption. Birth centers are either Hospital-based, (meaning on campus and subject to the protocols of the parent hospital) or free-standing. It is true hospital-based birth centers provide comfortable surroundings and are usually staffed by CNMs, but the risk of a "cascade of interventions" is very real for many moms. Riki Lake recounts her personal experience with this type of interference in the Business of Being Born. Her oldest son was born in a birth center, but the care she received wasn't exactly low-intervention.

    Free-standing birth centers are required to be well-staffed and equipped by law. (The requirements differ by each state's licensing regulations.) However, for families living within 5 miles of hospitals in my local area, their access to emergency backup ISN'T improved by choosing to deliver in a free-standing center over planning a midwife assisted home birth. Locally, three free-standing centers are located less than 5 miles from different hospitals. Our family resides 3 miles from the closest hospital, so the emergency response time is virtually the same.

    Our state's Licensed Midwives carry the exact SAME equipment to attend home births as is available in the free-standing centers. When I asked my licensed midwife why some of her clients choose to deliver at local birth centers she didn't mention safety as those clients' main concerns. Clients are already convinced of the safety measures in place for out-of-hospital births or they wouldn't have hired a LM. She said that the desire is usually driven by their specific living situation or personal preferences. i.e. In-laws and other relatives want to attend the birth, but mom is concerned that her home will feel cramped -or- Maybe, the expectant parents live in a multi-generational home, but desire privacy for labor. -or- The free-standing center's garden tubs are more accommodating than mom's small bath tub at home. Occasionally, she cares for a client whose home is noticeably farther away from hospital than the free-standing center. But, location is only one of many reasons a couple may decide to use a free-standing center.

    So sorry this comment is so long, but very little has been written about Lara's guess about birth centers. One last point, though. Her presumption doesn't take into account the safety of staying put. Driving a laboring woman (to hospital or birth center) isn't necessarily beneficial to the process of labor. Many moms report that progress slows during the drive to their chosen birth location. The small possibility of a roadside delivery is completely eliminated by opting to plan a home birth. The experience/training/practices of caregivers have a greater influence on safe outcomes than the chosen out-of-hospital location.

  28. I'd recommend the book: Safer Childbirth?: A Critical History of Maternity Care by Marjorie Tew to answer the initial questions. I'd also recommend it to any critics of homebirth as it provides clear statistical information.

    As for the hostility toward doctors, I am very sorry that good doctors get maligned along with the bad as I am sure there are many more well-intentioned doctors than not. Unfortunately, when someone has had a bad medical experience caused by medical professionals, the consequences may be incredibly severe and for the most part, mistakes will be denied or excused.

    I was recently verbally attacked by a pediatrician for choosing homebirth. She has no knowledge of homebirth and yet felt completely at ease denigrating my informed decision to birth at home. This will be my sixth homebirth, my first two children were hospital births which solidified my desire for homebirths.

  29. I'd be interested in seeing a study looking at the role of litigation/ malpractice insurance as a factor against home births by comparing attitudes and statistics of American doctors vs. those in Ontario, Canada, where malpractice insurance for both doctors and midwives is paid by the provincial medical system. Midwives are eligible for hospital privileges, independent of physicians, but are also free to use their clinics or homes for birth.
    Interestingly, the province can't graduate midwives fast enough to keep up with demand. The hour-long prenatal appointments, support throughout much of labor, at home or the hospital, and 6 weeks of newborn care (the first two weeks at home!) is quite appealing to many women. And the only thing I paid for was the herbs for my sitz bath.
    Lisa N

  30. So often its a number of different reasons that work together to explain most or all of a certain set of attitudes/beliefs/motivations/actions. I'd say all the reasons stated so far play into it and if we wanted to we could argue about which of them explains most of the variation.

    I offered another possible explanation on my blog where I speculated that doctors might feel threatened by the idea of home birth and low-intervention birth because it means something with much less education and expertise is qualified to handle non-complicated births which then leads to think that maybe their life's work and education involved a whole lot of wasted effort on their part.

    And if I'm right, how I wish I could tell hospital birth workers that their education, skill and expertise is so very appreciated, wanted and needed when complications arise that necessitate their labors. When they attend normal births, they are overqualified and wasting their skills and talents. Their efforts are needed where their skills will be utilized in appropriate circumstances. Obstetricians deserve to be treated like the specialists that they are.


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