Sunday, August 28, 2011

My experience with homebirth (i.e. how not to argue)

Back in May, I made a post on Mothers in Medicine about home vs. hospital birth. I have a few things to add to this, which may be controversial, so I will post here instead.

For starters, the reason I made the post in the first place was that a woman in an online pregnancy community that I'm part of posted some pro-homebirth propaganda. I didn't know how true the stats she gave were, but I hate obvious propaganda and it was hard for me to keep my mouth shut.

The thing is, I'm not an ob/gyn or a pediatrician. When I read this propaganda, I didn't know much about homebirth. All I knew was that when I rotated through L&D as a med student, I saw a few seemingly normal deliveries go south and it was a good thing the women were at a hospital. But I can't say I had a particularly strong opinion about homebirth aside from the fact that it was something I'd never do. It seemed like it was something that was probably okay for low risk women. But at the same time, I thought it was kind of insensitive to post propaganda scaring women into thinking that they were going to have a worse outcome with their hospital births, especially since many of them needed hospital births for medical reasons.

Like I said, I'm not an ob/gyn, pediatrician, midwife, doula, whatever. But I am a physician. I also did a research fellowship and have had multiple publications in peer-reviewed journals, so I've like to think I have some idea of how to interpret research. So when I get in a discussion with someone about homebirth, I can call bullshit on the following statement:

The fact that homebirth is safer is not even "controversial," as it is based on solid medical research.

That was said to me almost verbatim by more than one person. Let me tell you why this bothered me, in case it's not obvious:

1) No studies could be provided to me that in any way supported this. Every study I found myself showed the opposite.

2) Practically everything in medicine is controversial on some level. "Beta blockers should never be used in heart failure." "Oh wait, beta blockers are a good treatment for heart failure." To say that something that has never (and will never) be tested with a randomized trial isn't even controversial is just ridiculous. Especially when there are so many blogs arguing vehemently on both sides of the topic. Clearly it's a very controversial and emotional topic.

3) This statement was meant to imply that I could not argue further because the point I was arguing against was simply a fact, like the Earth being flat.

Before this argument, I had never heard of something called "birth trauma." I don't want to undermine the seriousness of birth trauma. But when every argument I made is shut down because it is triggering to people with birth trauma, that makes it hard to have a discussion. Especially if the other person refuses to stop making statements akin to "you will be butchered and raped in the hospital" around women about to give birth.

After participating in the most frustrating argument ever, in which I started even doubting my own name, I talked to a couple of the lovely women on MiM, who assured me that I wasn't crazy and that the official position of ACOG, based on what research is available, is that hospital birth is safer for both mom and baby.

I also discovered Dr. Amy's blog. I love this blog with all my heart. I wish I knew Dr. Amy so I could shake her hand. Every time I get irritated that a crunchy mom says that hospital birth will kill you, epidurals are the root of all evil, or vaccines/formula are poison, I read Dr. Amy's blog and her no-nonsense logic makes me smile. Pretty much any entry will do.

So that's the story of how I went from being pretty much neutral on the homebirth issue to being staunchly against it.

But the moral of the story isn't so much that I think homebirthing is a huge risk (although I do, sorry). Or that I'm going to go around telling random pregnant women not to have their babies at home (I won't). The moral of the story is something that has absolutely nothing to do with homebirth:

When you try to argue a point with someone, the goal is not to push them way to the opposite side.

Maybe this woman could have even convinced me that homebirth was a good option if she had:

1) Refrained from calling me names

2) Addressed my arguments instead of calling them all "triggers" or saying that the articles I cited had been refuted (and not saying where or how)

3) Provided me with actual links to articles instead of telling me they all got swallowed in some other comment she tried to write

Ultimately though, it was good because I learned a lot and discovered an awesome blog. (And had a non-traumatic hospital birth.)


  1. Holy Cow, Dr. Amy lays down the law:

    "In fact I know, and perhaps you know, too, that the Midwives Alliance of North America, the organization started by your friend Ina May Gaskin, is refusing to release their own death rates because an appalling number of the 23,000 babies in their database died at homebirth.

    But it doesn't take any specialized knowledge to count the growing number of dead babies, babies who died preventable deaths because their mother listened to you."

    Sounds like my kind of doctor. =)

  2. Exactly - and I couldn't agree more with you, btw. There are SO many things wrong with the homebirth movement. I can see why low-risk women would like to try a home birth, fine, I get it. But what I DO NOT get, and DO NOT agree with, is how the homebirth community bullies women that do not agree with their "alternative approach" - I mean, why are you less of a womam simply because you wanted some pain relief by getting an epidural? And why are you less of a woman because you used antibiotics (through an IV - mind you) in order to prevent your baby from getting GBS?! And why are you less of a woman because you wanted your baby to be monitored during labor, or had a C-section for your distressed or breech baby?! It's utter nonsense. Just the fact that you carried that child in your belly until their birth, and endured everything that comes with pregnancy (heartburn! constipation! nausea! oh my!), and gave him/her life, to me, makes every woman a SUPER woman. Period.

  3. I'm so annoyed by the women who think they've been robbed of some ideal birth experience by having a c-section or some other intervention. My son and I may not have made it without interventions. Oh yes, women having been having natural childbirth for millenia. Many of these women and children died as well. Still are in fact. Check out stats on some South American and African "midwife" assisted births.

  4. Oh, and check out some of Dr. Amy's recent posts as well. I'm sure you have seen them already:

    And the following:

  5. Just want to say, that just because some rabid people are arguing for more home births, doesn't mean that everyone who wants more home births is rabid. You will not hear from the reasonable people, because reasonable people generally do not get into arguments on the internet. (Present company excepted, haha.)

    There are certainly people trying for home births who shouldn't be. And I guarantee you that with a C-section rate around 30%, there are a LOT of people having C-sections that shouldn't be.

    Reasonable people who argue against interventions aren't talking in terms of what makes a person "less of a woman". They are talking about what kinds of interventions increase fetal and maternal risks, including the very real risks associated with C-sections. Laboring mothers are taking risks that they don't even know they are taking, and that is clearly not a good thing.

  6. It's interesting to me that even ACOG says barely 1/3 of their clinical guidelines are evidence based. The glacial rate at which change occurs in favor of evidenced based medicine in OBGYN is what drives most women who chose to home birth. That, and feeling completely ignored and undermined by their providers. Oh, and here's my link for that stat.
    As an example, how many years have we known immediate cord clamping isn't beneficial and, especially in the case of premature neonates, is harmful? 10? 15? and just now OBGYNs are starting to change the practice? It's unconscionable.
    and from JAMA

    Not all OBGYNs are bad. Not all home birth professionals are bad. Clearly, there are times when interventions are needed. (My sister nearly died from HELLP 20 months ago) I'm also not convinced every labor needs a trained surgeon or a hospital to achieve a healthy outcome. There's room for healthy skepticism on both sides of this argument.

  7. Dr. G and Linda: It definitely bothers me how women are demonized for things like wanting an epidural, just because it's not natural. I mean, in the olden days, they gave people ether for surgeries, but nobody suggests we do that now. It's terrible how women are made to feel bad about their births not going the way they wanted, even the ones who avoided a C-section and have a healthy baby.

    Jill: I know a lot of people who want to have homebirths are not crazy, although the ones who post about it extensively on the internet probably are. And then ones who have them in high risk situations like a VBAC probably are. Nothing will convince me that it isn't riskier for the baby to have a birth at home, but then again, people take tons of risks in life.... I take a risk when I jaywalk, but I still sometimes do it. The question is, how big a risk is it? And is it something you feel comfortable risking?

    Becky: It's impossible for there to be great evidenced based medicine in obstetrics, because it just isn't ethical to do those kinds of studies. It is unfortunate some women feel mistreated by their providers. I think it is entirely reasonable and possibly beneficial to be delivered by a CNM in a hospital setting. The risk is in being at home, where a hospital transfer may take a long time, especially when there's a midwife involved who may not have a high enough threshold for transfer.

  8. I think you're right that it's a question of weighing risks. Of course there are bad midwives, and there are bad OB's too. So that's a risk either way, that needs to be judged on a case-by-case basis. If you live closer or farther from a hospital, if you're more or less healthy, if you have any other risk factors, that should affect the decision whether or not to try a home birth. And the local culture at the hospital factors in as well -- there are hospitals where certain interventions are automatic, like continuous fetal monitoring, which as far as I know is associated with more C-sections and NOT with better outcomes. (I'm sorry, I don't have a reference for that.) If your hospital has a 35% C-sec rate and a near-100% rate for other interventions that you'd like to avoid because of their risks, it makes sense to avoid that hospital, especially if you're looking at a low-risk birth. It's a perfectly rational decision.

    If there aren't any OB's available that will actually do VBAC's, then a woman may feel forced into a home birth by her aversion to what she sees as an unnecessary major surgery. She might be trying to weigh the risks of the home birth against the risk of repeat surgeries, with little good data available on either side, since everyone is so hardcore about it. Just think - if you want to have 4 or 5 kids, and your first is a C-section, you're looking at choosing between giving up on your idea of what you want for your family and having that many surgeries, which is pretty dangerous. (Of course, if more OB's were willing to do VBAC's, this wouldn't be nearly such a big problem!)

    This book is several years old and likely out of date, but I sometimes refer people to "The Thinking Woman's Guide to a Better Birth". It talks about the science on various interventions, risks and benefits, and aims to educate women about what the data actually is, without ever getting into woo or the stuff about, you know, feeling your strong mother spirit or whatever. The bottom line is that the C-section rate is WAY too high in this country, and OB's on the ground don't seem to be moving in the right direction to start lowering it. For crying out loud, there are still OB's who do episiotomies on all their patients.

  9. Jill: I really like this post by Dr. Amy about VBACs (she seems to be in favor of theoretically trying them):

    She makes a really good point that it's not the fault of OBs that they don't like to do VBACs... it's the fault of women who try it, have a complication, then turn around and sue, saying they didn't understand what they were getting themselves into. If there were no lawyers, there definitely wouldn't be a C-section rate of 30+%.

    I'm sorry, but I think it's crazy to have a VBAC at home. The risks are too high in that case. Can you imagine your baby dying or even ending up with a dead baby AND a hysterectomy due to uterine rupture? If your dream is to have 4-5 kids, I'd say have 2-3 safe births and adopt another 2-3 kids. Lots of women don't end up with their "ideal" number of kids through no choice of their own.

    Then again, I also think skydiving is crazy. To each their own.

  10. My husband's grandmother had 5 midwife attended homebirths. She has 3 children. Enough said.
    It's not about the experience, it's about the outcome. I agree with you, Fizzy. A lot of these websites do little more than to fuel paranoia about doctors and hospitals, and may harm more people than they help.

  11. Thanks for this post so much. I have experienced "birth trauma" I suppose...but it was from a homebirth. I live in hippie granola land and we have a big, big problem with midwives extending their reach to more and more high risk women and women not being able to accurately assess the risk or their midwives' actual skills/competence/lack thereof because our state government essentially handed the midwifery board over to a bunch of lay midwives with ties to midwifery advocacy agencies. Real nice. My whole gig right now, other than raising my three little urchins, is exposing the horrifying stories beneath the slick ad campaigns put forth by local homebirth midwives. If anyone is interested, my blog is here:

    Oregon Homebirth Reality Check.

    I'd love to blog roll you because your posts are so funny and insightful. Would that be ok with you?

  12. The literature about cord clamping is FAR from conclusive. "Unconscionable"? Hardly ... early clamping results in fewer babies with neonatal jaundice, but more babies with early anemia. Which is better? Probably depends on the baby and should be an INDIVIDUALIZED decision ... sometimes the risk of jaundice/polycythemia is worse than the risk of anemia ... but then again I'm not an OB/GYN, just a dumb med student. I'm sure someone far more knowledgeable than I can comment on this ... but I thought I would at least take a stab at setting this one straight ...


  13. Astaea: Yes, absolutely you can blogroll me. I have heard about the issues in Oregon.

  14. Thank you, thank you, thank you! I too, have gone from being ambivalent on homebirth to staunchly anti, based on the idiot arguments and nastiness of the natural childbirth adherents to anyone who doesn't fall into step with every tenant of their religion. I still think that it may be an OK idea for a truly low-risk woman and skilled midwife, but the biggest problem is that skilled midwives who do homebirths are few and far between, and it's hard to tell the difference between them and the quacks until it's too late. I'd certainly never have a homebirth of my own, and would counsel anyone who asked my opinion against it as well. I'm blogging over at 10Centimeters, and we'd love to throw you on our blogroll as well.

  15. drinking from the Firehose: I can't find it, but there was study out of Canada(?) in the last two years that showed jaundice, where bili levels stayed in the high teens, had a function in enhancing the immune system. The study was supporting the argument that mild jaundice is actually good for neonates and need not be treated with anything other than watchful waiting. It's been a year since I read it for school, but that's what I recall. I'll put the subject back on my list of things to research more heavily.

  16. I would never have a home birth. I have plenty of friends that have and I believe to each their own. I had a hospital birth and COMPLETELY understand why women are traumatized by this and prefer home births.

    I am a *little* strong willed and before I was even dilated to a 2 was YELLING at the nursing staff while I was in labor. This is not okay. I should never have to yell to get them to do what I need them to do. At 5 am after 36 hrs of unproductive labor I finally got a fantastic nurse to listen to me. I delivered in 4 hrs (naturally) thanks to her.
    I am not an idiot I knew exactly what I needed- this is why women don't want to be in a hospital- people don't listen to us! They treat us like we are idiots and they are gods. (Plus, they starve us.)

    I will probably never have another child- I can adopt and avoid all the pain. But If I do- like hell will I have it in a hospital.

  17. Very much like weighing in on autism.

    I suggest going to one of my favorite sites (Science_Based Medicine)

  18. Thank you for this post! When I had my 3rd daughter, My "midwife" said "Oh, she's perfectly healthy". Yeah, a few hours later she was dead. The midwife failed to realize that she was in respiratory distress.

  19. Heather: Very true. And yes, you're welcome to link to me! :)

    Casey: Hospital birth is often very much about the luck of the nurses. I didn't have a great "birth experience" but I had a healthy baby so who cares?

    OldSquid: I like that site too :)

    Bambi: I am so sorry to hear about your loss and thank you for commenting.

  20. As a neonatologist, I have unfortunately witnessed too many complications from home births, and their subsequent emergent transfer to the hospital. I would never risk the health of my child for my own personal comfort. It's just selfish. I'm sorry, but I can't see it any other way.

  21. This is a very sticky issue to me - I am a premed student, planning to become an OB/GYN. I have an MPH and have worked in maternal/child health for many years. I had 2 out of hospital births with my children, one at a birth center, one at home, both while working on programs & services at a huge birthing hospital in a large metro region on the east coast.

    One part of this debate that bothers me is the general assumption that the decision to birth out of hospital is made with only the mother's well-being in mind and that most women are not also considering the well-being of their babies, and that they are in it for the experience. Personally, I didn't give a hoot about the experience, I cared about the outcomes, for me and for my baby (babies). I feel that I made the right choices for my personal life but I also recognize that most people I work with and will work with in the future think that choice is not just unwise but objectively *wrong*.

    But women will always make choices that fit their own lives and make sense to them, even if they don't make sense to others. I believe there will always be out of hospital birth, there will always be non-physician birth attendants. And as Dr. Whoo did in the original MiM post, I think it is important in the context of these discussions, to defend the right women have to make decisions about their health care.

    Beyond that, I think women have the right to a coherent and reliable system of care that provides them with a number of connected and communicating care options.

    One issue that I see on the midwifery side of things is the lack of professional and streamlined transfer protocols. Midwives don't say that they avoid hospital transfer to unfriendly institutions, they would certainly say they do not compromise their patents' care in considering transfer. But when relationships improve, transfers increase, patient outcomes improve and midwives themselves comment on the improved relationship. This reality is a midwifery equivalent to physicians practicing defensive medicine because of the real stresses and consequences of law suits. Non-medical circumstances influence the quality of care provided by each.

    We need to do something about both of these issues - midwives need to be accountable, qualified and supported. Physicians need to be freed to practice less defensively and in less fear of lawsuits (I'll get right on solving that one - right after I untie this gordian knot in my laptop's power cord) We need big, system-wide restructuring and we need good science, cool heads and collaboration.

  22. Larissa: Thanks for weighing in. Dr. Whoo and all of the docs on MiM may defend the rights of women to choose homebirth, but at the same time they do believe it's the wrong choice. I've actually never met a doctor before who wanted to birth at home. Since you have this background, I wonder if your feelings on homebirth will have chanced once you've gone through ob/gyn training. You should come back and let us know! :)

  23. I imagine it will change me, as all our experiences as humans inform our lives. One thing that happend to change me recently was moving to Oregon, where professional and lay midwives are legal & operating without as much oversight as I think there should be. I am completely blown away by Astraea's blog and the stories she's collected about these midwives.

    I look forward to keeping in touch! :-)