In Response to Tuteur's "Why Is American Home Birth So Dangerous?"

As we are constantly sharing about the brilliance of the human body, we felt inspired to take the time to respond to this article in the opinion section of the Times. Especially since it seems like this will be just the beginning of what we hear from Amy Tuteur, with her book tour en route (Her new book, Push Back: Guilt in the Age of Natural Parenting was just released).  It's important to note that we are not promoting home birth here. We are promoting people having access to information that has not been sensationalized by the media. We are promoting access to evidence-based and non-fear based information so that people can choose the birth setting and team that is appropriate for them.  And actually, this article does bring up some good food for thought, but the way it is presented (the headline alone says it all) is highly problematic. 

Now we may be mere laypeople by Tuteur's standards, but we are totally the women she is calling out to to get informed about C.P.Ms and the dangers of home births in America. So consider this us getting informed.

We must first begin with who this woman is and the perspective from which she writes this article as it certainly colors it all. Tuteur opens her article by calling childbirth "...inherently dangerous, and if an emergency occurs, the baby or even the mother may die." So off the bat we know that everything Tuteur has to say will be tainted by the fact that she first views childbirth as an opportunity for death instead of life. (That's like saying crossing a street is inherently dangerous because if a car were to hit us, we could die. Except, of course, we have been biologically programmed to give birth since the beginning of our species. Should we all avoid crossing a street unless we are wearing a helmet and bubble wrap? )

Also, her blog suggests (and it pains us to have to point you there) our "obsession" with natural childbirth might be a form of body dysmorphic disorder.  She refers to breastfeeding and natural birth as being industries, as well as suggests that c-sections might be the safest way to give birth.  She also believes "The best statistic for assessing obstetric care is perinatal mortality." Which leaves no room for trauma, overall patient care, patient rights, the effect on our economy (and we can go on and on) to play into the picture at all. Obviously, perinatal mortality is a major issue, but it is certainly not the only issue in assessing obstetric care.  

So let's just take a moment to remember, for those of us that scanned this article and walked away with the feeling that any woman who gives birth at home in America is putting herself and her child in danger, that this article is in the opinion section of the Times. And her opinion just doesn't seem to be taking all facts into consideration. 

Let us go through a couple of her points, shall we?

Tuteur states that it was the "switch from home birth to hospital birth over the 20th century that was accompanied by a more than 90 percent decrease in neonatal mortality and nearly 99 percent decrease in maternal mortality".  

This point is pretty funny if it weren't so sad because the 19th century was actually the century when female midwives were being replaced by male "obstetric" providers for the first time (if you could even call them that). This is what the birth landscape looked like: Prudery and modesty ran the country and so men were delivering babies having never performed vaginal exams in their lives and literally never looking at the woman's vagina during the birth.  Forceps were newly invented- and then experimented with on birthing women. This meant shoving forceps into the birth canal, no matter how much (or, in most cases, little) the baby had descended, hoping for the best. As you could imagine, it usually didn't end up "the best." "Doctors" were also giving ergot to cause uterine contractions with no antidote available and puerperal (childbed) fever was at epidemic proportions. So yeah, it doesn't take much to beat the mortality rates of the 19th century. Go back further and historians have estimated that even if all the women in the 17th century Plymouth who died during childbearing years died because of birth complications, birth was still successful 95% of the time.**

No one is arguing that modern medicine isn't of great assistance and has certainly helped better mortality rates. We are forever grateful for the advent of antibiotics and epidurals and surgery. They can be enormous tools and indeed, life-savers. 

But, in the 19th century not only were so-called doctors literally practicing on live, birthing women, none of the aforementioned tools were available at all yet in the places they could have been useful. So to give credit to hospitals alone for better mortality rates from the 19th to 20th century is just silly. Advances in medicine? You bet. Doctors no longer experimenting on their patients? Absolutely. 

As even the author admits, the truth is that home birth presents no higher risks of mortality for mom or baby than a hospital birth. But, Tuteur's point is that this is not the case in America.  That in America, home birth is just dangerous.

How does she come to this conclusion? Let us look at the evidence she provides.

The study (Yes, that is a singular study from one state, with information taken over one year and only looking at a little over 2,000 home births total) she uses to make her case states within it that:

"Women who planned out-of-hospital births compared to women who planned in-hospital births were more likely to have no prenatal care (2.8% vs. 0.4%) or inadequate prenatal care (9.8% vs. 4.8%), and less likely to begin prenatal care in the first trimester (63.6% vs. 76.6%)" 

So for her to say that racial or economic differences, or poor prenatal care aren't relevant is simply false.  It isn't about looking at our mortality rates against Canada's, as she suggests. We have to look at our own numbers and see what the breakdown is within them. The maternal mortality rate is 3 to 4 times higher for black women in America and obviously a woman who is not receiving prenatal care is at a higher risk than one who is. 

(It is worth it to point out here that the U.S has one of the highest maternal mortality rates as well as infant mortality rates in the industrialized world. With only a tiny more than 1% of births occurring in the home setting total, we wonder how this plays into the conversation.)  

In addition, both her and this study totally neglect the number of births that occur in rural areas that have no quick access to medical facilities in the case of an emergency even if proper prenatal care was provided. And it does not distinguish between high risk and low risk pregnancies. 

Moving on:

Tuteur also says, "Many studies of American home birth show that planned home birth with a midwife has a perinatal death rate at least triple that of a comparable hospital birth." 

This is actually just one study she points to in which numerous holes are poked here.

But, if you strip away the fear-inducing stats she uses totally out of context, what she is asking for here isn't entirely crazy: She asks that we, "Demand that all American midwives meet international standards; keep women at increased risk of complications from giving birth at home; insist on transfer to a hospital at the first hint of potential problems; and require that midwives have hospital privileges."

Art by Elle Luna

Art by Elle Luna

Most of that actually makes a lot of sense (though we obviously shouldn't be "keeping women" from choosing the provider of their choice).  The biggest issue here is that instead of this article focusing on how to better integrate home births into our current medical landscape, the entire article is spent making you feel like if you give birth at home in America you are putting yourself and your child in danger regardless of where you live and risk level. 

Tuteur also asks for us to do away with the C.P.M designation (or the "poorly trained laypeople with watered down credentials" as she calls them).  How we should better integrate home birth midwifery into our current system is a topic for a whole other day (and one we are not at qualified to partake in) but here is what we do know: There is no solid evidence to show that C.P.M's mortality rates are any worse than C.N.M's mortality rates as there are far too many factors to point to their training as the cause of death. We haven't been through C.P.M training (and neither has Tuteur) so can't really speak to the quality of the education involved, but we can certainly leave room for the idea that the training can be better and more standardized. 

So sure. We can certainly focus on informing pregnant women about the risks of home births in certain scenarios (key words: certain scenarios). But we should also be focusing on informing women that home birth for low risk pregnancies is a safe option.  We should also be focusing on increasing access to better nutrition and prenatal care.

And most of all, we should be focusing on informing women that they have the right to birth how they choose; That they are allowed to be active participants in their care; That they should always question and that ultimately, they should trust their selves and their instincts above all else in finding the birthing place and practitioner that is right for them. 

**From Lying In: A History of Childbirth in America by Richard W. Wertz and Dorothy C. Wertz