“Another example of cargo cult science is the plethora of two-arm acupuncture studies that compare a needling regimen using the traditional concepts, and compare it with a non-interventional placebo. These studies might have the appearance of clinical research, but they are inherently flawed and inconclusive, because they do not rule out the possibility that the observed results are mainly due to the painful stimulus and injury caused by a needle, which can occur regardless of the insertion point.”
I commented:
“I’ve often wondered if acupuncture carries the illusion of legitimacy because it’s penetrative in a way that other cam modalities are not.”
I suspect that the cargo cult metaphor would be a great paradigm for examining a variety of dubious alternative medical modalities and why lay people believe in them.
The problem is that in evaluating any alternative medical modality, the apparent intuitive knowledge “other/ancient ways of knowing” gives the impression of legitimacy. It’s the argument from antiquity. The ancient wisdom and spiritual-laden lore of natural, whole, organic ingredients and oils can offer calming, ritualistic alternatives to frightening and painful science-based treatments. Words that sound science-y and equipment that looks medical make some alternative claims very seductive. Add in the confirmation bias of self-limiting diseases, cancers going into spontaneous remission, or copious anecdotal evidence, and it all becomes terribly confusing.
It seems to me that homebirth in the US is often a form of cargo cult medicine. The survival of our species depends on more babies and mothers surviving birth than those who die, so it usually turns out okay no matter where the mother delivers. This feeds right into confirmation bias that homebirth in the US is as safe as hospital birth for low-risk women. The statistics tell a different story:
“‘While the risk of neonatal death is low overall, it may be higher at home births and that is a problem’, said Dr. William Barth, Jr., chair of ACOG’s committee on obstetrics practice and chief of the division of maternal-fetal medicine at Massachusetts General Hospital,
‘It’s one of those situations where overall the risk is low, but it is increased two to three-fold,’ he said. ‘Even though it’s a rare outcome, it is a catastrophic outcome. It’s preventable in that it is less likely in the hospital.’”
Explaining his stance, Barth cites a study presented by researchers from Maine Medical Center at the Society for Maternal-Fetal Medicine meeting in Chicago in early February. The study, a meta analysis of research from around the country comparing home births to hospital births, appeared to show a twofold increase in the rare event of neonatal death at a home births.”
Modern obstectics offers early diagnosis of problems, pain management, and surgical birth in the event of an emergency; however, we’ve all heard our mother’s horror stories about twighlight sleep, forceps, horrific vaginal tearing, and absolute lack of information and consent. Although modern obstetrical care is vastly different than those dark days, legends from that time percolate through the oral histories of women and misinform contemporary mothers.
Add to this the fact that some OBs are paternalistic jerks, and I can understand why lots of women flee! Many women, informed by such pop-culture sources as Mothering, seek midwife-assisted homebirth as a way to forcibly avoid any medical intervention during birth. According to the ABC News story I linked above, almost 50,000 home births took place in the US in 2005-2006.
I have previously addressed the ways I think childbirth becomes a litmus for status among a certain type of mothering peer group. I think this is an important phenomenon that adds social pressure to decisions surrounding childbirth. Briefly, mothers share birth stories as a bonding ritual as well as an assessment tool. There seems to be an inverse correlation between status and use of standard medical practices in childbirth, where C-section is the ultimate failure and homebirth is the ultimate ideal:
“The ideology surrounding natural childbirth is so powerful that consenting to medical intervention may lead mothers to deep disappointment and regret. My obstetrician reports that many women are harmed by such attitudes. Instead of experiencing joy at the arrival of a healthy child, they feel as if they have abjectly failed the first litmus test of motherhood. These mothers question every decision: maybe if they had waited at home longer, maybe if they had refused monitoring, maybe if they had refused an IV and so on. They wonder how they can possibly go on to become good mothers. The reality is that unmedicated childbirth can be incredibly difficult. My obstetrician actively supports natural childbirth and anecdotally reports that few natural childbirth patients maintain the calm and focus necessary for unmedicated birth.”
It’s heartbreaking that misinformation, unfair judgement and dogmatic attitudes rob so many women of the joy of birth and make adoptive mothers feel inferior. I have been reading Dr. Amy Tuteur’s various blogs about chilbirth for years. Her primary sources are usually very solid, and most of what I think I know about homebirth in the US comes from her.
Individual midwives obviously fall along a continuum of competency, but here’s the overview as I understand it. European countries have strict standards for midwife education, licensing and oversight. These midwives follow conservative transfer of care protocols and have reliable emergency transportation. In the US there are basically two types of midwives: Direct-Entry (DEM) also known as Certified Professional Midwife (CPM); and Certified Nurse Midwives (CNM). (Notice how similar the abbreviations CPM and CNM are.)
CNMs are registered nurses who have additional specialized obstetrical and pediatric training. They work in tandem with obstetricians and hospitals. They are supervised and follow a standard of care that attempts to err on the side of caution. They offer alternatives to the medical hospital childbirth experience by providing unmedicated alternatives at birthing centers attached to hospitals. In my mind this is the best of both worlds: it feels homey and cozy, you can bring your lavendar oil and iPod (just like in a hospital), the default mode is natural childbirth if that’s what you want, and yet there are surgeons and emergency equipment down the hall. It’s my understanding that CNMs don’t typically attend homebirths. I did read once about a physicians’ practice in the eastern US that supported homebirth with medical professionals.
A DEM is “A direct-entry midwife is an independent practitioner educated in the discipline of midwifery through self-study, apprenticeship, a midwifery school, or a college- or university-based program distinct from the discipline of nursing. A direct-entry midwife is trained to provide the Midwives Model of Care to healthy women and newborns throughout the childbearing cycle primarily in out-of-hospital settings.” These are the people who usually attend homebirth in the US. They often lack the safety net of OB supervision, transfer of care protocols, and reliable emergency transportation to hospital. But they call themselves midwives, and they appear legitimate. They speak the cloying language of self-empowerment and carry real medical equipment.
Anyone can purchase a “birth kit.” Expectant mothers go to a site like this and buy the kit their midwife recommends. It looks like real medical equipment to me. In fact I saw most of these items when I gave birth in the hospital.
I know several women who had fantastic homebirths and I know a handful of women and children who would not have survived outside of the hospital. Unfortunately when things do go awry, the DEMs are often not equipped to deal with childbirth emergencies. Dr. Tuteur has published many accounts of preventable homebirth death or severe damage that end with the midwife abandoning the family. The Daily Beast ran a recent piece about homebirth nightmares. There’s a story today (10.24) in the Guardian that describes the scene of a hombirth with an independent midwife. I love how the author sets the scene with all the cargo of homebirth:
“We had candles, mood music, a birthing pool. We knew how to breathe. We had massage oils. We were ready. My waters broke at night and I went into labour. My contractions were fierce. I was soon 10cm dilated. The contractions came every 30 seconds, pain grinding down my lower back. I felt I would crack open. My baby did not slip out like the Brazilian woman’s. I laboured for 36 hours. There is no describing the agony. The midwife put her hand inside me to turn the head, but still the baby did not come. I didn’t want candles or massage or music. I just lay on the bathroom floor and wanted to die.
My husband told me that the midwife had stood in the kitchen at a loss. By midnight on the second night, he insisted we went to hospital. Within three minutes of arriving, I had been given an epidural. Fifteen minutes later, the duty doctor told me that the birth was not progressing and I was exhausted. He would deliver the baby by emergency caesarean.
The independent midwife didn’t stay. This would not be a natural birth.”
As a veteran of two Pitocin freight-train births, it’s astonishing to me that women’s bodies don’t just go into shock and start shutting down. I can totally understand the allure of natural childbirth, but I don’t quite understand why women don’t just opt for that in the hospital or birth center where emergency help is a moment away. DEMs carry the cargo of legitimacy, speak of nature and empowerment, and represent themselves as medically competent professionals. I think women are seduced by that.
There are many reasons to give birth at home rather than “just have a natural birth” at a hospital. One of those reasons is that hospitals are often simply not conductive environments. Dr Amy Tuteur is just about the worst source for reliable information about homebirth – at least her current Skeptical OB website is. In her hatred for homebirth and homebirth advocates, she sometimes forgets the facts. Personally, I opted for homebirth for many scientifically valid, non new-age reasons. The local hospitals do not offer natural birth as an option (East Europe), but instead do of the things that were done in the US in the 1950s. Just like what you said: “we’ve all heard our mother’s horror stories about twighlight sleep, forceps, horrific vaginal tearing, and absolute lack of information and consent. ”
Those “dark days”, with a few differences, still exist over here. I didn’t want a 100 percent chance of having birth complications, so I opted for a homebirth.
Olivia, I have several friends who either have had or are planning homebirth. I understand the appeal, especially after hearing the accounts of friends’ awful hospital births. And even I might opt for homebirth in your situation, where hospital birth sounds much more dangerous than it is here.
I am lucky in that even with Pitocin I had fairly calm and very positive hospital birth experiences for both of my children. I actually got to help catch my daughter. At both there was no episiotomy–my OB massaged and stretched the skin instead, no one whisked either of my babies away ever, and I was free to accept or decline any intervention for myself or my babies. Even the busy pediatrician came back later because he didn’t want to disturb my daughter while she was nursing. In talking with friends I’ve learned that this paradigm might not be the norm here in the US either, unfortunately.
What I did have was high-risk pregnancies, so my tolerance for risk in childbirth is extremely low. I wanted the C-section fallback to be moments away just in case.
There is a difference between a planned homebirth assisted by a CPM and a “I want to give birth on a bearskin rug with my hippy-dippy midwife surrounded by my other children” homebirth.
CPMs–which aren’t DEMs or “lay midwives”–actually have to go through several years of rigorous training followed by nationally accredited certification and continuing education and recertification in adult and neonatal CPR, the use of oxygen, and risk assessment and transfer protocol. A woman who receives medical care throughout her pregnancy and is deemed low-risk by her obstetrician is generally no less safe delivering in the peaceful and familiar atmosphere of her own home, assisted by a trained professional, with a plan in place for medical intervention should anything unexpected come to pass. A 2005 study by the BMJ bears this out.
A woman with a high-risk pregnancy who chooses to deliver at home and/or chooses to use an untrained lay midwife is certainly putting herself at risk–as is a woman who chooses to treat a gaping wound with a Band-Aid and ultimately has to go to the hospital to treat cellulitis. When we talk about “cargo cult medicine,” it helps to distinguish safe, professional home care from untrained field medicine.
(Also, watch out for meta-analyses, which are only as good as the articles they analyse. In the MMC report, the researchers also performed a sub-analysis after discarding out-of-date and poor-quality studies and found that neonatal and perinatal mortality rates were actually comparable. It was only the conclusion that included the flawed studies that reported an increased mortality rate.)
Anthropologist Underground, I glad to hear that you had a nice, peaceful hospital birth. I sometimes think that natural birth advocates should spend more time “campaigning” to make hospital birth more pleasant and more patient-centered. After all, homebirth families are still in a tiny minority, and don’t we want birth to be as safe AND as satisfying as possible for the majority?
ACG, I agree with your note about meta-analyses totally. I even somewhat agree with your “hippy-dippy midwife” comment, though I don’t think there is anything “new age” or anti-science about having older children attend a birth. As a libertarian, I’m all about freedom of choice, and I don’t see a problem with the whole “hippy-dippy” thing, though it certainly doesn’t describe me. People have all kinds of reasons for making all kinds of choices, and that’s normally just fine, I think :). I just wanted to point out that choices that seem all “earth mother” at first glance may be well-thought out decisions that have nothing to do with… Hare krishna :).
ACG: thanks for underscoring the distinction between lay midwives or DEMs and trained professionals, CPMs. I hope I didn’t imply that CPMs represent a cargo cult–it’s the DEMs who misrepresent their competence and training.
Olivia: I totally agree with advocating for improving hospital birth experiences!
Comment fail above: Should say “I didn’t mean to imply that CNMs represent….” Sorry. Distracted.
You have about 7 minutes once the baby’s pulse drops before you start incurring brain damage. If there is a cord accident, then the clock starts ticking. If you aren’t being monitored constantly, you don’t know when the clock starts. If you intentionally put yourself more than 7 minutes away from a surgeon’s knife, you are taking a 1/200 chance (you can’t predict when their is going to be a cord accident) with someone else’s life, which is selfish. If you haven’t seen a baby go south delivering babies at home, you haven’t delivered enough babies.
There is, of course, a chance that you will have to have an emergency intervention if your kids are there. That could be unpleasant and unnecessary.
Honestly, the only time that I ever had to shut down my blog from comments was when the homebirth nutters came out of the wood work.
HJ
Bing: 7 minutes?! Not much time. Even if your attendant is a CNM, or the paramedics could arrive at your house in seven minutes, how much can non-surgeons do in that situation?
Exactly. When people say that home births have a higher success rate than hospital births, where do you think the problem births end up, thereby skewing the results of the studies? (Hint: not the living room.) You need access to a surgeon and constant monitoring for that small but actual chance of a cord accident. Have natural birth without drugs if you like, but as far as I can tell, if you have made a commitment to see the pregnancy to term, you have an obligation to another person to see that their delivery is as safe as possible.
HJ
Not sure this post lives up to the advert of women thinking critically…. why do we all lose our perspective when we talk about childbirth….?
There’s interesting data from the Netherlands where most births are homebirths. You might have considered including that. I don’t trust any studies from the US since there’s too much money to be made in hospital births and c-sections.
Good point in the comments about campaigning to improve hospital birth experiences. I see no reason why birthing rooms couldn’t be made much nicer, and staff trained to make a more conducive environment. It seems like this could particularly work in the US – at least among those with good health insurance. If it could be shown to save money on interventions it could work well in socialized medicine systems too….
I think women should also be campaigning for training in getting the right mindset for labour. We all talk about it as a traumatic event and the media hype it up, so we all get so stressed. I really think that helping women “get in the zone” and calm down about labour would be enormosly helpful. I think it should be part of prenatal care in fact. I think that’s why certain groups of people like homebirth – it’s easier to do that in your own home. But making it easier in hospital would help a lot more people.
[In case you care, I've had two children, one in the US (1st), one in the UK. Both hospital births on pitocin. I used "natural" forms of pain relief - including a TENs and gas and air in the UK. ]
Bing, that sounds a bit black and white, don’t you think? It’s amazing how strongly people voice their opinions when it comes to childbirth, and understandable to a point. But saying that everyone who does not get an abortion has a duty to give birth with a surgeon nearby is a bit… extremist, no? Not unlike “homebirth nutters” saying that everyone who has a c-section is a failure as a mother – both make no sense.
Karen, I totally agree with you.
Karen and Olivia the author stated quite clearly why she didn’t consider the Netherlands (or even the recent Canadian) study. In these countries midwives are all highly trained professionals supported through the medical system. In the US they are not. It is the US DEMs who have who knows what training that this post is discussing and they have no equivalent in the Netherlands, making that study irrelevant.
As an Australian I always find homebirth internet discussions interesting because we all come to it with different backgrounds. Often the ‘debates’ are simply misunderstandings between people thinking of the highly questionable trainging DEMs have and others who assume midwives are qualified nurses and professionals.
When I say that DEMs have questionable or who knows what training I mean it quite literally. There may be some who are very well trained but because it is not standardised there is no way of knowing. I would not have someone who had studied accountancy through that system do my taxes, why would I have them attend my birth? It is literally impossible to compare homebirths in other countries with US homebirths, the first element of critical thinking is to read the piece you are responding to and make sure you know exactly what they are saying.
On a lighter note – I meant to respond to this yesterday but got distracted by our own little homebirth. One of our guinea pigs had 4 babies, I was too busy keeping my toddler away to see the actual births but we saw her eating the membranes. She didn’t eat the placenta. Unfortunately one of them didn’t make it overnight but the other three are going strong.
I guess there is always an easier way …
Deb – In the U.S., there is actually a nationally accredited training and certification process to become a CPM, or certified practicing midwife. It makes it even trickier to judge, because you could be talking to a DEM who actually is a highly trained professional (CPM), or one who’s just watched women have babies a lot. Some states license midwives, but not all. To compare it to your accountancy example, in my state of Alabama, you’d have to drive to Tennessee to get your taxes done by a professional or stay in-state and take your chances with your neighbor’s kid who’s home from college for the summer. That countries like Sweden and New Zealand have such great birth records with midwives, and states like Alabama deliver more than a third of babies by c-section, is flabbergasting.
Congrats on the guinea piglets. (Is that right?) They are so cute when they’re little.
Karen, thanks for adding to the discussion. As I said in the article, I didn’t include data from other countries b/c my understanding is that the paradigm in the US is different. Many of the homebirth attendants here are not highly trained medical professionals.
I think we all go nuts about childbirth because no matter how we do it, we are judged inadequate.
The c-section rate is interesting but hard to drill down. I suspect that the high rate in the US has to do more with the threat of litigation than with profit, but I’m not sure about that. I realize that surgery costs the patient more, but what is the profit margin for surgical birth vs. vaginal birth? Is there a lot of profit in the charges for the OR, and equipment? Extra personnel? Extra supplies? Longer stay? I don’t know. There is probably some ideal rate that reduces (in hindsight) unnecessary C-sections while allowing mothers and infants to survive. If memory serves, the WHO puts this around 15%.
Olivia: My read was that Bing was advocating easy access to a surgeon, not necessarily mandating surgical birth for all. I think the hospital paradigm in the US is different from where you are in that not all women who give birth in a hospital end up in surgery. I think the rate of surgical birth in the US is around 32%.
Deb, thanks, and congratulations!
ACG, what a great analogy about how confusing it all is to sort out in the US system!
Henrik: Maybe next time…
Anthropologist Underground, I didn’t think Bing referred to mandated surgical births for all. But 32 percent is indeed a higher rate than is necessary or warranted, something that even the ACOG will acknowledge. The fact is that women birthing in hospitals are more likely to have a surgical birth simply because of their location.
Deb, I did not say studies from Canada or the Netherlands should apply in the US. While I believe there ARE professional, qualified midwives in the US (along with non-qualified, “God knows what training they have” DEMs, indeed!) my main point is that the birthing mother and her family should be able to make her own decision about care. If a woman has brains, she’s quite capable of judging whether or not a midwife, OB, or whatever other provider is suitable for her or not.
Olivia
The thing that makes the figures from those other countries interesting is that they indicate that having qualified professionals who are properly vetted and certified and integrate with the institutional health care system can work.
In our state of Kentucky the nature of the law is hostile to homebirth. What this means is that people who prefer homebirth are left with few choices and a confusing array of variables. The way it turns out, the midwifes that do handle homebirth are virtually required by law to bail if anything goes wrong (since fully certified providers for one reason or another, such as insurance, can’t or won’t practice at homes). This seems to lead to a lot of resentment on both sides.
In that environment you end up with 2 kinds of midwifes… Those who just want to stick it to the establishment and those who make the most of what they’ve got to work with. When my wife and I chose to have a home birth (3 now) we were pretty much on our own. We worked hard to determine that our midwife was not the sort to leave us stranded. Part of that was determining how often she determined that a person was a poor candidate for homebirth and how prepared she was for transport in the event of something going wrong.
In general we had good experiences with our homebirths, but it certainly leaves a degree of anxiety knowing that you’re operating outside of what could otherwise be a sturdy safety net… A safety net that could be there if lawmakers, the medical institution and midwives would just work together instead of against each other.
Aaron
Aaron,
Thanks for the comment! My state’s laws sound similar. I agree that there could (and should) be a much stronger safety net for families who choose homebirth.