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<em>Atlantic Monthly</em> Gets It All Wrong About Home Birth

What if the patient had been his hospital birth patient from the start, and had had this exact same labor?
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I had been planning to ignore the recent Atlantic Monthly piece arguing against home birth (The Case for Hospital Births, 3/15/12), since it seemed the kind of piece written not to inspire thoughtful discussion, but merely to start a click-bonanza flame war. And, as I've blogged about before, I'm sick to death of strident discussions of birth politics that have the nuance of a cow bell.

But it turned out to be not a "case" at all, just a whinge. But despite itself, it shows why birth politics ought to matter to anyone who cares about women's reproductive rights.

Here's the gist:

There was an OB in the hospital and a laboring woman came in with her midwife. She had planned a home birth, but after many hours of pushing, the baby hadn't arrived. Her midwife had advised her to transfer to the hospital because the birth was now outside the range of normal for home birth, which is just what home birth midwives ought to do in such a case, just as any kind of care provider ought to refer out when something is beyond their scope.

So, mom-to-be goes to the hospital and encounters Doctor. Doctor scowls at her (his description!).

He tells us that he would have recommended a c-section hours earlier. Not because the baby was in danger -- there is no suggestion that the baby was in danger when they got to the hospital -- but just because he would have "worried" (his word, again).

Mom wants to hear whether there are other options. Doc tells us that there was no medical reason to do a c-section then, but:

It would have been easy to tell Laura that a cesarean was recommended given how long she had pushed, but I knew it was the last thing she wanted, so I explained that we could try some other interventions ...

She agrees to try his suggestion of augmenting the labor with Pitocin to strengthen the contractions.

After they start the Pitocin, though, the baby's heart rate decelerates. Doctor again informs mom of her options. They can do a c-section. Or they can use some tools that we've developed for this situation, which give us a closer look at the baby and the labor. They are: the internal fetal monitor and the intrauterine pressure catheter, and they exist, ideally, to give us a closer look and, hopefully, avoid doing a c-section if there's no medical need.

She proceeds with them and, a few steps later, again with his counsel, decides to use the vacuum extractor to assist a vaginal delivery.

The baby is born safely.

At no time does the doctor say that he thought that the choices that he gave and that she chose were unsafe or inappropriately risky.

Afterwards, the mom conveys that she is happy the baby is born, but unhappy that she had to make the transfer and unhappy with this doctor's temperament. To his great surprise, she hopes to try for a home birth next time.

Why is this so astonishing to the doctor, and why does that prove, to him, the "Case" against home birth? To me, this story is actually a great example of

  • a patient engaging in responsible adult decision-making, communicating with her caregiver, learning her options, and making appropriate, safe personal choices.
  • how a coordinated system with competent backup for home birth could work.

In fact, it seems that the biggest drawback in this case was that the doctor was scowling, and the midwife -- who actually knew this patient -- had no privileges at the hospital and so she couldn't provide the kind of assistance that helps give better care than you can get from a stranger.

And why was this doctor scowling at the mom the entire time?

  • Because she tried for a home birth originally, and couldn't forecast this unlikely situation, which, though not dangerous to the baby (he acknowledges that there was no concern about the baby until after the mom received Pitocin) required a big change of plans?
  • Because she wanted him to provide more options than just "we can do a c-section"?
  • Because she expected personalized service, not a generic, "we do a c-section after 2 hours"?

To me it seems that the mom was pretty much the ideal consumer. Not because she wanted a home birth, but because she sought explanations and information and made good, competent, adult decisions about the care of her own body, with the counsel and guidance of the expert she was paying to help her.


At one point in the essay, the doctor complains that

Short of a cesarean, she had experienced about as invasive a delivery as modern obstetrics has to offer.

I don't get this complaint. The mom might feel disappointed, afterwards, that fate handed her this particularly difficult birth, which required medical intervention. But even really Birthy people, if they are sane and reasonable, don't reject the idea of medical intervention per se -- they reject the idea of using it when it's not necessary. In this case, everyone seems to agree that it was necessary.

And if this mom preferred Pit and IFM and the vacuum to a c-section, who is this doctor to say that she ought to have preferred the c-section and spared him the extra hours by her side? She is the customer. She is the owner of her body. She is the decider. He is the servant.

Women seem to like to make decisions about the care of their bodies. It is not "crunchy" to say that a competent adult woman can be trusted to choose, among safe options that have been explained to her, the course that will be best for her.


Finally, the doctor whines that he hated this birth because he was forced to clean up "the midwife's mess."

What mess?

What if the patient had been his hospital birth patient from the start, and had had this exact same labor? After a couple hours of pushing, he'd have suggested a c-section; she'd still have asked what the other safe options were.

Would he have forced a c-section on her? That's not allowed -- as long as we continue to say that laboring women are competent adults, you can't actually force one to do a c-section, especially when you admit that there's another safe option.

They'd have landed in the same exact place.

There they'd have been -- with her preferring to continue to push and use a little Pit and ultimately IFM and the vacuum, and him wishing she'd just do a c-section and get it over with. It's clear he doesn't get why the one is preferable to the other to her, but really? Who cares why she sees it one way. She's the customer.

If she'd been his patient from the outset and had asked for more options instead of doing a medically unnecessary c-section, and they'd proceeded exactly the same, with the Pit and the IFM and the vacuum -- would he have then said that he hated that birth because he'd have had to clean up his own mess?

Or would he have said, perhaps quietly, to a colleague, that he hated the patient because she asked questions, knew her options, and used her doctor as a guide, not a god. Would he confess that he longed for the days where women were conditioned to behave like docile little lambs, and not ask questions or realize they were competent to make decisions for themselves?

Or, maybe the "mess" he complains of is something else. Perhaps he means,

"If this woman had been with me from the outset, I wouldn't have 'let' her push for eight hours like the midwife did. I can't actually force, but I'd have worn her down and talked her into the c-section (which I've just admitted wasn't necessary) hours earlier.

In fact, I would have started working on it months earlier, with small comments in our pre-natal visits that suggested that the care of her body was so complicated and technical that it was beyond her understanding, that she should not ask questions and consider her options, that only flaky or crunchy people care about how they are treated in labor, that wanting to try any other safe option to avoid a c-section is naive and foolish, that asking questions and having opinions is bitchy and too demanding, that she should replace her judgment with my own.

Then, I wouldn't have been stuck dealing with my own anxiety, and with hours of waiting around, using other approaches just because it's what the patient wanted."

Let's say he had worn her down, because she was tired and laboring and very suggestible. Let's say she'd caved to his pressure. Let's say he'd gotten to do his c-section and go home.

And then she developed a post-op MRSA infection and was re-hospitalized for days and days after her child's birth?

Or had trouble breastfeeding?

Or was, "just", deeply unhappy, that she'd been bullied -- by someone she was paying to care for her -- into undergoing unnecessary major abdominal surgery?

Who would be cleaning up his mess, then?

An earlier version of this blog post appeared on the author's webpage,