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!

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