Should We Call the Midwife?

Earlier this month, a bill advanced in the Arizona state legislature that would ban the use of midwives in the state during births where the mother has had previous caesarean sections, is delivering multiples or might face breech birth. How best to give birth is, needless to say, a topic of perennial interest. What follows is a conversation between two Prospect staffers who stand on different sides of the midwife debate.

Amelia Thomson-DeVeaux: So basically, last year, Arizona overhauled its licensing protocols for certified professional midwives, allowing them to perform high-risk births at home. Vaginal births after cesarean sections, breech births, twins, etc. And now Kelli Ward, an Arizona state senator, wants to ban midwives from attending high-risk births. She says it's a pro-life issue. Choice quote: “I see the mom and the baby as two separate entities,” Ward said. “I would love to preserve the choice of the mother for their home birth, but that child also needs to have a choice ... the choice not to die.”

Monica Potts:  Right, so there's reason enough to be skeptical of her motives because she has a "think of the fetuses!" line. But I am definitely pro-women and infants living through childbirth.

ATD:  Midwives are too! And this isn’t a process without informed consent. Under the new licensing procedure in Arizona, women have to sign a form saying they understand the care that midwives provide and consent to that care. Of course, we’re talking about a fringier group of midwives too—certified nurse-midwives don’t usually attend home births and they definitely don’t do high-risk home births. CPMs are crunchier, for sure. They have an apprenticeship instead of going to med school or nursing school. But they still have professional standards.

MP: I think informed consent laws are good, but the fact that women are informed about the kind of care they’re getting doesn’t always mean they’re fully informed. I do think many women assume home birth is more "natural" and therefore "better," and aren’t up-to-speed about all the risks associated with any birth. Perhaps the information holes are bigger with home births than with hospital births because there are so few of them.

ATD: We're also talking about a really small subset of women. Midwives handle about one percent of births in Arizona. That’s less than ten thousand births a year, and most of those aren’t high-risk.

MP:  That's true, but home birth is getting trendier, and states vary a great deal on how midwives are licensed, what they're allowed to do outside of hospitals, and what kind of informed consent they must obtain. I do think there is a dearth of information in general about the risks of home births, and the real risks associated with hospital births. While no one knows exactly what all the risks are, a study in the American Journal of Obstetrics and Gynecology found that neonatal death was 2 to 3 times higher at home. There is possibly a higher rate of maternal death in childbirth, though the numbers on that are scarce as well. Part of the problem is that home births are rare.

ATD: Shouldn’t we be investing more resources in studying home births, rather than wringing our hands about the few high-risk cases?

MP: Yes, but labor and the birthing process are just dangerous for human females, and always have been. It's a legacy of walking upright, and if you look at the problems associated with births in the past or today countries where medical intervention is not the norm, a cesarean section rate of about 12 percent is natural. Our rate, of 30 percent, is much higher and there is reason to worry that we are doing too many C-sections, but 12 percent is still a lot.

ATD:  On the other hand, the home birth movement is giving women the tools and the language to take charge of childbirth in a way that vanished during the 20th century. When women started giving birth in hospitals, they lost their ability to control the process. It's not like today, if you give birth in a hospital, you'll be put into twilight sleep like Betty Draper. But the doctor isn’t with you the whole time. People at the hospital will ask you if you want drugs you may not want and that could make labor more painful or heighten the need for a c-section, and a lot of women feel like they can’t say no. All through pregnancy, women get told not to eat raw fish or drink wine, not to use their asthma medications, not to lift heavy things. There’s such enormous pressure to do pregnancy and birth right, and a lot of that has to do with obeying doctors without question. The home birth movement encourages women to question the way we’ve been doing things, and that’s good.

MP: A reaction against the paternalism of the last century is totally healthy and natural, but there is this weird pressure in the other direction now that tries to tell women that they are not REAL women unless they give birth vaginally, without drugs, without doctors, at home in a bathtub, and then breastfeed for years. I find that, on its extreme ends, it can be anti-woman, because it ignores the pain and time costs on women. No one says, "Let's do root canals like we did 100 years ago!" Sometimes medical progress is good.

ATD: C-sections are risky procedures too though, especially when you have more than one. And a 30 percent C-section rate is insane. Maternal mortality in the U.S. is higher than it is in Kuwait or Bulgaria.

MP: I suspect our comparison to Bulgaria probably has to do more overall with the dismal, disparate quality of our medical system than with anything specific to maternity care.

ATD:  Some of the high maternality mortality does has to do with health disparities more generally, but studies show that high c-section rates are a major factor.

MP:  I agree that rate is probably way too high. And doctors shortchange women in many situations, or do things to hedge liability.

ATD:  I guess I'm less worried about the power of the home-birth activists who will give birth to twins in their bathtub than I am about the power of the medical establishment. It seems like everybody's seen the Business of Being Born, but it doesn't have much reach beyond a subset of elite women and the thing that alarms me about the Arizona law is that it will make it seem like all midwives are bad, or all home births are risky.

MP:  Right, I agree with you that a law is not the answer, but only a few states require midwives to report data. The Midwives Alliance of North America released data that showed maternal death rate was 450 percent higher than in hospitals. Only a small number of the midwives shared data, so it is very incomplete, but I'm not sure home birth is the best answer for every woman. It's certainly not the only way to challenge the medical establishment. The presence of doulas [a non-medically trained birth assistant] in hospitals, for example, reduce medical interventions like C-sections and also help make women more active participants in their births. We also likely evolved that way—having lots of help from the other women around us—just because there were so many problems that could arise.

ATD:  Doulas are great! I did doula training a few years ago and I am a total evangelist for them. There's also a limit to how much they can do in hospitals if the doctors aren't cooperative. I think the bottom line is that women need to be informed about the risks associated with birth - and that goes both ways. There is a strain in the home birth movement that assumes that anyone who wants a hospital birth must be lazy or that they won't bond with their child and that's indefensible. There are lots of reasons to give birth in a hospital and that's a personal decision. But having hospitals be the default place for birth isn't good either. Really, we should be promoting birth centers that are attached to hospitals where midwives and ob/gyns can practice. The funny thing, too, about the Arizona law is that most midwives won't even attend high-risk births. Nurse-midwives don't, anyway. So it's making this sound like a MUCH bigger issue than it is.

MP:  Yes, the focus is certainly misplaced. I agree about the birth centers being attached to hospitals. Maybe it's the next step in health-care reform!

ATD:  I wish! The worst outcome of all of this would be that childbirth gets swept up in the debate about abortion.

MP:  Agreed.

Comments

Um I'm pretty sure 3/10 women aren't dying during delivery...maybe you want to correct that.  The actual rate given by the CDC is around 12-15 per 100,000. Pretty much in line with the data that are in the new MANA paper.

Which btw an independent statistician examined and the findings are fascinating.  You can find them here: https://dl.dropboxusercontent.com/u/27713670/MANA_STATS_response%20Orosz.doc

This law is an attack on a woman's right to control her body, full stop. The person best able to make decisions on behalf of an unborn child is the woman who is carrying that child. It's her body and her child, and she should be able to make medical decisions unfettered by laws that don't take her particular situation into consideration.

Yes, some babies and some mothers die. In the US, most preventable infant and maternal deaths are caused by the cascade of interventions that occur in hospitals. All other factors being equal, cesarean section leads to 5 times as many infant deaths and 25 times as many maternal deaths as vaginal birth. Yet no one is proposing laws that limit the circumstances in which doctors can perform occasionally-life-saving, often-life-risking, and always-profitable cesarean sections.

Disclaimer: I had 4 children at home with the assistance of CNMs. My eldest was transported shortly after birth and spent 10 days in a NICU. After spending those 10 days in a hospital observing how women and babies are treated (and mistreated) by medical professionals, it was clearer to me that women are safer at home for normal births.

I know women who have chosen to birth at home with high risk pregnancies. In one case, the woman had a previous ectopic pregnancy where 25% of her uterus was removed. In another case, the woman was pregnant with twins, the first of which was breech. I've known many women who chose to birth breech babies at home. All of these babies were born safely. Their mothers were intelligent women who made informed decisions about their birth options. In some cases, they birthed without any medical help because the homebirth midwives refused to attend them at home.

Bottom line: women have the right to decide medical issues about our own bodies, regardless of the contents of our uteruses.

Could you please cite your source on the information you quoted? Home birth has significantly higher risk associated with the 'lower intervention rate' showing those interventions were actually necessary.

Breech homebirthing had an absolutely appalling risk of death. So much so that anyone who sees the numbers and still chooses to is insane.

Look at that evaluation of the mana paper. It's very interesting.

Here's the conclusion:

Conclusion:

The mothers in the MANA STATS cohort experienced fewer childbirth interventions than comparable-risk women giving birth in the hospital.

However, the rate of intrapartum stillbirth or neonatal death was considerably higher, and the difference was particularly alarming among high-risk subgroups such as breech and VBAC. The incidence of low APGAR was significantly higher and may have been much higher. The risk of postpartum hemorrhage was substantially higher.

Women considering home birth should be aware of these risks. Furthermore, the risk of death is increased for babies in breech presentations, and infants born to first-time mothers or mothers with a prior history of cesarian birth.

Thanks for correcting the 30% maternal mortality rate.i figured you meant c section rate but since homebirth/CPM supporters seem to latch on to anything that validates their opinion I'm very glad you corrected it.

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