Last week, in response to a blog post I wrote entitled In the News: Stores About Childbirth, I received some heated comments from one of my frequent readers. The sentiments in her comments are highlighted here:
“This article from the UK just today…
“Home births are three times riskier for babies than those which take place at hospital, new research suggested yesterday.
Doctors warn that women could be putting their unborn children at risk by not given birth on traditional maternity wards with specialist care and equipment on hand.”
Also this for consideration of all sides to the debate..
“A newborn baby died from an infection just days after two midwives told the mother not to bother giving him antibiotics.”
(She added a third comment, pointing to the same article above, as if it was evidence of another study.)
So, here’s my response:
Yes, of course, you can always find a study to support your point of view. Just like this article, from the very same newspaper “Shelly” referred to, about a newborn who died of hemorrhage and heart failure do to a lethal overdose of hospital-administered glucose.
And what about and this study, published in the same medical journal as the study referred to in Shelly’s second point, which concludes, “Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.”?
And how about this article (again, same newspaper as referred to above) about a new mom who died hours after giving birth to her son, following a legal narcotic overdose administered by hospital staff?
Shall I go on?
How about this article on CNN.com about how the US has the second worst newborn mortality rate in the developed world (incidentally, maternal mortality rate here is 15.1/100,000–worse than several northern European countries, Australia and Japan–many of those communities in which midwife-attended births are more common than here).
Have you ever heard about the Safe Motherhood Quilt Project by esteemed midwife Ina May Gaskin? Go here to see actual quilt squares that represent hundreds of women who have died surrounding their baby’s births–a vast majority of them having delivered in hospital.
An article on Our Bodies Ourselves reviewed a couple recent studies (one being the study from BMJ–referred to above) including a study published in the Canadian Medical Association Journal (follow link above to OBO website, then click on link to CMAJ article–mid way through the post) about a retrospective study of almost thirteen thousand women who gave birth at home with a midwife, in hospital with a midwife and in hospital with a physician in attendance. Although outcomes were similar, the neonatal mortality rates (death of the infants) were best among the home birth cohort, second best among those who delivered in hospital with a midwife and third best when attended by a physician. (The leap of an implication is, of course, that the physicians handled the more complicated cases and, therefore, realized higher rates of neonatal mortality.)
And yes, there are also other articles and studies out there that will further defame the practice of midwifery (heck, The American College of Gynecologists has an official statement on their website denouncing the practice of delivering babies in a home environment. In some cases, I totally and completely agree with this: when a pregnant woman is deemed high risk–due to cardiac or other significant health conditions, gestational diabetes requiring insulin, moderate to severe high blood pressure to name a few–she absolutely should have her baby’s birth attended to in a hospital and most likely by an OB. (other definitions of high risk are well outlined in the OBO article, linked to above) But for low-risk women with no foreseeable complications, birth should not be attended to as if it is a medical disease state from which she needs saving.
Delivering a baby in a hospital includes having quick access to medical intervention. In the small percentage of cases when in-depth intervention becomes life saving, there is, in my opinion, no legitimate argument against this (that’s why the best of the best midwives out there always have some transfers each year to the hospital from a home birthing environment.) But the truth about medical interventions (aka-hospital births) is that much of the high-tech/high intervention practices (labor induction/augmentation, breaking the bag of waters, constant fetal heart beat monitoring, episiotomies, c-sections) are employed unnecessarily…carrying with them well documented risks.
Take labor induction with the use of Cytotec, for example. While prohibited in some hospitals due to its risk of uterine rupture, uterine over stimulation and fetal stress, Cytotec is widely used in other hospitals as a labor induction medication. From nursingcenter.com, regarding labor induction medications including Cytotec:
“Cytotec, a brand of misoprostol, is FDA approved for prevention of nonsteroidal anti-inflammatory drug-related gastric ulcers. It is listed as Category X (not to be used) in pregnancy. Physicians in the United States, however, may use FDA-approved drugs for “off label” indications. Hofmeyer and Gulmezoglu (2003) recommended further research to establish the ideal route of administration, dosage, and safety for this drug and stated that information on informed consent for misoprostol use and women’s views of the drug are “conspicuously lacking” (Hofmeyer & Gulmezoglu, 2003).
The risk of maternal or fetal death among Cervidil, Prepidil, and misoprostol is comparable. In 25 trials that involved 3,651 subjects, however, misoprostol was shown to be more effective and had more rapid onset of action. There was an increased rate of uterine hyperstimulation with FHR changes and meconium-stained amnionic fluid. Clinicians were advised in this study to be concerned about this apparent increase in uterine hyperstimulation, because it might increase the risk of uterine rupture (Hofmeyer & Gulmezoglu, 2003). These same authors found that the cesarean birth rate for failed induction after misoprostol was not significantly reduced compared to the other prostaglandins or oxytocin. Evidence for its use, aside from cost savings and rapidity of action, is no stronger than for other prostaglandin preparations.”
Translation? US doctors are granted the privilege, by the FDA, to use approved medications for non-FDA researched purposes. (In some cases, this IS a good thing–but that is the topic for another post.) While Cytotec forces a woman into labor quite efficiently, it puts both mom and baby at risk because of how hard and fast the uterus begins to contract. Cytotec is a Category X medication for pregnancy–meaning there is no way, no how a pregnant woman should be consuming this medication. And yet, despite all facts above, it is still widely used intervaginally to synthetically begin a woman’s labor for her.
My point here? Allopathic medicine is not infallible, either. Nobody is. That’s a part of being human and having the power of choice.
Are there midwives out there employing less than best-practices maternity care? Sure. I had a sixteen-year-old young lady attend my Lamaze class series a couple years ago, as a part of a distance learning midwifery program. If she graduated from said program “on-time” she’d be practicing home birth midwifery by the time she was nineteen. She may have been extremely smart, applied, motivated and well instructed in one form or another, but she was sixteen.
The potential of this scared the heck out of me. Because, really, how many teenagers in present-day USA do you know who have the maturity to safely and logically handle the (rare) birth-related true emergency–like a retained placental postpartum hemorrhage, a severe shoulder distocia, or a newborn in respiratory distress?
My very long-winded point here is this: it’s easy to quickly cite one or two articles or studies and use those to make a big, sweeping statement that supports your opinion. But before doing so, I would encourage anyone to look closely at the data:
1. Is the study/article truly unbiased?
2. Does the study compare apples to apples? (similar patient populations in each cohort)
3. Are the numbers and percentages represented statistically significant?
4. Are individual articles cited worthy of applying to a whole system or group of people, or are they just that–individual stories about isolated events?
5. Do larger bodies of work support conclusions made by smaller studies? Is the result of a study reproducible? What do studies conducted by organizations like the World Health Organization, National Institutes of Health and Cochran Database say?
I have always been leery about sweeping generalizations and I would encourage you, dear reader, to follow suit.
I also encourage and invite feedback on my thoughts contained herein. What are other folks out there reading/teaching/learning?