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Extreme Birth, Indeed

Routine maternity ward monitoring, inducing, and anesthetizing have added up to millions of unnecessary cesarean sections: a hospital childbirth system gone insane.
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You'd think that between Erykah Badu's home-birth twitter and Ricki Lake's film success and the New York Times coverage that we'd moved beyond dissing home birth as fringe -- "extreme." Apparently not. The current New York magazine titles a feature about it "Extreme Birth." The piece, by Andrew Goldman, tries to be a character study of Cara Muhlhahn, the home-birth midwife and now memoirist featured in Lake's film The Business of Being Born. But after raising her to a teetering pedestal, crowning her "the fearless -- some say too fearless -- new leader of the home-birth movement," Goldman shoots her down. It feels more like a character assassination -- of both her and the movement.

This is unfortunate for many reasons. As Goldman himself admits, routine maternity ward monitoring, inducing, and anesthetizing have added up to millions of unnecessary cesarean sections (latest CDC rate: 31.8%) -- a "hospital childbirth system gone insane." Midwives who attend home birth provide a much needed, safe alternative. But Goldman can't quite buy that (or manage to cite any research one way or another). He claims that Lake's movie "de-radicalized home birth, conflating it with garden-variety natural childbirth and allowing Muhlhahn, largely unchallenged, to argue for its safety."

Here's the deal on safety: The American College of Obstetricians and Gynecologists claims that it isn't safe; the American College of Nurse Midwives and the American Public Health Association claim that it is. The research evidence clearly demonstrates that birth outside the hospital with a trained midwife is not only as safe for the baby, but safer for the mother, provided she is considered "low risk" -- a healthy woman carrying one full-term, head-down baby.

What does Goldman mean by "garden variety natural birth" and where can you get one? The sad truth is that it's an uphill battle to avoid unnecessary intervention once you check yourself into a garden variety U.S. maternity ward (I call this "pushed birth," and it is epidemic). In many places, like NYC, there is very little gray area between the extremes, if you will, of home and hospital. And freestanding birth centers are great if you can find one, but there's no real clinical difference between there and at home: every piece of equipment at a birth center a midwife can bring to a home birth. If labor isn't progressing normally or a complication develops in either location, you transfer care to the hospital.

This concept of transporting a birth from home to hospital is a toughy, especially for reporters -- it looks like failure. The anonymous OBs quoted in New York magazine call transports "dumps" and "train wrecks." In reality, transports are normal and appropriate. These are the women who actually need advanced medical intervention; most just need pain relief or antibiotics (the C-section rate for planned home birthers is under 5%). The option of transport to a fully equipped hospital is what keeps home birth safe. Supportive physicians embrace the role of providing appropriate medical intervention and emergency care, rather than demanding that every woman give birth in the hospital and be treated as if she's an emergency.

Several times in the New York piece, Goldman thinks he's catching Muhlhahn in flagrant malpractice, but this is because midwifery standards and obstetric standards differ so, and because Goldman is relying on a cultural bias that obstetrics is more scientific. But it's not.

Yes, hospitals and physicians restrict women to 24 hours of labor after their waters have broken (many providers want you induced with Pitocin immediately after membrane rupture), but that's just standard protocol, not science. The best, largest study actually showed that a woman can labor four days without risk to the baby. Goldman also sanctions Muhlhahn for underestimating a baby's weight, and quotes an OB who claims she should have known the baby was "too big." But again, the evidence shows that even the highest-tech ultrasounds can be off by two pounds, and that it's impossible to predict which babies' shoulders will get stuck. Even ACOG doesn't recommend inducing or sectioning based on size guesstimates.

The truth is, standard maternity care is not evidence-based care (see this recent report.) And this is why more women are interested in giving birth at home. Not just so they can have candles and music and a better "experience," but because they know that checking into a hospital means exposure to preventable risks.

Which is really the shame in all this. Because most Americans are skittish about home birth, and no woman should feel it is her only option for a regular 'ole, supported, physiological birth.

As for the higher-risk births (twins and breeches for instance), the ideal setting is a hospital in theory, but midwives like Muhlhahn may agree to attend them at home because they know that their clients have zero chance of a vaginal birth otherwise. They feel an obligation to support women's choices and help them avoid unnecessary surgery. And they have the skills to do it (the current obstetric training for breech delivery is a cesarean section!). The system is shameful to an extreme.