Birthplace in England: A Tale of Medical Reporting

A large prospective study comparing planned place of birth (home, hospital, freestanding midwife units, and in-hospital midwife units) for low-risk mothers in England, the BirthPlace study, was just published in the British Medical Journal. What has followed is a barrage of news headlines about the study--with drastically different conclusions.

If you click on the Daily Mail report, you'll be warned that "First-time mothers who opt for home birth face triple the risk of death or brain damage in child." TopNews Arab Emirates reports that "Motherhood is bliss but a minute mistake in planning the birth may lead to severe complications," while its US affiliate asserts that "According to a recent study, first time mothers should always opt for hospital birth." Even more dramatic is NewTonight's comment that home birth is "an extremely dangerous practice." (Definitely some one-upmanship going on here!)

If you're thinking that home birth is akin to traipsing over a minefield, you only have to turn to another set of news headlines that herald the opposite conclusion. "Study finds home birth is safe" proclaims the Peterborough Herald. "Women who have low-risk pregnancies should be able to choose where they give birth -- hospital, home or midwifery units -- researchers in Britain say," according to UPI. The Huffington Post declares that "over half of all pregnant women could give birth at home."

I've seen one report claiming that Professor Peter Brocklehurst, one of the study's authors, has "expressed disappointment that there is a significant increase in the number of first -time mothers who are planning to deliver their baby at home." (Granted, this was not a very reputable-looking site.) In contrast, the Huffington Post quoted Brocklehurst thus: "Birth isn't an abnormal process, it's a physiological process. And if your pregnancy and labor is not complicated, then you don't need a high level of specific expertise."

If news reports are this conflicting, imagine what's going on in the blogosphere. "SEE I TOLD YOU HOME BIRTH KILLS BABIES!" is coming from one corner of the net, while "SEE I TOLD YOU HOME BIRTH IS SAFE!" is coming from another. This controversy will keep certain bloggers entertained for months.

At this point, a reasonable response would be "what the $#@! is going on? Can't anyone agree on anything?"

Another reasonable response would be "So what about midwifery units? All the hullabaloo has focused on home and hospital birth and left out the other two studied locations!" 

This is how I'm feeling right about now:

I'm not going to tell you what to think. But here's where I'd suggest starting:

1. Read the original study.
2. Read the official National Health Service discussion of the study's significance and ramifications.
3. If your statistical skills are a bit rusty, you can polish them up over at Science and Sensibility's statistical discussion of the study.
4. Another statistical examination of the study: Are homebirths really risky? at Statistical Epidemiology

Original Study
Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400

Project details, including qualitative case studies and economic analysis
http://www.sdo.nihr.ac.uk/projdetails.php?ref=08-1604-140

News reports emphasizing risk

• Home birth 'carries higher risk' for first-time mothers BBC News
• First-time mothers warned over home birth risks The Daily Telegraph, November 25 2011
• Home births three times more risky than hospital, says study Metro, November 25 2011
• Women with low-risk pregnancies 'should have birth choices' The Guardian, November 25 2011
• First-time mothers who opt for home birth face triple the risk of death or brain damage in child Daily Mail, November 25 2011
• Home as safe as hospital for second births The Independent, November 25 2011
• Home birth risks up for new mums The Sun, November 25 2011
• Home Birth Imposes Higher Risks for First-Time Mothers MD news press release
• Home birth riskier for first time moms Press TV
• Home Birth Can Be Dangerous for a Baby TopNews Arab Emirates
• Hospital Birth Safer As Compared To Home birth TopNews United States
• Home birth 'carries higher risk' for first-time mothers International News Network
• Home births riskier for first-time moms: Study IBNLive

News reports emphasizing safety

• Study finds home birth is safe Peterborough Today (UK)
• British researchers OK birthing options UPI.com
• Home Birth a Good Option for Second-Time Moms Associated Content
• British Study: Half Of All Pregnant Women Could Give Birth At Home Huffington Post
• England study: Low-risk births don't need hospital Aurora Sentinel

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I need a guinea pig!

A new company Intimina recently contacted me about reviewing their Laselle Kegel exerciser. I don't have any underlying pelvic floor issues, so I offered to find someone more appropriate to test and review the device. (If I didn't know what these were, I would have guessed some kind of baby toy!)

If you'd like to try it out, send me an email describing why you'd be a good candidate. If I select you, you agree to test the Kegel exerciser and write up a detailed, honest review. The device will be yours to keep in exchange for doing the review.

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The problem with nursing covers

On the surface, nursing covers seem to be the perfect solution for moms who want to breastfeed but are uncomfortable doing so in public. Moms can nurse "discreetly," passers-by aren't made uncomfortable by seeing a woman's breasts in action, and babies can eat when they're hungry. Nursing covers are often marketed as breastfeeding helps. According to some of the most popular nursing cover sites, they "allow you to breastfeed anytime, anywhere." You can "nurse discreetly and in style."

Are there any potential downsides to nursing covers? In this post I explore how nursing covers may do a disservice. Here are some of the reasons why:

1. You need to see it to learn it
In order to breastfeed successfully, women need to watch other women nurse their babies. A lot. They need to see how to hold a newborn, how to help them latch on, how to deal with those pesky arms, how to adjust an uncomfortable latch. They need to see it again and again, until those actions become so ingrained that they become second nature.

As I argued in my presentation at the 2011 Lamaze Conference, breastfeeding in a modern, Western context is like learning a foreign language. We no longer speak breastfeeding fluently. In earlier times, it used to be our mother tongue, but now most of us are second-language speakers. Hiding breastfeeding underneath a blanket keeps us from gaining fluency in this language. It's the equivalent of trying to become in French by reading textbooks, but never hearing spoken French or going to a French-speaking country. It is nearly impossible to become fully conversant in a foreign language without interacting with native speakers.

2. Caution: Keep Out
Nursing covers ghettoize breastfeeding by creating an artificial divide between public & private breastfeeding, then labeling public breastfeeding as inappropriate unless carefully hidden. They perpetuate shame and guilt for an essential, life-giving act. The cultural mandate to hide breastfeeding extends into private spaces; some women use nursing covers even in designated mother's lounges! Covers draw attention to an act that would otherwise be easy to mistake for holding a sleeping baby.

3. One (unnecessary) degree of separation
Nursing covers make breastfeeding unnecessarily complicated by placing a layer of fabric between the mother and her baby. This layer keeps mothers and babies from making eye contact and visually interacting. Many covers have attempted to compensate for this by incorporating a rigid band of plastic or metal band that arches the fabric away from the mother's chest and allows her to peek at her baby. It's a solution to a "problem" that doesn't need to exist in the first place.

4. Hiding hooters & covering udders
Nursing covers reinforce women's status--and their breasts in particular--as objects of sexual desire. (Hooter Hiders, anyone?) By hiding breastfeeding, they send a message that nursing a baby is the equivalent of a sexual act.

The photos below, taken from the Udder Covers website, show women in sexually alluring makeup and poses. This first photo shows a heavily made-up woman with false eyelashes, bleached hair, and an inviting, seductive expression. You could easily transplant her head onto the body of a Victoria's Secret model selling lingerie or swimwear.

This next picture shows models with whitened teeth, false eyelashes, and carefully groomed hair. It sends the message that showing skin is acceptable, as long as it is not in the context of breastfeeding. Bare shoulders? Fine. Cleavage? No problem. Breasts in action? No way. 

Sometimes nursing covers do not sexualize women; instead, they make them look entirely asexual.

I mean, who wants to wear an bib? That's so toddler. Even with a cute floral print.

5. The problem is cultural, not individual
Nursing covers hide the fact that disapproval of nursing in public is a cultural problem. Instead, the rhetoric of "covering up" frames breastfeeding as an individual person's issue that can be solved with the right product. (I'm not confident enough to nurse uncovered. I don't want to see women whip it out. Nursing is okay but I feel it should be discreet.) By keeping the focus on the individual, nursing covers keep us from seeing the issue as a cultural one.

6. Breastfeeding: The anti-porn
"But what if my 12-year-old boy sees it?" My response would be "Awesome! He'll have a healthier view of the female body by seeing breasts in their proper function." The pornographic view of breasts sees them as objects of male desire. A functional view of breasts--not hidden under a cover, not exposed with the intent to arouse sexual desire--sees them as objects that nourish and comfort.

Nursing covers ultimately aren't an aid to breastfeeding--they are a well-intentioned tool that inadvertently undermines breastfeeding. The solution to breastfeeding in public isn't to hide it under a bib; it's to make nursing so ubiquitous, so everyday, that the divide between nursing in private and nursing in public disappears. I long to live in a culture where there is no such thing as "nursing in public"--a place where breastfeeding is, simply, breastfeeding.

Reader Challenge:
This photo is begging for some awesome captions. The best caption gets the official Stand & Deliver seal of approval.

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God Was My Midwife: My Interview with Shifra Mincer

Last week, I spoke with Shifra Mincer, who runs the Jewish birth site Layda Birth. She had intended to interview me about my dissertation findings on unassisted birth, but our conversation soon took a more personal turn. We spoke about why I chose to give birth unassisted the first time--and why I did not for my subsequent two babies. We also discussed the LDS understanding of the Feminine Divine (a.k.a. Heavenly Mother) and how I found strength and wisdom from turning towards her in my first pregnancy. We ended with my thoughts on feminism's near silence on birth issues. If you're interested to read more, please read God Was My Midwife.

An excerpt:

A Mormon, Freeze has the practice of speaking to God directly through prayer and meditation. Mormons have the concept of God the Father and God the Mother, a kind of Godly husband and wife, she said.

When she was pregnant with her first child, Zari, Freeze said she found herself reaching out more than ever before the Divine Mother, asking her for guidance. “I did find myself, during my birth and pregnancy, connecting to my Heavenly Mother. I was like, okay Father, I need to talk to Mother." Then I would tell her, "I need your help and guidance, I need you to be there with me for this process. I need a female presence to guide me through this process.”

As she meditated and listened to hypnobirthing CD’s before the birth, a visualization kept coming to her: “My pregnant self was walking down this long hallway next to Heavenly Mother, this serene Mother who led me down to the room where I would give birth. There I had to do it myself. And then after I gave birth, I came out another door where I saw these crowds of women who had gone through this before.” Throughout the meditation she said felt a sense of real closeness with the Divine Mother and of “needing her with me. I really relied on that heavily during my first pregnancy.”

Read the rest here.

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I no longer have a placenta in my freezer, version 3

A shipment of six dwarf fruit trees arrived on Friday: Asian and Bartlett pears, Bing and Black Tartarian sweet cherries, Elberta peach, and Methley plum. I turned a lovely sunny spot of the yard, next to the vegetable garden and driveway, into a fruit orchard.

Inga's placenta has been lurking in the depths of our freezer, and it was time to plant her tree of life.I'd like to say there was some deep symbolism behind which fruit tree the placenta went underneath. But honestly, I decided that I really liked dark sweet cherries and so under the Black Tartarian it went!

Zari helped me dig the holes. She wanted to touch the (still frozen) placenta and umbilical cord before the burial.

Zari's placenta went underneath a climbing rose. Dio's went under a rose tree. Now that I've branched out to fruit trees, I wonder what type of plant the next placenta will nourish.

Do you still have a placenta in your freezer? What are your plans for it?
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Rep. Roybal-Allard Applauds Consensus Agreement of Home Birth Summit

For immediate release:
November 16, 2011
Contact: Douglas Farrar
(202) 225-1766

REP. ROYBAL-ALLARD APPLAUDS CONSENSUS AGREEMENT OF HOME BIRTH SUMMIT

WASHINGTON, D.C. - Congresswoman Lucille Roybal-Allard (CA-34) spoke in the House of Representatives today [click here for video] to recognize the significance of the consensus document produced by the Home Birth Consensus Summit that took place in Warrenton, VA between October 20 and 22.

"The publication of the Home Birth Consensus document is of critical importance to all current and future childbearing families in this country," said Rep. Roybal-Allard. "I am pleased that the report supports the need for maternity service reform which I champion in my MOMS for the 21st Century Act (H.R. 2141). With the support of the diverse stakeholders of maternity services, I call on Congress to act to pass this important legislation to make evidence based maternity care a national priority. The mothers and babies in this country deserve nothing less."  
The Home Birth Consensus Summit marked the first time a multi-disciplinary group of maternity care providers came together with consumers and industry leaders to determine what the maternity care system could do to make homebirth the safest and most positive experience possible for all moms and babies. The Delegates were charged with finding common ground to move the issue of safe home birth beyond professional differences and toward consensus-building. The result of their effort was a consensus document released on November 1st of this year. This important document sets out 9 essential statements of agreement about the ideal system to promote the safest and most positive birth outcomes across all birth settings including:

• All childbearing women, in all maternity care settings, should receive respectful, woman-centered care, including opportunities for shared decision-making to help each woman make the choices that are right for her.  
• Physiologic birth is valuable for women, babies, families and society and appropriate interventions should be based on the best available evidence to achieve optimal outcomes for mothers and babies. 
• Collaboration within an integrated maternity care system is essential for optimal outcomes. And when necessary, all women and families planning a birth center or home birth have a right to: a respectful, safe, and seamless consultation, referral, transport and transfer of care.
• All health professionals who provide maternity care in all settings should have a license that is based on national certification that includes defined competencies and standards for education and practice.
• In order to foster effective communication and collaboration across all maternity disciplines, all students and practitioners involved in maternity and newborn care must learn about each other’s disciplines, and maternity care in all settings.

Additionally, the Consensus Document calls for:  medical liability system reform, a compulsory process for the collection of patient data in all birth settings, the elimination of disparities of care and increased consumer participation.

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SRSLY illustrated

My little brother created this for me:

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SRSLY?

Some things make me go "You can't be serious. They actually SAID that?"

#1: Old uterus = deflated balloon

Commenting on Michelle Duggar's annoucnement that she is expecting her 20th child, NBC chief medical editor Dr. Nancy Snyderman said: "She [Michelle Duggar] is a high-risk pregnancy because she’s 45, and because that uterus can’t have any spring in it anymore. I mean, really, it’s gotta be like a water balloon that has no tensile strength."

This is your uterus

This is your uterus on kids

#2: Breast is best, so feed your baby formula

From an report about a recent study showing--surprise!--that formula advertising decreases breastfeeding rates, I found this gem:

Alex V. Castro III, executive director of the Infant Pediatric Nutrition Association of the Philippines that groups infant formula makers, said the association fully supports breast-feeding.

Ha. Hahaha. Seriously!?! If you fully supported breastfeeding, you wouldn't be in business. Your business is dedicated to fully undermining breastfeeding. 
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Neither/nor, or how getting a job improved my life

Since I began teaching freshman composition this fall, I no longer fit into any tidy label. I'm a stay-at-home mother (mostly). I'm a working mother (partly). I'm neither fully one nor the other. And you know what--I love it!

I feel so lucky to be able to spend the bulk of my days raising my little children. I also love teaching and keeping current with my academic endeavors. Teaching one class per semester has created the perfect balance for me. Three mornings a week, I slip away to teach my 8 am class. Immediately after class, I exercise at the college gym. Eric meets me on campus at 10 am with all three children. He goes to his office; I go to the locker room with the kids and shower. (Our university athletic facility has a free laundry service, so I never have to tote exercise clothes back and forth from home. Amazing.) Then we're off for our morning activities.

You know what the best part about teaching is for me? 3 days a week I don't have to get the kids up, dressed, fed, brushed, or out the door. It's positively brilliant. Getting my children ready in the mornings is one of my least favorite things, and working lets me skip out of that responsibility. It's a win-win situation for both Eric and me. I get a break from the kids, while he gets more time with them 3 days a week. We're both really happy with our situation.

I''d also argue that this job has improve my marriage. Since Eric and I finished graduate school, our interests and activities have drifted farther apart. My world was increasingly dominated by babies, breastfeeding, toddlers, and preschoolers. My being involved in academia again--albeit as a teacher rather than a student--has given us more common ground. I like being able to ask Eric about what teaching strategy he'd suggest or which books he likes best for a given course. We can discuss grading strategies, groan over grammar errors, and celebrate when we see excellent writing or have a lively class discussion.

I like being in the nebulous area between a stay-at-home mother and a working mother. I recognize how fortunate I am: I get to do something I love and get paid well for it, without sacrificing time with my children. It's a dream situation for me right now.

I have had to give up some things: most evenings, internet time and blogging have been replaced by grading papers and prepping for class. It's a trade-off I'm happy to make, though.

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Join IFFC

You're invited to join the IFFC (Inga Freeze Fan Club). The delightful Judy Norsigian, executive director of Our Bodies Ourselves, has enthusiastically volunteered to serve as President.

Judy and Inga at the Home Birth Summit. Photo courtesy of Jill at The Unnecesarean.

Membership is free and open to all. IFFC Benefits include updates of Inga and cute photos.

Warning: joining IFFC may cause your ovaries to go into overdrive.
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Zari is 5!

Zari turned 5 on Halloween and we were too busy doing Halloween-y things to write about it. Like carving birthing pumpkins and dressing up as Zorro (Eric), a "fancy lady from a long time ago" (me), a jellyfish (Zari), a dragon (Dio), and a "mini me" (Inga in a black cape that matched Eric's).

We also didn't take any pictures of her. Oops!

But I did take several pictures of her cake. Zari requested an "earth cake." Can do. Using the same recipe from Inga's Blessingway cake, I dyed the batter blue and green to match the frosting. 

North America turned out pretty well.

Europe, Africa, and Asia were a bit iffy.

After I did those continents, I realized that I left no room for Antarctica and the Arctic. Blame it on global warming.

We had lots of batter left over, so we made a few dozen cupcakes decorated with Swedish Fish. Why Swedish Fish? I don't know...it seemed appropriate.

We also had a volcano-shaped piece of cake trimming. I dyed applesauce red to make lava. Only the final effect was meatloaf with ketchup, not a volcano spewing molten lava. It's still sitting in the fridge.

We had family visiting over the weekend: my mom, my two younger sisters and their kids. 6 adults + 8 children in one house = 1,352,759 decibels. I needed to decompress from the noise and commotion.

I've been telling Zari, "I am happy that you are 5 years old but sad that you're growing up so fast." This usually leads to a conversation about how she will some day be grown up and become a mama with her own children, and then I will be the grandma. I mentioned once that I would be sad because she wouldn't be living with me any more when she is grown up.

She replied, "But I don't want to live in a different house. I want to live in your house when I am a mama!"

I can't argue with that.

Five years is a huge milestone. Zari is learning to read, just mastered riding a "real" bike, speaks fluently in French as well as English (thanks to Eric speaking only French to her starting a bit over a year ago), and has a vivid imagination and a very good memory. She's old enough to have lifelong memories now. Wonderful and kind of scary, from a parent's perspective.

In lieu of birthday pictures, here's a snapshot from a few nights ago:

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Common Ground Statements from the Home Birth Summit

What Were the Outcomes of the Home Birth Summit?

The following statements reflect the areas of consensus that were achieved by the individuals who participated in the Home Birth Consensus Summit at Airlie Center in Warrenton, Virginia from October 20-22, 2011. These statements do not represent the position of any organization or institution affiliated with those individuals.

In creating these statements relating to maternity care and birth place in the United States, we acknowledge the complexity inherent in each topic of concern, as well as some disagreement about how to best achieve or demonstrate these principles. While all agreed that there is great value and need for further work in these areas, action plans that flow from these principles may be carried out by individuals or in newly formed, multi-stakeholder work groups according to their own, or shared, values and priorities.

Summary statements such as these can be interpreted differently by different readers. Therefore, although there was both unanimity and consensus about the topics addressed, there was not necessarily unanimity as to all of the specific words chosen to create the statements. For example, words such as “autonomy”, “independence”, and “collaboration” may have different implications for practitioners, policy makers, and consumers.

These common ground principles are intended to provide a foundation for continued dialogue and collaboration across sectors, as we work together towards a common goal of improving maternal and newborn care for families choosing home birth.

STATEMENT 1

We uphold the autonomy of all childbearing women.

All childbearing women, in all maternity care settings, should receive respectful, woman-centered care. This care should include opportunities for a shared decision-making process to help each woman make the choices that are right for her. Shared decision making includes mutual sharing of information about benefits and harms of the range of care options, respect for the woman’s autonomy to make decisions in accordance with her values and preferences, and freedom from coercion or punishment for her choices.

STATEMENT 2

We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes. All women and families planning a home or birth center birth have a right to respectful, safe, and seamless consultation, referral, transport and transfer of care when necessary. When ongoing inter-professional dialogue and cooperation occur, everyone benefits.

STATEMENT 3

We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes. This system provides culturally appropriate and affordable care in all settings, in a manner that is acceptable to all communities.

We are committed to an equitable educational system without disparities in access to affordable, culturally appropriate, and acceptable maternity care provider education for all communities.

STATEMENT 4

It is our goal that all health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice.

We believe that guidelines should:

• allow for independent practice
• facilitate communication between providers and across care settings
• encourage professional responsibility and accountability, and
• include mechanisms for risk assessment.

STATEMENT 5

We believe that increased participation by consumers in multi-stakeholder initiatives is essential to improving maternity care, including the development of high quality home birth services within an integrated maternity care system.

STATEMENT 6

Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings.

To achieve this, we believe that all health professional students and practitioners who are involved in maternity and newborn care must learn about each other’s disciplines, and about maternity and health care in all settings.

STATEMENT 7

We are committed to improving the current medical liability system, which fails to justly serve society, families, and health care providers and contributes to:

• inadequate resources to support birth injured children and mothers;
• unsustainable healthcare and litigation costs paid by all;
• a hostile healthcare work environment;
• inadequate access to home birth and birth center birth within an integrated health care system, and;
• restricted choices in pregnancy and birth.

STATEMENT 8

We envision a compulsory process for the collection of patient (individual) level data on key process and outcome measures in all birth settings. These data would be linked to other data systems, used to inform quality improvement, and would thus enhance the evidence basis for care.

STATEMENT 9

We recognize and affirm the value of physiologic birth for women, babies, families and society and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies.


In addition to practitioners, consumers, insurers, lawyers, ethicists, administrators, and policy makers, the participants included researchers with expertise in epidemiology, public health, midwifery, obstetrics, pediatrics, nursing, sociology, medical anthropology, legal, and health policy research. However, the goal of this summit was not to examine, debate, or form a consensus statement regarding the evidence published regarding safety or maternal-newborm outcomes of planned home birth. Rather, the goal was to discover areas of common ground among these diverse stakeholders, when considering the future of home birth in the United States. By addressing our shared responsibility, we were able to identify several important and relevant topics that may benefit from ongoing multidisciplinary engagement.

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To read more about the Home Birth Consensus Summit, visit the website. If you would like to contribute towards supporting the Summit's expenses (which exceeded the anticipated budget), click here.

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