When Obstetricians Hate Homebirth Midwives, Birth Becomes Less Safe For Everyone

In the years I’ve spent researching and writing about birth and newborns, I’ve interviewed doctors, midwives, health care professionals, nonprofit administrators, government officials, corporate employees, new parents, and dozens of others.

So many of the stories I hear keep me up at night:

• The government official (who spoke to me off the record) who publicly and vociferously advocates for vaccines and has published peer-reviewed scholarly articles about the benefits of childhood vaccination but who privately chose not to vaccinate his youngest child.

• The second-time mom whose baby was breech and was “not allowed” a trial of labor by her obstetrician. After the Cesarean birth she got methicillin-resistant Staphylococcus aureus (MRSA), a hospital-acquired infection that almost killed her, leaving her so sick she couldn’t hold her baby for months.

• The second-time birthing woman whose obstetrician—who had been paged more than a dozen times and showed up in a Tie-dye shirt with wet hair—cut an episiotomy so long Grandma, who was watching the birth, told her later she was “horrified.” It took weeks for this mom to be able to urinate without extreme pain. Two years later, when I interviewed her, she told me things still “don’t feel right” down there.

• The third-time healthy young mom who would like to have a vaginal birth after cesarean but who cannot find a doctor anywhere in her state who will even let her try. Too afraid to have a home birth and wanting to be in the hospital in case something goes amiss with the VBAC, she has been bullied into accepting a scheduled C-section.

Here’s another story that still haunts me. Names and some details have been changed to protect privacy.

Julia, a homebirth midwife in California, brought her client, who was in active labor, to the hospital because she was worried. This third-time mom—a healthy, albeit overweight, 32-year-old hoping for a vaginal birth after a previous C-section—was becoming exhausted and possibly dehydrated.

An experienced homebirth midwife, Julia was concerned about the mom and about the baby, who she thought might be in distress.

Sure enough: once at the hospital the fetal heart monitor showed little variability in the baby’s heartbeat.

“I think this baby needs to come out now,” Julia told the doctor on call.

Refusing to acknowledge that Julia was talking to him, the doctor only addressed the laboring mom, who confessed she was still hoping for a vaginal birth. He recommended getting her hydrated and waiting for the results of some lab tests before making a decision. Then he left the room.

When Julia sought out the doctor to tell him the baby wasn’t improving and the heart beat seemed dangerously low, the doctor saw her coming down the hall, swiveled in his chair, and turned away.

It took more than two hours from the time Julia’s client was admitted to the hospital for the doctor—who had had one previously negative experience with a home birth transport—to finally perform a C-section.

The baby, born floppy, died two days later.

“The doctor was in the room for less than five minutes total,” Julia remembered. “He wasn’t paying attention to the case, wasn’t asking me any questions. Both the labor nurse and I were trying to speed things up, I was literally hopping up and down on the balls of my feet, saying, ‘This baby doesn’t look good. This baby needs to come out. This baby looks like crap.’ The doctor just had such distain for homebirth and midwifery, and he probably had a fat bias, which a lot of doctors do, that he wouldn’t listen to us.”

It’s sad that some American obstetricians disdain homebirth, an attitude that comes partially from ignorance and inexperience, partially from professional hubris, and partially from being in the unfortunate position of only seeing homebirth moms when something goes wrong.

Doctors in America are trained to believe that birth, even low-risk birth, is dangerous. Pregnancy is at worst an accident waiting to happen, at best a disease that will be fatal without immediate and extreme medical intervention. Both pregnancy and childbirth, to the average American obstetrician, must be managed and controlled.

How could they think otherwise? Most American obstetricians have never even seen an unmedicated childbirth when they finish their residencies; very few these days (unlike in the not-so-distant past) has attended a home birth or given birth at home.

Despite the fact that a Fall 2012 Cochrane Library Review (considered the gold standard of independent inquiry and scientific objectivity) reports that home birth is as safe or in many cases actually safer than hospital birth, the American obstetrical community continues to publicly oppose homebirth, citing safety concerns as their main argument.

“…[T]heir train wreck or their disaster shows up at my doorstep and I become responsible for their irresponsibility,” said an Indiana-based obstetrician, who believes homebirth midwives do not practice an appropriate standard of care.

“We only see what goes wrong,” explained an East Coast obstetrician to me.

Julia believes that the problem between obstetricians and midwives is also exacerbated by how some midwives behave in a hospital setting, where they feel marginalized.

“As time goes on and I speak more candidly with physicians, I realize how little they know about what we do,” she tells me. “They didn’t know we use a Doppler to listen the baby in labor, for instance.” Most homebirth midwives also carry oxygen and pitocin. “It’s hard not to get frustrated with them,” Julia continues, “but the responsibility also rests on midwives for perpetuating these adversarial relationships … We know we have valuable information and a relationship with that mom. When we walk in there as midwives that have a chip on our shoulder, with a defensive posture, doctors perceive us being unwilling to cooperate.”

Guðrún Eggertsdóttir, the head midwife of the labor ward at Landspítali, the largest hospital in Reykjavik, Iceland, tells me that when a homebirth mom transfers to their hospital she is welcomed warmly. The birth professionals (the vast majority of whom are nurse midwives) at Landspítali do not scold the laboring mom for wanting a homebirth. Instead, they are glad to see her so they can help her have a safe and healthy delivery.

This positive attitude towards homebirth makes so much sense and is one clue to how we can make our birthing system safer: A baby slated to be born at home who is instead delivered in the hospital should not be seen as “a failed homebirth,” but as a safe delivery.

When a mom, like Kristina Delores Adkins, a healthy 35-year-old who died Thursday, March 7, in Coral Springs, Florida, from “complications during childbirth,” dies in the hospital the cause of death is not listed as “hospital birth.” Even when she dies from a C-section birth (which account for the vast majority of hospital childbirth deaths), we do not question the mom’s choice to have her baby in the hospital. Despite the fact that every year over 68,000 women have “near miss” experiences during hospital childbirth–complications so serious they almost die–we do not berate her for being stupid for choosing a hospital birth.

Birth should be a joyous, safe, and fun experience, whether a woman is birthing at home or in the hospital.

This is the 21st century. We live in America, a country that prides itself on freedom and tolerance.

It’s time to demand a safer, more evidence-based birth system.

It’s time for doctors and midwives to start talking and listening to each other, and to the birthing women in their care.

It’s time for all of us to set aside our anger and our prejudices and help women, their partners, and their babies have the best birth they can.

Jennifer Margulis, Ph.D., is a senior fellow at the Schuster Institute for Investigative Journalism. Her latest book, The Business of Baby: What Doctors Don’t Tell You, What Corporations Try to Sell You, and How to Put Your Pregnancy, Childbirth, and Baby Before Their Bottom Line, will be published next month by Scribner.

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Comments

  1. Fantastic article. You’re right. So many things related to birth and the care around birth are skewed by prejudices, misconceptions, and failures to communicate. It’s important to remember that, out of that, moms and babies are hurt the most.

  2. Courtney

    so true. I’m so sick of the attitude that a mom was “asking for it” or is “stupid” if something happens in a home birth.. but if something goes wrong in the hospital? (which it often does) then it’s “well you did everything you could”. mutual respect is non-existant.

  3. This is such a sad situation you describe. I read your book and found it fascinating. So much has changed, not necessarily for the better, since I was of an age to give birth. I was reminded of that yesterday when I saw an elderly allergist. He took my blood pressure himself, checked my ears, ears and mouth, touched my neck. That was when I realized it has been years since a doctor had done so.

    • Elisabeth

      I had that same experience with an elderly pediatrician (who retired shortly after). He was so gentle with my baby, and so kind, my mother begged me to hire him even though he was not taking new patients (since he was about to retire). In Salt Lake, it is an older Neonatologist who will support a woman who wants a vagina breech birth.

  4. “Most American obstetricians have never even seen an unmedicated childbirth when they finish their residencies. ”

    That is simply a lie, and a sexist lie to boot. 50% of obstetricians are women and have copious professional AND personal experience of unmedicated labor.

      • Voice of Good Sense

        Sharon, Amy is no longer a licensed doctor. It’s not appropriate to refer to her when she currently is not one. I’m concerned calling her Dr. Tuteur or Dr. Amy may mislead women who aren’t sure into thinking, “She’s a doctor, so must know what she’s talking about.” She hasn’t been licensed in years, and spends so much time arguing against women having birth choices that it’s highly doubtful she’s kept up with current meaningful research.

        • ratiomom

          Wrong. When you finish medical school, you’re a doctor for the rest of your life, whether you practice or not.
          You only lose the right to the MD title when your license if revoked. No such thing happened to Dr Amy, so she has every right to call herself MD.

          • The Computer Ate My Nym

            Another point: Dr. Tuteur’s license was not revoked, she chose not to renew it when she decided to stay at home with her 4 children rather than practicing. Given that a medical license in a given state can cost hundreds to thousands of dollars per year to keep, I think that not renewing it when you don’t plan to practice is a very reasonable decision.

        • Common Sense

          Really? Voice of Good Sense? Like when Dr. C. Everett Koop dies at 96; former U.S. surgeon general gets published all over the Internet, as a doctor? Like all the other Medical Doctors get addresses for the rest of their lives as doctors. What about Dr Mardsen Wagner and Dr Sears? Do they get to keep their title? And what “title” does Ina May Gaskin have? Has she completed any formal training? And how all the PhD Doctors get addressed as doctors for the rest of their lives, even though they are not “practicing”. You and others like you just like to pick and choose who gets to keep their well earned title when it suits you.

      • Rachel

        I graduated residency in 2009. My residency was a class of 11(one of the largest in the nation). 10 were women, one was male. 4 of us had babies in residency, another three had children before residency. The year I had my first son there were 11 babies born to 10 residents (total number of residents was 41). Since then the majority of us have expanded our families even more. I saw more un-medicated deliveries during residency than I do now in private practice–I now deliver about 250/yr. Of my classmates, only one had a c-section which she found very disappointing. Ob/gyns are trained to be strong proponents of vaginal delivery (my personal rate is less than 10% for primary c-section). However, I also understand that women have autonomy and the right to choose their mode of delivery including elective c-section. I also know that more than once the c-section I performed was not only necessary but life-saving. It certainly wasn’t done for my personal convenience. How did I get sucked into replying on one of these boards again? It won’t make a bit of difference.

      • ratiomom

        What a sexist remark. Can a man never be a decent obstetrician? Can an infertile woman?
        Let’s broaden the scope a bit: must a resident first get cancer to become a good oncologist? I sure pity those poor trauma surgeons. Should they jump off a cliff to obtain your approval or would a tumble down the stairs be sufficient?

        • Jade

          Ratiomom–seeing you manage to extract “a man can never be an obstetrician” from Dr Tuteur’s statement, a whole lot of the outright misinformation that circulates in the natural birthing community suddenly begins to make sense.

    • crystal

      youre right amy tuteur…it is a lie.
      the appropriate way to word it is “most OBs have never seen a VAGINAL birth, let alone an unmedicated vaginal birth, when they finish their residencies”
      thank you for bringing this to light….bc the truth is that they are skilled surgeons. they are taught to do surgical procedures. and the sad truth is that most, if not all, have yet to witness a true vaginal unmedicated birth upon completion of their residencies.
      i work in the hospital.
      ive interviewed numerous OBs and this is the sad truth that they conveyed to me.
      like it or not, it is true.

      • Anne

        Considering less than 10% of US births are midwife attended and the c-section rate is roughly 30%, who is attending the other 60% of women with vagunal births if not OBs and residents? Are you saying that they chain residents to the OR while all the vaginal births are attended by doctors who are out of residency? Your statement, besides lacking any evidence whatsoever and being insulting and inflammatory, just doesn’t make any sense.

        • Siri

          Hey – what’s one more lie when your errand is to defame and denigrate one group of professionals (obstetricians) and extol another (hobby midwives)?!

      • Melinda

        The Listening to Mothers II survey showed that 14% of women had no pain relief in labor. Did the residents miss all of those? Residents oversaw the labor and delivery of both of my babies sans pain meds.

      • Sullivanthepoop

        Crystal,

        When you need to lie to yourself to make your beliefs believable there is very a serious problem.

      • Eyerolling

        “the appropriate way to word it is “most OBs have never seen a VAGINAL birth, let alone an unmedicated vaginal birth, when they finish their residencies””

        Wow – that’s even less true than the original untrue statement. None of you have any idea what doctors actually do, do you?

        • Elisabeth

          I would assume the writer meant natural vaginal birth, period…without a bunch of interventions. The problem is many doctors see vaginal birth as “natural” even if forceps or vacuums are used, an epidural and pitocin are administered, episiotomies are cut, Moms are urged to stay in the supine position their entire labor, they are hooked up to a monitor, IV, and catheterized. Then the myths are perpetuated that women can’t have babies safely without all these gadgets when midwives like Ina May who has participated in peer reviewed studies has proven that for MOST women these things are not needed. Dr. T is just another doctor who just doesn’t know, she is just more outspoken in these forums, but it is not she personally but the entire community she represents that women who choose home birth are trying to get away from.

      • Common Sense

        Wrong Crystal, OB/GYN are primary care physicians who take care of adolescent girls, provide contraception and STD prevention, annual exams and preventative medicine, treatment for abnormal menstruation and infertility, cancers, osteoporosis, menopause and yes pregnancy! Oh yes, and OB/GYNs can perform surgery too, just in case you need it. If you need laparoscopy, hysterectomy, cesareans, or repairs of third and fourth degree lacerations, OB/GYN can do it all. You should never take on a job or activity that you cannot handle any of the many complications that may occur during the process of that job or activity. OB/GYNs can help you with your normal unmedicated delivery and if you need options or have a complication, the OB/GYN doesn’t need to transfer you anywhere but can take care of you. Unlike the Homebirth midwife!

    • Rachel

      This makes me think of a female OB that I used to work with. While pregnant with her third child, we asked when she was due. She proudly replied, “he’ll be here October 2! I have scheduled c-sections!” I was speechless. Yuck.

      • ratiomom

        This comment really boggles my mind. Everyone here pays lip service to a woman’s right to make her own birth choices.
        Apparently this right exists only for women whose choices are identical to your own. Are you really proposing that women who don’t want a vaginal birth should be forced to have one against their will?

      • The Computer Ate My Nym

        So much for supporting women’s choices. Have a woman make a choice you don’t agree with and-without even asking what her reasons are-you jump right in and shame her. Nice. Did you ever consider that maybe she had reasons that you don’t know about for making that decision-from medical issues that make vaginal birth unsafe to a preference that is none of your business?

        • I can’t speak for everyone, but it is bothersome to me that women choose to have elective surgical births because I cannot possibly believe that a women that is FULLY AWARE OF HER CHOICES would EVER ‘choose’ to have a surgical birth. It is a false sense of ‘choice’.
          I’m no expert, but in addition to the vast amount of research I did before my 2nd child (homebirth), my experience with an ob before I switched to a midwife with that same child, my experience with a medicated vaginal hospital birth w/ my first child, my experience in talking to dozens of women that have had surgical births, in addition to all that anecdotal ‘wisdom’, I have taken a graduate level Sociology of Medicine class that was an in depth look at our current medical system from a sociological perspective and we spent a couple of weeks talking about the medical model of birth and the alternatives. It was required of me to read a number of scholarly journal articles whose authors addressed the notion of ‘false choice’ regarding birth ‘choices’ in depth.
          In short, given the amount of cultural ignorance about the history of birth, the amount of fear instilled in women regarding birth, and the lax attitude of ob’s towards surgical births, and the shear amount of ignorance and naiveté in women regarding birth….any elective c-section starts to look a lot less like a real choice and a lot more like a choice made out of fear and lack of knowledge about their own bodies and what they are capable of.

          Also, it is cringe worthy to me to hear of elective cesarean’s because I feel like those women and their babies are having something stolen from them. It is very rare (I’ve only come across 1 story) for any women to come out of a c-section (elective or not) feeling empowered. It is extremely common, on the other hand, for that magnificent sense of empowerment to be a side effect of an un-medicated vaginal birth

          Also, the risk of maternal death goes up significantly with every successive cesarean in any given woman. By electing to have a cesarean,( that first one is not any riskier than a vaginal but 2-? is), you elect to have a higher risk of maternal death.

          • Eleanor Eisley

            Wow Serina, just wow. A female OB chooses CS for her deliveries and your response is that she must not be “educated?” The mind boggles. Have you asked yourself why you believe that women and babies of CS are having something “stolen” from them? Could it be your own cultural bias at work, as a member of the NCB movement? Women historically haven’t seen birth as “empowering,” and I find it highly problematic that the new thing is to find empowerment through bodily functions that are not within our control. If you read historical diaries of women and historical fiction, the prevailing attitude you’ll find is that birth is something to be endured, and the goal was to survive with a live baby.

          • Common Sense

            Sedona, you studied all that and never came across a woman who only wants one or two children and wants a cesarean? Maybe she was raped when younger and doesn’t want a vaginal birth. Maybe she had anal fissure or fistulas in the past and had them repaired and doesn’t want to risk reinjuring them. Maybe she has herpes or HIV and doesn’t want to risk transmission. Maybe she has obstructing condylomata and wants to avoid vaginal birth. Maybe she has an android pelvis or platypelloid pelvis and really has a large baby ( like that 15 pound child in the UK recently ) and doesn’t want to risk a shoulder dystocia or cystocele, or rectocele, or uterine proplapse. Maybe on her first child she had a fourth degree tear or cervical tear and had to go to pelvic physical therapy for months after the repair and she wants to avoid reinjury. Maybe she already had a TVTO and cystocele repair after her first one or two babies and wants to avoid reinjury. Maybe she has a breech baby and wants to avoid a head entrapment with a vaginal birth. I can go on, but you could not come up with any of these with all your research? All you came up with was a false sense of choice. You obviously don’t work in obstetrics.

          • Jade

            Elective c-sections are actually safer for babies than vaginal births (I know, I know, it is complete heresy to say this in the natural childbirth world–but it is true). Having an elective c-section is a perfectly rational decision to make if you care a lot more about the safety of your baby than being “empowered” during birth.

            Do you actually know how much the risk of maternal mortality goes up for women of equivalent risk having elective c-sections?

          • yenta vegan

            I was fully aware of my choices and I was in the right frame of mind when 12 years ago I requested a c/sec for the birth of dd5.
            the risks of maternal deaths due to repeat c/sec are compounded by pre-existing health issues. it is not the c/sec that determines the fatal outcome, it is the health of the mother prior to labor that has the real impact on maternal death.

          • J Larson

            As a student midwife in AZ, I have heard the same argument about not being educated from the medical camp too. The state of Arizona wants all home birth moms to get a signature from an OB in order to have a home birth. Because the medical community doesn’t believe that anyone would choose a home birth. I find it fascinating that you would use the same argument.

            We are ALL sporting women. We differ on style. I believe everyone has the best intentions and we fit a need for women to have choices. I will always support a woman’s decision. She is in charge. We don’t always know why she makes the choices she does, but it’s about her, not us. Lets support each other, not create a bigger canyon.

      • Siri

        Yuck?!! So freedom of choice applies only to those whose choice corresponds to yours? Could you get any more self-righteous, judgmental or anti-woman?!

        • Elisabeth

          Oh comon people! Her problem is that this woman is an OB, caring for other women having babies, and is excited about an elective c-section. Maybe she really does need it…fissures are real problems and so is placenta previa and a couple other great reasons to elect a c-section. But it is likely she is like the rest of the OB’s out there…she is a surgeon, she is used to seeing pathology in labor, and she may just want a c-section out of fear and lack of knowledge. YES lack of knowledge, because actually, midwives know FAR MORE about actual birth, normal birth, natural birth, and nowadays with better cleanliness practices a home birth is actually quite safe. For a time, before we knew that doctors were spreading germs from patient to patient in the hospital, home birth was actually FAR SAFER than hospital birth (at the end of the 1800′s and early 1900′s). Today is is about the same on mortality rates, and morbidity is far lower at home, simply because women are NOT messed with as much during their labors, allowing for a safer passage of the baby. This is all proven in many studies, as Serena has explained. I too chose home birth…after also taking an anthropology class at my university, not at all expecting to come out of it with such aradically different view than when I went in.

          • Jade

            Elisabeth, you need to read on .. because the available evidence shows that homebirths in the US do NOT have the same mortality and morbidity rates.

            Also–did you consider that maybe the doctor was just excited about the fact that she was having a baby?

      • KanDoc

        @Rachel: So you favor women having autonomy to choose out-of-hospital birth but you judge and condemn someone who chooses an elective cesarean section? Hypocrisy at it’s finest.
        I don’t know why I respond to the irrational, but I delivery about 200 babies a year, with a primary Cesarean section rate of 12% (including women who choose an elective cesarean delivery, which is their right as AUTONOMOUS HUMAN BEINGS), and deliver about 1 baby per week, about 40-50 per year, to women who have NO interventions in labour. Which is more than most CPMs do in a year.
        The article was interesting, although the Cochrane Review is actually incomplete, but the comments here are disappointingly ignorant and lacking in depth.

    • Voice of Good Sense

      You are not a practicing doctor, so I will not refer to you as a doctor. Would you care to share how many years it’s been since you’ve had a license, and then to tell readers why you’re passing yourself off as a doctor and dispensing medical advice without a license, Amy? Or would you prefer Ms. Tuteur?

      Your “research” hasn’t been published in peer-reviewed journals. You aren’t respected by doctors who currently practice. You once berated me for going against a c-section my doctor wanted based on an old medical condition she wasn’t familiar with, claiming I’d die without one and saying I should be brought up on child abuse if I go through with a homebirth. (My daughter is playing with toy ponies now, so I guess I’m a zombie.)

      Considering your distrust for doctors after the death of your dad, I find is suspect that you believe we should all 100% trust doctors in the field in which you practiced, and that you have firmly been against deliveries attended by anyone other than doctors in hospitals. You believe we women are stupid if we trust a midwife who spends more than a passing minute with us at appointments, and who stay with us our entire labors. You’d rather we place our trust in people who know is so little that we’re lucky if our names are remembered without a look at a chart on the way in the door to a room that might be shared with a few other laboring women.

      Natural, unmedicated childbirths in hospitals are increasingly rare these days. With so few natural, unmedicated deliveries, you’re trying to mislead people into believing that half have seen one of these labors. Use of pitocin and epidurals have helped lead to a 33% rate of c-sections. OB/GYNs are trained as surgeons first. Few are in the room for much more than the time to tell a woman when she’s allowed to push, telling her to ignore when her body is naturally trying to contract.

      Your attempt at misleading readers into thinking half of OBs have COPIOUS experience in natural childbirth IS A LIE. How can this be the case when only 67% of births end up vaginal, and of those, most are medicated?

      Ah, you may wonder how I’m claiming you’re trying to mislead readers. You say half had “personal experience of unmedicated labor.” What about unmedicated delivery? Politically stated to claim half of OBs are women who’ve had unmedicated LABOR. What percentage of the labor was unmedicated? The time it took to get to the hospital for an epidural? Unless you’re really stupid, I believe you hoped women would read that and think half of doctors have both copious experience with AND have experiences fully unmedicated childbirths.

      You should be ashamed of yourself, Amy.

      • suchende

        There are few things I have seen as misogynistic as this campaign against calling Dr. A a doctor. So any woman who earns an MD then leaves her field to raise children isn’t a real MD anymore? How about lawyers, spend a stint as a SAHM and I guess your opinion doesn’t count anymore, eh? I hope you are ashamed of yourself.

      • Eyerolling

        Notice that people only complain about how Dr. Tuteur is not a doctor when they wish to discount what she says and have no evidence to do so. The rest of the time, people in this community don’t pay any attention to currently practicing doctors either.

        The refusal to call Dr. Tuteur “doctor” reveals your implicit acknowledgement that doctors really do know more about the physiology and dangers of birth than midwives do.

      • Common Sense

        Dear Voice of good sense, as stated above retired medical and PhD doctors do retain the ability to be addressed as Dr after retirement. So many examples like Dr C Everett Koop, Dr Wagner, etc. and I would definitely take advice from a retired doctor as opposed to a SAHM or architect, or woman with PhD in literature. Especially from a retired doctor who continues to read the medical literature and research studies.
        Amy doesn’t have to publish anything in a peer review journal to be validated. I see anti Amy proponents say this all the time. Dr. Amy directs to articles that are written in peer reviewed journals like the BJM or AJOG. Or she directs you right to the CDC or states statistics that are available for everyone to review. You make it sound like she is making up stuff by not having recently published anything herself. Unlike Margulis who stares she knows so many doctors who don’t vaccinate their kids without referencing any names or articles, right?
        Please cite a reference saying current doctors don’t respect her, for there are many doctors, nurses, ex-CPM, LC, on her site and other comment sections where she posts that agree with her! I have never seen a place where she posts that other doctors comment about how right she is. This post is no different. Hint hint.
        Dr Amy has never said doctors are infallible, just that Homebirth midwives are more infallible. And that delivering with a CNM in the hospital is ok. Dr Amy even had two unmedicated births and breasted too. Dr Amy doesn’t want you to place your trust in Homebirth midwives who you know so little about. MANA hides their mortality rates and so many times when they transfer you they disappear.
        Pitocin and epidural are a safe option that allow women choice and comfort. They both have allowed many women to continue on getting their vaginal birth. The Total CS Rate is 32-33%. Meaning elective and repeat CS are included in that. The primary CS rate for women who are in labor trying for a vaginal birth is more like 12-19%. Gets your statistics straight, because now you are scare mongering. You should be ashamed of yourself, you are all opinion with no fact or citations.

    • You’ll notice that Ms. Margulis has provided no documentation for her claim, basically acknowledging that there is no evidence to support it.

      I’d also like to know why Ms. Margulis fails to acknowledge the hideous death rates at planned homebirth with licensed homebirth midwives in Colorado (4x term hospital birth) and Oregon (8x higher). No less an authority than Judith Rooks CNM MPH publicly testified that Oregon homebirth midwives are not safe providers.
      Amy Tuteur, MD recently posted…No evidence that breastfeeding promotes bondingMy Profile

      • Amy, Oregon has some of the safest best homebirth stats in the country IF YOU DON’T COUNT PORTLAND. But once you add the Portland stats into the mix, our birth outcomes get very poor. This is a huge problem that must be addressed. Like you, I advocate for complete transparency from homebirth midwives and from hospitals. Of course some providers are not practicing safely. I myself had a terrible experience with homebirth midwives in Massachusetts (and when I wrote about it I was bashed by the natural birthing community. And when I tried to talk to the midwives about how they had harmed me, they ignored my concerns.) I would like to be as open as possible about the problems in both systems in order to make both better. I really don’t think there is a right way. It’s outrageous that the woman who wants a hospital VBAC is not allowed to and was basically being bullied by her doctor. It is no less outrageous when homebirth midwives are not adequately trained, do not transfer as soon as they should, or practice in an unsafe way. I think we should acknowledge that we are on the same team and we all want the same thing- the best possible outcome for mom and baby, a safe and happy birth, and a good start in life.

        • 1. I notice that you have not supplied evidence of any kind for your utterly fabricated assertion that obstetricians never see unmedicated births during their residencies. You simply made it up or cribbed it from someone else who made it up.

          2. “Oregon has some of the safest best homebirth stats in the country IF YOU DON’T COUNT PORTLAND.”

          You’re joking, right? That has to be one of the most inane excuses I have ever heard. Of course Portland has most of the deaths; it has most of the homebirths. You can’t exclude it no matter how much you’d like to pretend that you can.

          Oregon has one of the highest, if not the highest, rates of homebirth in the US. It has midwives licensed by the state. Their death rates are hideous. No less an authority than Judith Rooks wrote to the Oregon legislature:

          “Note that the total mortality rate for births planned to be attended by direct-entry midwives is 6-8 times higher than the rate for births planned to be attended in hospitals. The data for hospitals does not exclude deaths caused by congenital abnormalities.

          Many women have been told that OOH births are as safe or safer than births in hospitals…

          But out-of-hospital births are not as safe as births in hospitals in Oregon, where many of them are attended by birth attendants who have not completed an educational curriculum designed to provide all the knowledge, skills and judgment needed by midwives who practice in any setting.”

          Homebirth kills babies who didn’t have to die. Homebirth advocates, including Melissa Cheyney and MANA, have been desperately trying to hide that fact. Now it’s out in the open and you have to deal with it.

          Homebirth midwives are not professionals. What kind of professionals, when confronted with an appalling death rate at their own hands, try to hide it and make absolutely no effort to improve their education and training? Homebirth midwives are lay birth junkies who lack the education and training of ALL other midwives in the first world. Their hideous deaths rates are evidence of their gross incompetence. Why are you defending them?
          Amy Tuteur, MD recently posted…No evidence that breastfeeding promotes bondingMy Profile

          • “What kind of professionals, when confronted with an appalling death rate at their own hands, try to hide it and make absolutely no effort to improve their education and training?”

            Good question. If you ask Marsden Wagner, MD, a perinatologist and perinatal epidemiologist from California and director of Women’s and Children’s Health in the World Health Organization for 15 years, he will tell you: Doctors.

            Please read his book BORN IN THE USA: HOW A BROKEN MATERNITY SYSTEM MUST BE FIXED TO PUT WOMEN AND CHILDREN FIRST. It gives a detailed account of the lengths obstetricians will go to obfuscate data when the information makes them look bad.

            I have a binder of over 1,000 pages of evidence about the safety of out-of-hospital delivery in Oregon. I suspect you will discount this as evidence. But the issue in Oregon is not Portland. It is one out-of-hospital birth center that has some midwives who have not been practicing safely.

            Dr. Melissa Cheyney is a careful and scrupulous researcher. I have a high regard for her work. If you find errors in it — as opposed to simply calling her names — I would be interested in learning more.

            I am sorry that when the facts don’t agree with your point of view you resort to ad hominem attacks. But I do appreciate that it makes for an interesting discussion.

            If you have more comments on this post, you are welcome to add them. I will let you have the last word.

            Let me try one more time: I would like for everyone who cares about birth in America, as you and I both do, to try to remember that we all want the same thing: the best possible outcome for mom and baby, a safe and happy birth, and a good start in life.

          • Actually, we don’t want the same things. Homebirth midwives and homebirth advocates couldn’t care less about the best possible outcome for mothers and babies. When babies die they ignore them, try desperately to hide the evidence, and make absolutely no effort to improve midwives’ education and training or hold responsible midwives accountable.

            Your central premise, when obstetricians hate homebirth midwives, birth becomes less safe for everyone, is completely backwards. Obstetricians “hate” homebirth midwives (to the extent that they think of these fringe “providers” at all) because they are uneducated, untrained lay “birth junkies” who have horrifically high death rates.

            Homebirth kills babies. You can keep trying desperately to hide the tiny bodies, or ignore them as you are doing now, but the truth will out. If you really care about the best outcomes for mothers and babies, you can join me in my campaign to abolish the CPM, as Canada has already done, and insist that homebirth midwives be required to meet the same education and training standards of ALL other first world countries.
            Amy Tuteur, MD recently posted…Stupidest excuse for homebirth deaths everMy Profile

          • Alexis

            Marsden Wagner is not a perinatologist. I don’t know why people continue to refer to him as one. He has done a residency in pediatrics and a fellowship in Neonatal-Perinatal Medicine. This makes him a neonatologist. Perinatology is an outdated (but still popularly used) term for a maternal-fetal medicine specialist, who is an obstetrician. Referring to Wagner as a perinatologist is misleading because it makes people think he has an obstetrics background, which he doesn’t.

          • Elisabeth

            Where are you peer reviewed published studies supporting your claims? I happen to know that doctors are not scientists, and in general most do not employ the scientific method in their so-callled “studies.” They teach the next generations of doctors the same stuff they were taught, ignoring the literature (I have friends who are medical doctors who admit this is the case). No, I do not know the specifics on Oregon, Colorado, whatever, but I do know that the US is about 19th for birth mortality and yet we use the most “technology” than the 18 developed countries that rate better than us, and our rates have not improved in over 30 years, in spite of increased cesarean rates and use of routine procedures such as IV’s, Epidurals, and Electronic Monitoring. This can all be found and journals cited on the WHO web page.
            By the way, I have no problem calling you doctor and I wish people would stop making a stink about it. But I really wish I could understand why you are so completely and adamantly against all this natural stuff, from natural birth to breastfeeding and beyond. Why why why? It doesn’t make any sense to me.

        • Eyerolling

          Hmm. If you don’t count Portland?

          Is there something deadly to babies in the air in Portland? Something in the water? Maybe you could do a study!

          • Jade

            Elisabeth, I know none of this is going to make any difference to you, as you have made up your mind about what you want to believe. But here goes anyway.

            First, there is no such measure as “birth” mortality. The correct measure is neonatal mortality. Different countries measure this in different ways so international comparisons are not straightforward. Here is one study that adjusted the rates and found the US ranked 11th in neonatal mortality–with very little difference (less than 1 in a thousand babies) between the US and the first ranked country. http://www.bmj.com/content/344/bmj.e746

            If you don’t have any scientific or statistical training (and I don’t believe you do) then you are in no position to make the claim that medical researchers don’t “use the scientific method in their studies.” You can’t give me a technical description of how they fail to do this, right?

            You are very sure that poor outcomes in childbirth are due largely to an overuse of interventions, but I bet you can’t give me any actual evidence of that. I can give you evidence to the contrary, though: look up the UK Birthplaces study, which compared women of equivalent risk in home and hospital births. The women in hospital had more interventions–but they didn’t have worse outcomes. (And if you want to know why that study does NOT show that homebirth in the US is safe, go ahead and ask.)

            Have you ever considered that outcomes in childbirth are due to a myriad of factors? Have you ever thought about what some of them might be? There are a number of rather obvious ones that are much more likely to explain outcomes in the US.

            (By the way, debunking false information about natural childbirth and breastfeeding is not the same as being against them.)

        • Common Sense

          Homebirth in America is as Homebirth in America does! You cannot exclude the bad Homebirth outcomes and say Homebirth is safe. You cannot use CNM presided homebirths that risk out breech, twins, FTM, previous cesarean, post dates and transfer appropriately statistics and use them to say CPM/DEM homebirths of these high risk women have the same outcomes.

          • Jade

            Oh, and Elisabeth–you really need to double check that claim that US neonatal mortality rates have not improved in the last 30 years. It’s so wrong that … well.

    • Courtney

      it’s certainly not a lie. even if they see an unmedicated vaginal birth.. it’s still not a fully natural one. it’s unnatural to have a woman poked with a “routine” IV line, it’s unnatural to have bright lights and strangers wandering around etc. etc.

      Even if they DO manage to witness one of the rare instances where a woman removes all unnatural obstacles from her hospital birth..I HIGHLY doubt the resident stayed with her through her birth from start to finish to observe. even your own OB won’t do that.

      • Sarah T.

        Courtney, under your definition of “natural” , the only time a woman would have a natural birth is she was “UCing” and had absolutely no interventions. Have a midwife? Unnatural because primates in nature do not have midwifes. Check the fetal hearttones with a dopler or fetal scope? Unnatural because this does not occur in nature. Get in a pool to ease the contractions? Unnatural because primates in nature do not get into water to give birth. Ridiculous, right? So is you saying that OB’s never see unmedicated vaginal births.

        • Common Sense

          Yeah, and black and blue cohosh is natural as is evening primrose oil, castor oil, garlic in the vagina, acupressure, accupuncture, saline water injections, water tubs, moxibustion, chiropractor adjustment to stimulate labor, power labors, membrane sweeps, rebozo scarf therapy, placentophagia (what other mammals eat placentas?). Am I forgetting any other interventions that Homebirth midwives use that really wouldn’t be considered found naturally to be done in nature? Are these the Homebirth midwives “cascade of interventions”?

      • The Computer Ate My Nym

        even if they see an unmedicated vaginal birth.. it’s still not a fully natural one. it’s unnatural to have a woman poked with a “routine” IV line, it’s unnatural to have bright lights and strangers wandering around etc. etc.

        Oh for…communicating with strangers over the internet is about as unnatural as it gets. Begone foul creature!

      • Common Sense

        Courtney, there is someone with the woman in labor from start to finish. OBs commonly work as a team with the L & D nurse. Doulas can come in the hospital. The husband is there too. She is not left there by herself unassisted (as some women do at home!). So many Homebirth midwives leave their clients in early labor and come back later. Birth stories on the Internet abound of this, baby Dickey had a three day long labor and the midwife left her alone crying. Another story had the midwife leave to finish her Christmas shopping only to make it back after the baby was born. In the hospital, the labor team in there from start to finish. Sure the doctor comes at the beginning, a couple times during and again at the end, but the nurse and sometimes a doula is there the whole time.

      • Elisabeth

        I have to add that things like needles and strangers in the room won’t seem to matter unless you have an understanding that these sort of things DO disrupt a rather complex and delicate experience that is labor and birth. Many people do not understand this.

    • Elisabeth

      I don’t see how this is a sexist lie…whether an OB is a woman or a man doesn’t seem to matter much. How many female OB’s have had babies before they finish their residency? And how many of them choose unmedicated labors for themselves? I would be surprised if it was more often than the general population that has babies in the hospital (but I do know of OB’s who have chosen homebirth, oddly enough, though not many). Personally I don’t hire an OB as my primary caregiver when I have babies. Midwives, both home and hospital, have MUCH more experience with “normal” labor and birth, and understand the value of it for the health of baby and mother. They also have stricter definitions of “natural birth” that align better with my own…NO unnecessary interventions at all. Breaking the water, episiotomy, IV’s, continuous fetal monitoring, the list goes on and on…I consider unecessary in a normal unmedicated birth, and so does the research (look for recent article from Consumer Reports). If OB’s in their residency have not seen a “normal” birth, that simply doesn’t surprise me.

      • suchende

        “They also have stricter definitions of “natural birth” that align better with my own…NO unnecessary interventions at all. Breaking the water, episiotomy, IV’s, continuous fetal monitoring, the list goes on and on…”

        So any necessary intervention is part of a natural birth, then?

      • Common Sense

        If homebirth midwives are good for normal labor, what do you do when the situation changes and becomes an abnormal labor? Transfer to someone who can handle both normal and abnormal labors, ie: an OB? And risk the baby and yourself in the process. Research risk prevention would suggest starting with someone who can handle both normal and complicated labors from the getgo would be prudent.

  5. It is upsetting that a Dr would refuse to engage a midwife who had followed the labor for many hours and had a sense of how things were progressing. Did that mom have a healthy baby in the end?

    • That baby died, Brette. The midwife was investigated and found to have made no errors in care. The mom trusted her and liked her so much that she asked her to oversee her next pregnancy but she was so upset by what had happened that she refused. The mom went on to have a healthy baby a few years later. The doctor was reprimanded by the hospital. Though it was not made public and no charges were pressed, he was clearly in the wrong. He was not fired but her contract was not renewed. Unfortunately he is still practicing obstetrics albeit in another city (and getting terrible on-line write-ups. Always good to check what other moms are saying about your doctor.)

      • Siri

        So ebil obstetricians are both trigger-happy scalpel fiends, desperate to cut wombyn open as soon as look at them, AND lazy, lackadaisical layabouts who won’t go near wombyn with a scalpel until it’s too late… Also, you said the woman still wanted to try for a vaginal delivery, so in other words the midwife wanted to overrule the OB AND the woman, and force an operative birth on the mother. Do you even read what you write?

      • Siri

        Also, you blame the poor OB for talking to the woman instead of to the midwife -hello?!! Doctors really can’t win, can they? You really think the OB should have ignored the labouring woman and talked to the midwife instead?! How is that empowering women? Whose labour, birth and baby was it? The midwife’s? In fact it was nobody’s; you made the whole thing up, and couldn’t be bothered to check if what you wrote made any kind of sense.

    • Common Sense

      Obstetricians collaborating with Homebirth midwives for safer births is like the police collaborating with vigilantes for safer neighborhoods. Vigilantes carry guns and can wear kevlar. And vigilantes are trained in law enforcement as much as Homebirth midwives are trained in anatomy, physiology, pharmacology, biochemistry, genetics, statistics, labor and delivery, epidemiology, preventative care, ethics, psychiatry, and handling complications.

  6. Sarah T.

    I am curious if you read the cochrane study that you linked to. Right on page one, in the abstract, it states
    “Main results

    Two trials met the inclusion criteria but only one trial involving 11 women provided some outcome data and was included. The evidence from this trial was of moderate quality and too small to allow conclusions to be drawn.”
    From the plain language summary – “However, there is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. Only two very small randomised trials have been performed. Only one trial (involving 11 women) contributed data to the review. They did not allow conclusions to be drawn except that women living in areas where they are not well informed about home birth may welcome ethically well-designed trials that would ensure an informed choice.”

  7. Elizabeth

    • The government official (who spoke to me off the record) who publicly and vociferously advocates for vaccines and has published peer-reviewed scholarly articles about the benefits of childhood vaccination but who privately chose not to vaccinate his youngest child.

    I’d like to know more about this. I worked for a neurologist once who advocated vaccines but then also said he never blamed families for not wanting to give them given the risks associated with them.

    • Elizabeth – it is very interesting to talk to doctors, immunologists, and other medical professionals when they are not around their colleagues or in a public forum. You will find that the choices they make for themselves and their families are often different from what they feel they have to publicly endorse. The fact that so many medical professionals refuse the flu shot is a good case in point.

      • Natalie

        “The fact that so many medical professionals refuse the flu shot is a good case in point.”

        that’s interesting. Can you support this claim?
        I’m guessing not. Any medical provider or healthcare worker is required to maintain their immunizations- including an annual influenza vaccine.
        The only way it would be possible to not is if a provider is in private solo practice (increasingly rare). I still doubt they would not immunize themselves considering they are some of the most exposed to the flu.
        I myself am required to get an influenza vaccine annually as a medical student. I missed the deadline by a day and they put a hold on my financial aid and academic records.
        So sure “medical professionals refuse the flu shot”. Uh huh. Prove it.

    • Voice of Good Sense

      Elizabeth, I’ve personally known many doctors who publicly support vaccines (being against them is almost career suicide), but who are personally too weary of them. The included brochures that most patients never read literally state that the risks include neurological problems, including autism, and death. These are the manufacturers stating this. Next time you go to get a vaccine for your child (if you do), demand to see this insert. Doctors are required by federal law to let you see it. You can read the manufacturer-admitted risks for yourself and decide if you’re more comfortable with those risks or the possibility of your kids getting the measles, which the CDC itself reports is a mild illness from which a full recovery is expected in America. Whatever you decide, just make sure you hear the risks from the manufacturers too, and compare it to the expected outcomes the CDC admits.

      It’s not too hard to see why many doctors don’t vaccinate their own kids unless they’re traveling to certain areas overseas.

      • suchende

        “he included brochures that most patients never read literally state that the risks include neurological problems, including autism, and death.”

        I am dying to see a package insert that says any vaccine has a risk of autism.

        • Eyerolling

          Yes, please. Take a picture of that flier, upload it to photobucket or something, and post the link here. We’re waiting.

      • Common Sense

        Many is a strong term. If you know of studies or questionnaires that show more than 50% of doctors refuse vaccines, than site them. Otherwise state you are aware of some doctors and nurse who have refused them. But to so many or most without siting a source is arrogant and naive.

      • Elisabeth

        Yes, too bad, I like this post but disagree about autism. I have never seen this on a vaccine insert. However, I would encourage people who are not already confused enough to read up on aluminum in vaccines, and damage to the brain. I like Dr. Sears The Vaccine Book. Though it has not made any decision I have had to make easier, at least I am making it with my eyes open (Dr. Sears admits that in general doctors don’t actually know anything about vaccines, he wrote the book when he actually started doing research and realized parents had legitimate concerns. His book is an attempt to help parents make their own informed decisions).

  8. The entire plain language summary reads: “Most pregnancies among healthy women are normal, and most births could take place without unnecessary medical intervention. However, it is not possible to predict with certainty that absolutely no complications will occur in the course of a birth. Thus, in many countries it is believed that the safest option for all women is to give birth at hospital. In a few countries it is believed that as long as the woman is followed during pregnancy and assisted by a midwife during birth, transfer between home and hospital, if needed, is uncomplicated. In these countries home birth is an integrated part of maternity care. It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications. In a planned home birth assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary these drawbacks are avoided while the benefit of access to medical intervention when needed is maintained. Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications. However, there is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. Only two very small randomised trials have been performed. Only one trial (involving 11 women) contributed data to the review. They did not allow conclusions to be drawn except that women living in areas where they are not well informed about home birth may welcome ethically well-designed trials that would ensure an informed choice.”

    If you read the part you quoted in context, you will see that it is a call for more studies in light of the fact that “Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications.”

    • Sarah T.

      Here is what you wrote – “Despite the fact that a Fall 2012 Cochrane Library Review (considered the gold standard of independent inquiry and scientific objectivity) reports that home birth is as safe or in many cases actually safer than hospital birth, the American obstetrical community continues to publicly oppose homebirth, citing safety concerns as their main argument. ” How did you get that sentence from that study? The study clearly states that you can not draw conclusions from it, yet you seem to be drawing a conclusion from it that home birth is as safe or safer than hospital birth. A study of 11 women can hardly be called comprehensive.

      • Kelly

        Sarah, while it’s been a while since I’ve read that Cochrane review, my remembrance is that you are talking about “randomized” trials…the gold standard in research. However, so far nobody has managed to create a study where the participants will allow you to randomly choose their place of birth for them. Hence the very small amount of randomized trials. But that is not all the research on planned homebirth. There are many, many other studies comparing like groups of women (low-risk, vertex, not preterm, singleton, etc.) in homebirth versus hospital birth. Those are also taken into account in the Cochrane review. So the review is based on far more studies than 2 with 11 people…it’s just that is all of the *randomized* trials that were included. HTH.

        • Kelly

          And to clarify myself, I did just go refresh my reading. They are citing the observational studies as examples of homebirth safety and recommending that they be used to review the safety of planned homebirth. So, in a way, you are correct, the randomized trials were 2 and very small and obviously that is not enough to draw a strong conclusion. But the observational studies (comparing like with like in both settings) have increasingly strong evidence and the authors are recommending adding that in a review of PHB.

      • This is what the authors say, Sarah: “It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications. In a planned home birth assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary these drawbacks are avoided while the benefit of access to medical intervention when needed is maintained. Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications. ”

        There are more than half a dozen other studies from several countries that have found home birth to be as safe as hospital birth (a very low standard considering how dangerous hospital birth sometimes is.)

        Here are a few:

        1. Outcomes of planned home births with certified professional midwives: large prospective study in North America

        Results 655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.

        Conclusions 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.

        2.Home birth as safe as in hospital for low risk women, study shows BMJ 2009 Home birth is as safe as hospital birth for women at low risk, according to the results of a Dutch cohort study of 529 688 women. But the authors say that a prospective study is needed (British Journal of Obstetrics and Gynaecology 2009;116:1-8).

        “In our research, we studied more than half a million women in primary care and compared planned home births with planned hospital births,” said the lead researcher Simone Buitendijk, head of the child health programme at the Netherlands Organisation for Applied Scientific Research.

        3. An earlier systematic review from Cochrane states, “‘In countries and areas where it is possible to establish a home birth service backed up by a modern hospital system, all low risk pregnant women should be offered the possibility of considering a planned home birth and should be informed about the quality of the available evidence to guide their choice.” See Olsen O, Jewell MD. Home versus hospital birth. Cochrane Database of Systematic Reviews 1998, Issue 3. Amendment 19 May 2006.

        4. This PDF includes 43 references to evidence of home birth safety: http://www.aims.org.uk/OccasionalPapers/benefitsOfHomebirth.pdf

        Perhaps you didn’t see the above statistic that 68,000 women in America nearly die during hospital birth? When I gave a talk about episiotomies recently the audience gasped — and women came to talk to me afterwards to tell me how they are STILL in pain down there from having an episiotomy. There is also the psychological pain that women go through when they are bullied. Safety can be measured on a variety of parameters. Obstetric intervention when well used can be life-saving and there are good reasons for some women to birth in the hospital. But women report more satisfaction, less intervention, less tearing, and less post-partum complications when they have out-of-hospital births.

        • Sarah T.

          The problem with all of that is that most of those studies refer to Europe and Canada, not the U.S. The midwives that they use in Europe and Canada are univeristy trained midwives, similar to CNM’s in the US that practice both in hospital and out-of-hospital and have appropriate risk out criteria and have extensive medical training before becoming licensed . I have no problem with that and support CNM’s attending homebirths with risk out criteria and transfer privledges. CPM’s in the U.S. however, do not have this level of training and this is why I believe we are seeing horrific death rates in states like Oregon.
          ” My name is Judith Rooks.
          I’m a certified nurse-midwife, a past-president of the American College of Nurse-Midwives, and a CDC-trained epidemiologist who has published three major studies of out-of-hospital births in this country.
          In 2011 the Oregon House Health Care Committee amended the direct-entry midwifery—“DEM”—law to require collection of information on planned place of birth and planned birth attendant on fetal-death and live-birth certificates starting in 2012.
          Oregon now has the most complete, accurate data of any US state on outcomes of births planned to occur in the mother’s home or an out-of-hospital birth center.
          This table summarizes that data (PTT slide):
          On the 1st row, you can see that nine babies died during or soon after labor in homes or birth centers.
          The total mortality rate for planned out of hospital births was 4.5 per thousand, as seen in the last column of that row.
          I have included the number of neonatal deaths both with and without the death of one baby who died of congenital abnormalities. That death cannot be attributed to the care given by the DEM attendant.
          The 2nd row shows data on deaths associated with planned OOH births with direct-entry midwives as the planned birth attendants.
          The total mortality rate associated with those births – excluding the one involving congenital abnormalities – is 4.8 per 1000.
          For comparison, data on births planned to occur in hospitals is provided in the bottom row of the table.
          Note that the total mortality rate for births planned to be attended by direct-entry midwives is 6-8 times higher than the rate for births planned to be attended in hospitals. The data for hospitals does not exclude deaths caused by congenital abnormalities.
          Many women have been told that OOH births are as safe or safer than births in hospitals. This is true in some places, including British Columbia.
          2
          But out-of-hospital births are not as safe as births in hospitals in Oregon, where many of them are attended by birth attendants who have not completed an educational curriculum designed to provide all the knowledge, skills and judgment needed by midwives who practice in any setting.
          Most women who have OOH births with direct-entry midwives are very happy, support them strongly, and many will contact their legislators to argue that DEMs do not need more education or regulation.
          Oregon needs more direct entry midwives. More and more women want to have out of hospital births, and they want direct entry midwives. But currently the collective practice of these midwives is not safe enough.
          In 2012 six Oregon mothers lost their babies in births attended by DEMs. They may feel guilty about having chosen a home birth with a DEM and are unlikely to lobby their legislators.
          The more than a thousand women who had good outcomes and are happy are the ones who will call you. The legislature won’t have another opportunity to make the law stronger on behalf of safety until 2015. Please keep the six women who lost their babies last year in mind as you legislate this year.”

          • Courtney

            so in other words, home births aren’t dangerous.. hiring people without proper training is.

            hiring some one without proper training would be dangerous in a hospital too, that literally has nothing to do with home birth being safe or not and everything to do with the US needing licensing laws so that midwives can practice legally, and attend schooling correctly.

          • Sarah, please see my comment above. As someone who lives in Oregon, I share your concerns about the safety of homebirth. As I mentioned to Amy, when you talk Portland out of the equation, our state has some of the best stats in the country. At the same time, it is true that some midwives are not practicing safely. That does not mean that home birth is unsafe but it does mean that we need to make sure all practitioners (especially doctors since they are overseeing most of the births) are adequately trained.

      • MCHadvocate

        I am a PhD researcher in maternal child health. My third birth was a planned home birth and was a wonderful experience. That said, no one I know in academic birth research (and there are many of us who support home birth) would ever cite that Cochrane review as evidence of home birth’s safety. There is no RCT indicating that either home or hospital birth is safer. The research we do have points to risks in both home and hospital births. These risks may differ among different women (for instance, nulliparous vs. multiparous), and women should understand what the risks are so that they can make informed decisions about their personal circumstances. Certain risks may be more or less acceptable to certain people.

    • Eyerolling

      ” In a planned home birth assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary these drawbacks are avoided while the benefit of access to medical intervention when needed is maintained.”

      The trouble is that you are deliberately overlooking a large portion of your community here. Midwifery in America is filled with quacks and untrained, ignorant fools. Until having a CNM is the minimum standard for midwifery in America, the needless deaths of babies and mothers at home will continue.
      BTW, If birth is so safe and medical intervention is rarely needed, why should midwives need a collaborative backup system of transfer at all? And if you acknowledge that it is needed, why not start down the hall from the needed interventions instead of 10+, 20+ 30+ minutes away from the hospital?

  9. Anj

    Ms. Margulis,

    I saw mention of Kristina Delores Adkins, but was unable to find out where she labored, where she delivered, where she was when she suffered the severe post partum hemorrhage and where she was when she suffered the cardiac arrest.

    I have no proof, no verifiable source that she was in a hospital for any of those events. If you have that source, that data, that evidence for your assertion that she died as a result of a “hospital birth”, I would be most grateful if you would share it with us.

    • She died after a hospital birth. I do not know the details of the birth, how much intervention she had, what drugs she was given. I don’t think we can say that her death was the result of a hospital birth. Sometimes healthy women die in or just after labor, which is tragic. But the reason more American women die than women in any other industrialized country is not because something is wrong with us American women but rather because OUR birthing system in the hospital has become increasingly unsafe. Here is a link to a post about her that links to her obituary and her girls’ education fund. This blogger says the placenta did not deliver properly but I do not know the source of that information: http://www.empowernetwork.com/kelliott/blog/kristina-adkins-dies-at-35-having-a-baby/

      • Anj

        I’m sorry, that doesn’t tell me what hospital she was in at all.

        BTW – she was totally high risk as a grand multi para.
        Risks associated with grand multiparity[8]

        Increased risk of:

        Abnormal fetal presentation
        Precipitate delivery
        Uterine atony
        Placenta praevia
        Uterine rupture
        Amniotic fluid embolism
        Obstetric haemorrhage
        Stress incontinence and urinary urgency symptoms[9]
        Levator ani dysfunction[10]
        http://www.patient.co.uk/doctor/gravidity-and-parity-definitions-and-their-implications-in-risk-assessment

        Without medical records, it is impossible to know what happened or what her cause of death was. A cardiac arrest is consistent with amniotic fluid embolism which is often fatal.

        I don’t know for certain any details of her labor, birth or the contributing factors of her death.

        Neither do you.

        • Mommy Sarah

          You don’t know details but you write about it? I thought the first rules of journalism is research and verify. You did not do this. (Other than a half-ass Google search).

          All you are doing is passing of gosssip as fact. Shame on you. This is poor, unethical writing at best. I hope your book is better. But if this is an example of the work you did, it is not.

          • Anj

            I looked up every detail I could and came to the conclusion that there was no evidence for the place of birth.

            In other words, my conclusion was that I did not know.

            Ms. Margulis came to the conclusion that the woman had a hospital birth, apparently based on the same information I had access to.

            Why did we come to different conclusions? I came to my conclusion based on evidence, or the lack of evidence.

            Ms. Margulis came to the conclusion that the woman had a hospital birth, ….based on ______. She doesn’t tell us how she reached this conclusion. I would appreciate it if she would because I am always interested in knowing if I am missing essential information.

            Verifiable information trumps unsupported assertions every time.

          • Siri

            I heard that some woman died, and it was the OB’s fault. Oh, and her baby died too. There, see how safe homebirth is? This tragic story keeps me up all night. Oh wait, it’s my own shoddy, biased excuse for journalism that does that…

        • Elisabeth

          Without blaming each other, let’s just admit there is major fault in our medical system if hospitals are not required to report on specific cause of death when women and babies die in childbirth. Only Massachusetts requires it, and they don’t enforce it. In the UK they publish the information every year. It is “anonymous” as to the specific provider but required.

          • Anj

            If that’s true, then we can say that hospitals and midwives have the same reporting practices…

            …if you only count reporting the cause of death.

            There’s a ginormous data deficit on home births because most midwives don’t have mandatory reporting of outcomes. If only we had mandatory reporting for all midwives in all fifty states, we could finally compare the outcomes for midwife attended births to OB attended births.

            Bring on the data!

      • Siri

        So you think that if she had haemorrhaged after a home birth, she would still be alive… Because home birth midwives carry large supplies of crossmatched blood and a portable operating theatre?

    • Common Sense

      Like Caroline Lovell died after a Homebirth cardiac arrest speculative after a post partum hemorrhage at home?

  10. Samantha

    I just have to say THANK YOU!
    Thank you for the article.
    THANK YOU for putting up with the “bashing” that some people can do when you talk about having a home birth. Plain and simple it is MY right after I’ve weighed my options and risks to benefit on any one choice I make…but it is my RIGHT to do so… to make any choice I see best to fit me and my baby.
    I have had a home water birth and I have never experienced anything more wonderful. My midwives were caring, knowledgeable and professional. I never once felt vulnerable ..and that is VERY HARD to say when going through labor. I will be having another child soon and am doing another home water birth. I advocate highly the benefits of home birthing as well as water birthing. If anything I would love to see more birth centers attached to a hospital. As well as obviously LESS SCARE tactics and more education given to new Mothers or pregnant Moms in general.
    I had to fight my husband about a home birth until I started showing him stories and statistics from the US’s OB’s sites! The C-section rate is outrageous and the use of medication is ridiculous. Now, if you feel you need it SURE go and use it…that is what our “modern day medicine” is for. But a “routine” IV and “Routine” pitocin…you are ASKING FOR TROUBLE. And I’m not talking to the Mom’s here… the Ob’s are willing to pump this into your body because they chose not to wait to let nature take it’s course. They want to rush a NATURAL thing and when that is done, horrible things come of it.
    I recently came to know of an acquaintance who went in to the hospital and had two epidurals and was put on pitocin when getting to the hospital…later ending up having a c-section after laying in the bed for hours.

    There NEEDS to be a change that is made in how Mother’s are “shuffled through the process” in labor and birth.

    I was never told…HOLD IT ..HOLD IT…. OK, NOW PUSH!

    It’s like telling someone to not throw up, “just yet” ???? you can not help it.. I do wish they would allow more CPM’s to practice so they CAN make more studies to show they have BETTER statistics than do hospital births.
    Things can happen either place but you are almost guaranteed to receive too much interventions going into a hospital …ie episiotomies. epidurals. Ivs/pitocin/cytotec (stated on pamphlet to NOT use in pregnant women) and on and on.
    most “policies” don’t allow you to move around, use a laboring pool, change positions or eat or drink when needed.
    All these things slow the progress of labor and in return are harmful to Baby and Mom. Very very sad.
    Another example, a doula/midwife attended a hospital birth for a client, Mother was doing amazing on hands and knees..baby was almost out with another few pushes…Doc walks in say’s “I can not deliver the baby like that, get on your back!” Another 30 minutes + she finally had the baby :(

    Doctors/Ob’s need to ALLOW MOM TO DO WHAT IS BEST FOR HER BODY!

    • Elisabeth

      Hospital Birth Horror Story (no death, though). Mom was about to push same time as another Mom nearly, they told her to “wait” b/c the other Mom had to go first b/c she had been in labor longer. She did have an epidural so she did her best not to push. An hour later the doc came so she could deliver her baby. Her baby was born oxygen deprived enough that they kept baby in NICU for 2 days. She wonders if “waiting” was part of the cause. Oh, and because her labor went about an hour over, they charged her for an extra day. Now, we don’t know if baby ended up in NICU b/c of waiting to push (FYI she also wanted to go without an epidural and pitocin which def increases chances of fetal distress but various factors she feels now were not necessary led to her having them). But it is sad to be left to wonder, ‘was that necessary’. I had the most wonderful time bonding with my baby in those first days. I feel sorry for what this Mom lost, and her questions as to why.

    • Siri

      How do you know what happens in hospitals when you have never given birth there? What makes you think that any of the things you write are true? You don’t, because none of it is true. It’s just your ignorance and prejudice talking. Most women have perfectly satisfactory births in hospital, some have wonderful births in hospital, and some women have disastrous births at home. Most hospital staff are only too happy to accommodate women’s wishes, while some home birth midwives are only interested in catering to their own preferences. Stop writing nonsense about things you know less than nothing about!

  11. Rebecca

    This is why I want to train as a midwife and a doctor, because I believe that we need the best of both to truly serve families.

    • That’s an excellent idea Rebecca. There are several wonderful doctors who were either first midwives, are married to midwives, or who learned over the years that collaborating with midwives is the best way to insure good outcomes. If you are not familiar with her work, Dr. Aviva Romm, M.D. began her career as a midwife.

    • Common Sense

      Yes Rebecca, get a good education and training, unlike the CPM and DEM model. Oregon and Colorado already show dismal outcomes with Homebirth as Homebirth is practiced. And I am sure the MANA mortality outcomes are being hidden because they recapitulate this.

  12. I have a story to add: A first time mom having a homebirth with a CNM when the midwife loses fetal heart tones. Tones are reestablished when mom is moved into hand-and-knees (compressed umbilical cord?). Midwife transports to hospital and the nursing staff there totally ignore her and make mom LIE ON HER BACK for several minutes while they strap fetal monitors on her, make her do paperwork, etc. Luckily, there is eventually a c-section and healthy baby.

    • Eyerolling

      Your last sentence undermines everything else you are talking about, even though you act as though the fact of the healthy baby and mom were a miraculous accident.

      Bottom line – the hospital knew what they were doing and didn’t need the input of an untrained “medical practitioner”.

    • Siri

      Are you qualified to evaluate and comment on the actions of the hospital staff? I am a midwife, and I can tell you have no relevant knowledge, experience or qualifications. Your anecdote is just silly.

  13. Bambi Chapman

    I have a story too.

    Experienced homebirther, midwife arrives an hour after birth, parents discuss several concerns about baby, midwife explains it all away and it seems plausible. Hours later baby is rushed to the hospital where a room of big bad doctors and nurses does everything in their power to bring this newborn baby back to life. Weeks later, parents learn the midwifes negligence cost them their baby and a hospital birth would of saved her life because those competant individuals we know as medical professionals would of realized the baby was in trouble. The morning my daughter died, one nurse quit. Everyone cried. The neonatologist still carried that morning with her last time we talked. Who wasn’t traumatized? The midwife.

  14. Amother

    What bothers me so much about the homebirth debate is that we have ample scientific evidence to show that homebirth is safe for low risk women. Take the latest study of close to 16,000 women who birthed in birth centers:

    http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full

    As we all know there is no difference between giving birth in a birth center and giving birth at home. This recent study was done in the US, with women who were attended by CPMs. Once again we have a study that supports homebirth for low risk women and yet there are still people who are vocal that homebirth is dangerous for all. I would like to see one piece of scientific evidence that shows that homebirth for low risk women is dangerous. There is none. Even Amy Tuteur, the most outspoken person against homebirth, had to admit that this study showed that homebirth was safe for low risk women. Taken from her blog:

    “The study found that birth in accredited birth centers was very safe:

    There were no maternal deaths. The intrapartum fetal mortality rate for women admitted to the birth center in labor was 0.47/1000. The neonatal mortality rate was 0.40/1000 excluding anomalies.

    This is comparable to death rates for low risk hospital birth.”

    So, women *can* be away from an OR when giving birth and as long as those women are low risk, it has no bearing on mortality rates. Why is no one paying attention to this? This is a very valuable piece of information. It means that the fight against homebirth should *only* be focused on informed consent for high risk women and the creation of a system that prevents midwives from practicing after they have demonstrated negligence. Claiming that homebirth is dangerous across the board is a flat out lie. If you perpetuate that lie you are no better than those who claim that homebirth is safe for all; you are just as guilty as they are for lying to women.

    • “As we all know there is no difference between giving birth in a birth center and giving birth at home.”

      No, we do not all “know” this because it isn’t true. This study involves accredited birth centers with strict eligibility standards staffed by certified nurse midwives . Homebirth in Oregon involves homebirth midwives (lay people with a credential that they made up and awarded to themselves), often far from hospitals and with no standards whatsoever. Hence the dramatic difference in outcomes: the birth centers had a death rate of 0.9/1000 while homebirth in Oregon has a death rate of 5.6/1000, more than 7X higher!
      Amy Tuteur, MD recently posted…Stupidest excuse for homebirth deaths everMy Profile

      • Amother

        Wrong. The birth centers were staffed by CPMs,CNMs, and LMs. Read the study again, Amy.

        And “strict eligibility standards” means “low risk”. Unless you mean super, duper, extra low risk? In that case, what’s the difference? There is nothing special or different about a low risk birth center birth and a low risk homebirth. No difference. Can you tell me one?

        Homebirth for low risk women is safe. Do you have any scientific evidence that proves otherwise or negates the abundance of evidence we now have that show it’s safety? And the birth centers had a death rate of .4/1000. That is actually safer than low risk birth in the hospital.

        • Perhaps you ought to read the study again. Care was provided by CPMs in only 14% of the cases.

          The only people who think homebirth is safe are homebirth advocates. All the existing US statistics show otherwise. Don’t even bother mentioning the Johnson and Daviss BMJ 2005 study. Johnson “forgot” to mention that he was the former Director of Research for MANA, and has since acknowledged (in response to my criticism) that he made homebirth look safe by comparing it to a bunch of out of date studies extending back to 1969. If he had compared homebirth in 2000 to low risk hospital birth in 2000, it would have shown that homebirth had nearly triple the rate of neonatal mortality.

          The Midwives Alliance of North America (MANA) has been hiding their own death rates for years. They have amassed a databse of 27,000 homebirths attended by their members. They’ve released the C-section rates, interventions rates, transfer rates, etc., but they refuse to release THEIR OWN death rates. That’s because they are hideous.
          Amy Tuteur, MD recently posted…Stupidest excuse for homebirth deaths everMy Profile

          • Amother

            Actually, it was 20% of care. But do you see how misleading your original comment was? I suppose you hoped that I hadn’t read the study and you could trick people into believing that all CPMs are worthless and dangerous. And sure, let’s bring up the Johnson and Daviss study. Has anyone criticized it besides you? Usually when there is a flawed study, quite a few qualified people speak out and point out exactly where and how the study is flawed. That never happened with the Johnson and Daviss study. However, I do recall a few epidemiologists pointing out the flaws in *your* criticisms when you wrote a post about it on Science Based Medicine.

            There are numerous studies now that show that homebirth is safe for low risk women. Studies
            from Canada, the Netherlands, the UK and now the US. Your assumptions about MANA aren’t evidence and I find it laughable that as a “skeptic”, you would use that as your “proof”.

        • The Computer Ate My Nym

          And the birth centers had a death rate of .4/1000. That is actually safer than low risk birth in the hospital.

          Actually, the neonatal mortality for women age 20-44, with full term, singleton, normal weight, vertex infants in hospitals is 0.3/1000 per the CDC wonder web site. And that’s not excluding women with contraindications to vaginal delivery or medical issues, i.e. a higher risk group than the ones who achieved the 0.4/1000 number. Remove congenital anomalies and the number goes down to 0.18/1000. The birth center you mention has decent numbers for out of hospital, but it’s still not quite up to hospital standards.

          • The Computer Ate My Nym

            Sorry. My bad. I forgot to add that this was in women with prenatal care starting in the first trimester, another criterion of being “low risk”.

          • Amother

            I have never seen or heard the mortality rate for low risk hospital birth to be that low. It’s pretty much universally known to be approx. .6/1000 in the US. Take a look at this for example: http://m.medwire-news.md/45/60228/ObGyn/Triple_death_risk_for_cesarean_babies
            If your rate was correct, elective cesareans would have an almost 6 times higher death rate than vaginal birth? I don’t think so. Actually, the true neonatal mortality rate in the US is much higher. Try 7/1000. See here: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_08.pdf

            The Oregon mortality rate was also .6/1000 as was the rate that Amy Tuteur came up with here: http://www.sciencebasedmedicine.org/index.php/the-tragic-death-toll-of-homebirth/

            So yes, I would say that in some cases homebirth is slightly safer than hospital birth. This study showed very similar rates, also showing homebirth to be safer: http://www.cmaj.ca/content/181/6-7/377.full

          • Amother

            Ahhh, no wonder. How many women even know they are pregnant in the first trimester? A very, very small number. I knew I was pregnant at less than ten weeks, but by the time I took the test, made an appt with an OB and started prenatal care I was just about out of the first trimester of pregnancy. That is the norm.You are not deemed high risk if you happen to start prenatal care at 14 weeks pregnant or so, sorry. You need to go back and crunch your numbers again.

          • The Computer Ate My Nym

            Changing the parameters to include patients who had care starting in the 4th month actually brought down the mortality just a bit, to 0.29/1000. (Still without removing women with medical risks, as that is not accessible in the CDC wonder data.) It may be that women who present earlier are more likely to be older, possibly taking fertility treatment and therefore just slightly higher risk. But I doubt your statement that most women don’t know they’re pregnant before the end of the first trimester. Given that the majority of abortions occur before the 8th week, I’d say that quite a number of women know that they’re pregnant earlier.

          • Jade

            Amother:
            Using prenatal care in the first trimester as a filter doesn’t need to capture all low-risk women. It’s obvious it doesn’t. It’s simply a tool that enables you to capture a sample of them in the absence of other information. You also seem to have missed the obvious fact that even if it doesn’t capture low-risk women, then all using it as a filter will do is make the hospital figures worse–or the same–than if it wasn’t applied. Which doesn’t help your argument at all–right?

            Anyway, you are wrong when you say that very, very few women receive prenatal care in the first trimester. Why don’t you try actually looking up the numbers? It’s surprisingly easy.

          • Jade

            Uh, Amother–a heads up–you are confusing low risk stats with stats including all-risk births.

        • Common Sense

          Amother, Homebirth uses variations of normal to describe breeches, twins, previous cesareans for HBACs, FTM , AMA, and post dates as Homebirth “low risk” candidates. Happens all the time. This does contribute to why the Homebirth outcomes are worse in Oregon and Colorado. These patients are risked out in most legitimate birth centers.

          • Siri

            Amother, most women buy pregnancy tests that work before their next period is due, so they know they are pregnant from the very earliest possible moment. Any GP will tell you that women are seeking anl care earlier and earlier as a consequence of knowing so soon.

      • I’m responding to one of your earlier comments, b/c it wouldn’t let me respond there. You wrote, “Homebirth midwives and homebirth advocates couldn’t care less about the best possible outcome for mothers and babies.”

        That’s sweeping generalization that is most definitely not supported by the evidence and research.

        • Jade

          Then why do they fail to advocate for–or even acknowledge–the need for homebirth midwives to release their safety statistics? You can’t even start to improve outcomes if you don’t acknowledge what the outcomes ARE!

        • The bottom line is that the ONLY people who claim that homebirth is safe is the people who profit from it: homebirth midwives, doulas, childbirth educators, etc.

          Homebirth midwives and homebirth advocates couldn’t care less about safe outcomes. Consider the behavior of MANA, the organization that represents homebirth midwives as well as state “Friends of Midwives” organizations:

          1, Instead of investigating a midwife who presided over preventable neonatal deaths, MANA promoted her:

          “it should be dually noted that none other than Clarice Winkler, CNM from Greenhouse Birth Center is named as the Program Chair for MANA. Never mind criminal investigation, state investigation, multiple deaths, previous sanctions, and multiple bankruptcies…why not give her a position of leadership at MANA?”

          2. Instead of investigating Amy Medwin who presided over homebirth deaths in North Carolina, the Friends of North Carolina Midwives held a rally to support her, without making any attempt at all to determine if she committed malpractice.

          3. MANA refuses to release its own death rates from the 27,000+ planned homebirths in its database. While publicly declaiming on the importance of informed consent for homebirth, MANA is hiding the most important piece of information necessary for informed consent.

          4. Though the MANA leadership disingenuously claims that licensing homebirth midwives will provide accountability, MANA leaders like Melissa Cheyney, Head of the Board of Direct Entry Midwifery in Oregon, are publicly opposed to any requirements for becoming a homebirth midwife, let alone oversight of homebirth midwives’ practice.

          5. MANA has made no attempt to investigate the appalling homebirth mortality rate of licensed Colorado homebirth midwives. The death rate keeps rising and MANA keeps ignoring the deaths.

          6. Though homebirth midwives in North Carolina are not licensed by the state, most are credentialed by MANA. Nonetheless, there has been no attempt by MANA to investigate the extraordinary number of neonatal deaths that have occurred at the hands of North Carolina CPMs.

          7. MANA has taken no action in against mother and daughter Idaho CPMs who have presided over 5 separate homebirth disasters and face a $5 million dollar judgment against them.

          8. When asked by State of Oregon to release the homebirth death rates for that state, Melissa Cheyney refused to do so. That’s why the state began collecting its own statistics, hiring Judith Rooks CNM, MPH to analyze them. It’s not surprising that Cheyney wouldn’t release the death rates. They are appalling, 9X higher than term hospital birth.

          MANA clearly does not care whether babies delivered by homebirth midwives survive. I’m not aware of any actions they have taken to investigate homebirth deaths, let alone to hold the midwives involved responsible.

          Of course I would be very happy to be corrected. If anyone wants to present any evidence that homebirth midwives and homebirth advocates have held anyone accountable for the dozens of homebirth deaths that occur each year, I will gladly publish the documentation.

          Real health professionals have professional standards, hold weekly peer review meetings, discipline members who fail to meet standards, and carry malpractice insurance and they DON’T hold rallies for colleagues accused of malpractice. Homebirth midwives have no intention of doing any of that. It’s all about them and if babies die in the process they issue their standard hideous response that “some babies are meant to die.”
          Amy Tuteur, MD recently posted…Real midwives and homebirth midwives: apples and oranges.My Profile

          • Common Sense

            The Sisters in Chains website or Facebook page clearly shows how Homebirth midwives are practicing for the safety of babies and mothers. Everyone on there has had one or more bad outcome and instead of getting more education, embracing probation or suspension, helping the families of those harmed, they are rallying to get right back to practicing without bettering themselves so women have the right to choose and the midwives have the right to be reimbursed.

    • Siri

      The only problem is that when low risk suddenly becomes immediate, life-threateningly high risk (unexpected haemorrhage, shoulder dystocia, rapid onset eclampsia), being in hospital gives you a good stab at survival. Being at home may mean certain death. I am a midwife, and so I know that low risk does not mean no risk. I have given birth at home, with properly trained and qualified midwives, but I would not allow a CPM within a mile of me or any baby of mine. They are too ignorant to know what they don’t know.

    • Common Sense

      Netherlands

      http://www.bmj.com/content/341/bmj.c5639

      Conclusions Infants of pregnant women at low risk whose labour started in primary care under the supervision of a midwife in the Netherlands had a higher risk of delivery related perinatal death and the same risk of admission to the NICU compared with infants of pregnant women at high risk whose labour started in secondary care under the supervision of an obstetrician. An important limitation of the study is that aggregated data of a large birth registry database were used and adjustment for confounders and clustering was not possible. However, the findings are unexpected and the obstetric care system of the Netherlands needs further evaluation.

  15. Mom and Doc

    Can you please provide a source for your assertion that most OBs never see an unmedicated birth? I spent 3 weeks on Labor and Delivery as a med student. I witness at least 10 unmedicated births. One of those was even an unmedicated vaginal birth of twins.

    That’s what I saw in three weeks. You’re telling me that after FOUR YEARS most OBs don’t even see one tenth of what I did?

    I call bull.

    • Siri

      Of course it’s bull. All obstetricians will have followed lots of women through their labours (as opposed to just showing up for the last few minutes) and seen countless normal deliveries. There’s no arguing with home birth fanatics, though, as they won’t believe anything that doesn’t fit in with their deluded worldview.

  16. Susan

    I second the bull call. I was a labor and delivery RN for 20 years and I was present for countless unmedicated births and SO WERE DOCTORS!

    Obviously the author has an agenda. I once had a homebirth so I was a member of the club. I can say that without any doubt the doctors and in hospital CNMs I knew were far more concerned about safety and self critical than the homebirth midwives and advocates I knew. I think women have a right to give birth at home. I don’t believe the people who care for them should have a substandard education. The people who take on the responsibility for home birth care should be at least as educated as a CNM or European midwife. The CPM either should be abolished or educational programs need to be on par with CNM education.

  17. The Computer Ate My Nym

    The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America

    I don’t know where the Cochrane review pulled this claim from, but if you look at either the CDC numbers or the Oregon numbers, the risk of death for low risk vaginal births is less than 1 per 1000 in the hospital (0.6/1000 in the Oregon data). If you exclude congenital anomalies, a dubious exclusion since not all CA are fatal if prompt treatment is given, the rate goes down to more like 0.2/1000. So, at best, you’ve got the infamous 3x greater risk again. Probably worse.

  18. Jade

    As a new transplant to the United States, there are two things about the American maternity system that seem to me to be of actual, urgent concern. First, there is the fact that a developed country can allow midwives who are neither properly trained, regulated, accountable nor integrated into the rest of the healthcare system. Not only this, but they are not even required to report their outcomes (and as a consequence conceal them)! Why is this not a concern to you? As an outsider it’s shocking.

    Second, while there is certainly a problem in terms of maternal outcomes in the USA, it is a problem of a shocking racial disparity. Your article, much like every thing I have ever read by a homebirth advocate, completely ignores the issue of race. Probably not surprising, given that women who choose homebirth tend to be white and of a relatively high socio-economic class. Nonetheless, it’s a joke that anyone can discuss outcomes during childbirth in the US without mentioning race.

    The complete blindness that you demonstrate to these two issues just makes me think that you are more interested in finding evidence that supports homebirth as a choice than in actually improving outcomes for woman and children during childbirth. The reality is that there are no accurate statistics available with regard to the safety of homebirth in the USA, because homebirth midwives refuse to release them. Those few states where they have been compelled to do so show horrendous outcomes. I urge you–and all other homebirth advocates–to try to put your personal biases aside and take a clear eyed look at the statistics, even if you don’t like what they say.

  19. Moderation

    I have read your article, read Dr. Teuter’s response and gone and looked up the noted midwife death rates in Oregon, which are listed as 8-9 times greater than births in a hospital. I have made note of your response that the numbers look much better if you exclude Portland. (Population Portland/Population Oregon – 2.7 mil/3.9 mil) I agree that with any epidemiological research there might be a reason to exclude some participants (differences in population, training or qualification of the care providers, etc.). What would be the reason to exclude the homebirths in Portland vs the rest of Oregon?

  20. anonymous

    I suggest if you want to write on such topics, you should educate yourself in the sciences. A PhD in literature does not give you the authority to rewrite encounters with doctors and midwifes and pander them as facts. I am sure would not come to scientist if you wanted to write a mystery novel.

    As an educated woman, you should be more responsible. You are putting a lot of women who need the care of doctors at risk just as people who refuse the pertussis vaccine based on such information kill their babies.

    Also, please enjoy the royalties from your book, which was published in mass production by a corporation whose goal is to make money. Shame on you.

    • Common Sense

      I agree, any Homebirth tragedy in the news should be forwarded to the author so that she may consider that she may have provided an arguement for that woman, husband, and family to choose Homebirth as being safe.

  21. I would hope that “hospital birth” (or “home birth”) would not be listed as a cause of death in any case – I’d like to know the actual cause of death. As a “near-miss” myself – due to eclampsia and HELLP syndrome – I find it more important to look at the conditions that actually cause near-misses and deaths. I would guess that most deaths and near-misses have little to do with interventions or lack thereof – this may make the difference between a near-miss and a death, but I doubt that many near misses are due solely to the location of the birth. I would also expect that most near misses and deaths would happen in hospitals because that is where the high risk and complicated births tend to happen. I don’t care whether my doctor has seen “normal” birth. I care whether the midwife (or doctor) has seen and can recognize the complications that lead to maternal and infant deaths.

    • Jade

      Agreed! The leading cause of maternal mortality in the US is cardiac disease, followed by other pre-existing conditions. These things have nothing to do with too many “interventions” and everything to do with the general health of the population. It constantly amazes me that the homebirth advocates who are so ready to blame c-sections on US maternal mortality (despite ample evidence to the contrary) and who so tout their “research” have apparently never bothered to look up this basic information.

  22. Alexis C.

    I’m shocked that Margulis is allegedly a “senior fellow” in journalism. I worked in the field for over a decade, and no editor I know would have accepted a story with so many unnamed sources or missing details.

  23. Stacy Herlihy

    Hey Jennifer,

    Have you finally gotten around to recanting the misinformation you said on Frontline about the hep b vaccine? Are you finally going to admit that hep b is administered because the younger you get the disease the more dangerous it is? Or that the disease is over fifty times as infectious as HIV and can linger on surfaces for up to seven days?

    It is very difficult to take you seriously as a resource for anything when you go on national television and spread lies.

  24. It’s scary that something so beautiful as birth has all this corporate crap attached to it. We used midwives for hospital births for our two babies in the 1990s, and there were struggles and standoffs back then, too. My husband and our midwife had to practically barricade the door at one point when the doc insisted on drugging me. My husband and midwife won. The kid is 18 now and just fine, thank you very much.
    Jane Boursaw recently posted…HBO Hosts Game of Thrones Exhibit with Kit Harington, Sophie Turner and CastMy Profile

  25. Jennifer,

    As a mom of a very botched hospital birth I am so happy about your book. It will empower many parents.

    “First they ignore you, then they laugh at you, then they fight you, then you win.” – Gandhi

    That some are so upset about you is a good thing. The tide is turning. Stay strong! Keep focusing on why you wrote the book and who you wrote it for.
    Michelle O’Neil recently posted…EasterMy Profile

    • Jade

      Michelle, nobody is upset about the idea of improving hospital care, and nobody is saying that malpractice doesn’t happen and that it shouldn’t be dealt with. The problem is when this devolves into the claims that 1) homebirth in the US is an acceptable alternative to hospital birth and 2) the main reason for poor outcomes in hospitals is opposition to natural birth (and the inevitable c-section)–all the while completely ignoring much more real problems such as the huge disparity of outcomes by race; the high prevalence of pre-existing health conditions in the general population; and access to healthcare. In other words, don’t pretend health outcomes is your concern when really you just want to advocate for the philosophy of natural childbirth.

      I am very sorry you had the experience your did. And Jennifer–thank you for allowing the strong opposition to your views to be heard. All too often this is not the case.

      • Eyerolling

        Exactly. Jennifer’s argument here seems to be, according to the one anecdote she gave us (totally scientific, I know) that since doctors sometimes don’t perform C-sections as fast as a midwife wants them to, all doctors are stupid and giving birth at home is safer. Even typing that grossly illogical sentence made my brain hurt.

    • Siri

      I am not upset about her, I simply laugh merrily at her nonsense. It is rare to see so perfect an example of someone so completely out of their depth that only the most ignorant and deluded are impressed.

  26. Amanda

    I used to be someone who thought that a woman who had an elective c-section was being selfish and didn’t care about her baby. But I evolved and realized I was wrong. I realized how narrow minded and unhelpful that attitude was. We must support each others choices.
    The point of your article was that animosity towards homebirthers and Midwives is dangerous. And I think that this Dr Amy lady is demonstrating that point beautifully.
    Wow, I never knew how many people hated me for choosing to birth at home.

    • Jade

      Good grief, Amanda–nobody hates you for choosing a homebirth. You have completely misunderstood everything that’s been said here.

    • Eyerolling

      Here, have a cookie. You deserve it with how persecuted and hated you are. Would you like a pedestal to stand on for your pity party? Here. YOU GO BIRTH MAMA! EVERYONE HATES YOU IN THE WHOLE WORLD! *throws confetti*

    • Siri

      You are entirely mistaken! No one hates anyone, least of all for their chosen venue for childbirth. Lots of us, including me, have had homebirths. Why do some people not understand the difference between disagreeing with a cause and hating a person? I guess because it’s easier and less challenging to assume you are hated. It removes the need for marshalling a rational argument.

  27. Megan K

    Amen! Powerful and beautifully written article, Jennifer. As a woman who had one in-hospital birth center birth and one home birth, I truly believe that the key to the problems is building a bridge, which I hear you recommending. So heartbreaking to hear these stories, and that hubris and miscommunication is harming women and babies. Keep doing what you are doing — you are making a difference!

  28. James Newton

    Interesting points on both sides. What bothers me is the lack of desire of the in-hospital side to even consider working with the out-of-hospital side. Even if you question the morals or ability of e.g. midwifes, why wouldn’t you work with them to educate, communicate, and try to integrate all the people a prospective mother may turn to for help? By shunning / shaming / devaluing the “other” you simply force mothers to go all one way or all the other. Jennifer may not have every fact perfectly backed up. She may, in some ways, be wrong. But she is advocating for cooperation and understanding between the sides. And that alone makes her approach the better one.

    • Jade

      James, how can the “in-hospital” side work with the “other” side when they won’t even acknowledge the most basic of facts? (For example, the scandalous refusal of homebirth midwives to release their safety statistics.) And why should homebirth midwives need the sympathy and help of others to get them to meet the same basic standards of every health professional anyway?

      By the way, an article that makes a point of portraying obstetricians as hypocritical, arrogant and incompetent practitioners and then trots out the usual tired untruths (they have no experience of unmedicated deliveries; their practice isn’t evidence-based) isn’t exactly doing a fine job of “advocating for cooperation and understanding between sides.”

    • Common Sense

      CPM and DEM titles need to be abolished. These women can earn a CNM title, get a license, get malpractice, be accountable for their outcomes (unlike Sisters in Chain Facebook page), and maintain number of deliveries per year and CME hours per year. Then they will be educated and trained enough. But the CPM and DEM only want to be licensed so they can get reimbursed from insurance companies, not to be safer for the familes thay are caring for. Even the insurance companies and malpractice companies and the hospitals give prileges to Board Certified doctors, why would the insurance companies grant CPM and DEMs? Even the insurance companies dont want the risk. The police do not collaborate with vigilantes. Doctors are not going to collaborate with “birth junkies”.

  29. I come from the veterinary world, not the human medicine one, but the tone / content / downright meanness of this series of comments reminds me of things that happen in the dog / puppy world as well.

    It’s a shame when conversations about what’s best get so ugly, with personal attacks.

    Just as in human medicine, Many status quo veterinary MUST DO items are now coming into question, including overvaccination, the growing cons of spaying / neutering dogs too young, the heavy pressure (but little real need) for certain “preventive” drugs.

    A lot of things we’ve been told are best turn out to have other consequences, and those are conversations we NEED to have … if we truly have what’s best for the patient (human or canine) in mind.

    Unlike others who’ve commented, I’ve had the opportunity to READ your book in its entirety. I found it not only riveting but relentlessly documented.

    Let people quibble with this data point or that. Your underlying thesis that the prenatal, birthing, and baby wellness system is greatly stacked against families remains intact.

    New moms need to know what’s necessary (or not) and to make their birthing decisions accordingly — whether they CHOOSE a hospital or a home birth.

    • Common Sense

      As a vet, would you allow animal care junkies to provide care to animals and birth animals (bull dogs, Boston terrier, pugs) without an education similar to what you have?

  30. From my perspective as a perinatal relationship specialist, all other reasons aside (I an no expert on the situation in the U.S., only an observer) – at the very, very least, a birthing woman’s heightened sensitivity is negatively affected by any stress and conflict in the room – or even if it’s outside the room but affects the way she is being communicated with. If mum sees the OB barking at the midwife or senses they are engaged in a power struggle, she is more likely to become compliant and lose her own power. And then these are the emotions she and her partner go home with after wards to process. Any displacement is likely to cause conflict between them then (displacement is when the boss yells at the husband, the husband goes home and picks a fight with his wife, the wife yells at the kid and the kid kicks the dog…)

    You might be interested to know that the two hospitals I gave birth in here in Sydney use a midwifery driven model – and the OB’s defer to them.

  31. Jessie Blalock

    Negativity always comes into the picture when people feel the need to stay at one extreme or the other instead of compromising. I’m sorry you got such rough commentary. I love the way you finished off your post:

    “It’s time for doctors and midwives to start talking and listening to each other, and to the birthing women in their care.

    It’s time for all of us to set aside our anger and our prejudices and help women, their partners, and their babies have the best birth they can.”

    Communication and alignment over shared goals is so important – our focus should be the health of mama and baby, not who gets credit for making sure both get a safe & healthy delivery.

  32. Denise

    There is nothing wrong with having your baby at home. I read Dr. Teuter’s comments. It is very childish of her to jump onto someone else’s blog and bash them.

    • Mom and Doc

      See, here’s the thing. She hasn’t jumped onto someone else’s blog and “bashed” them. She has responded to points made in the blog with facts and asked for clarification. That’s not bashing. That’s discourse.

      “Childish” is people attacking Dr. Tuteur by saying that she’s “not a real doctor” or by calling her “Ms” Tuteur. That doesn’t elevate the discussion at all.

      This is a blog. Often blogs are filled with opinions, but Dr. Margulis has presented several things as fact, and Dr. Tuteur has asked for clarification. The reader can be left to make their decision based on the evidence. There’s nothing childish about that.

      I appreciate Dr. Margulis’ efforts to keep the comments section open and to not delete dissenting opinions.

    • Jade

      In those few states where homebirth midwives have been forced to reveal their safety statistics, it is has been found that babies are (by a conservative estimate) 2-6 times more likely to die than those born in hospital. We can only guess how much more likely they are to have preventable brain injuries. Do you see nothing “wrong” with that?

      At the very least, women deserve midwives who are properly trained, regulated, accountable and integrated into the rest of the healthcare system. They deserve to know how safe or unsafe homebirth is. Do you disagree with that?

  33. ADMIN: I appreciate everyone contributing their diverse opinions to this comment thread and am delighted to see such a robust discussion and debate taking place. I must, however, set some guidelines in order to keep the conversation respectful. With regard to comments, personal attacks and deliberate or unnecessary rudeness will no longer be tolerated.

    Any future comments on this thread that do not show respect towards myself and other commenters will be deleted, and the commenter will be blocked from commenting on this blog in the future.

    Thank you for keeping this a respectful space where we can discuss these important issues from a variety of viewpoints.

    Sincerely,
    Jennifer Margulis
    Jennifer Margulis recently posted…Women Against Women: How the Media Denigrates MomsMy Profile

  34. I’m long past my child-birthing years; but after reading the comments on Jennifer’s article, I’ll be buying the book just to see what all the commotion is about. And good for you, Jennifer, for requiring good manners when commenting here. It is possible to have a healthy debate without all the mean-spiritedness. At least, that’s my hope or our society is doomed.
    Donna Hull recently posted…Seven tips for planning a multigenerational tripMy Profile

  35. Nathan

    Several homebirth supporters wanted peer-reviewed literature:
    Here it is:
    Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study. Evers AC, Brouwers HA, BMJ. 2010 Nov 2;341:c5639.
    Infants of pregnant women at low risk whose labour started in primary care under the supervision of a midwife in the Netherlands had a higher risk of delivery related perinatal death compared with infants of pregnant women at high risk whose labour started in secondary care under the supervision of an obstetrician.
    Infants of pregnant women at low risk whose labour started in primary care under the supervision of a midwife in the Netherlands had a higher risk of delivery related perinatal death compared with infants of pregnant women at high risk whose labour started in secondary care under the supervision of an obstetrician.

    Infant outcomes of certified nurse midwife attended home births: United States 2000 to 2004. Malloy MH. J Perinatol. 2010 Sep;30(9):622-7
    Deliveries at home attended by CNMs and ‘other midwives’ were associated with higher risks for mortality than deliveries in-hospital by CNMs.

    The bottom line of data again and again is that homebirths kill and maim babies. The CDC data of birth certificates support it.

    The most important aspect in obstetrics is to offer the best conditions for delivery and to ensure the best outcomes to have a healthy baby and mother
    This aspect is counteracted by the evidence-based increased risks of adverse outcomes in homebirths
    Anyone touting convenience and supposed lower costs of homebirth over safer hospital births does not understand the basic premise of safe obstetrics.

    From the Talmud:

    “Whoever destroys a soul, it is considered as if he destroyed an entire world. And whoever saves a life, it is considered as if he saved an entire world. “

  36. stacy21629

    Jennifer, you referenced the hospital death of Kristina Delores Adkins. Ms. Adkins died following severe post-partum hemorrhage. Are you saying she would somehow have been SAVED if she delivered at home? Home birth midwives carry blood products with them now?

  37. stacy21629

    “Despite the fact that a Fall 2012 Cochrane Library Review … reports that home birth is as safe or in many cases actually safer than hospital birth”

    It does NOT. It says (paraphrasing) “we looked at just ONE study consisting of only ELEVEN women and that’s so small a group you can’t draw any conclusions from it.”

    You really shouldn’t lie to people. I thought you believed in informed consent.

  38. chefholly

    I get very tired of hearing about the “cascade of interventions” that WILL happen to you during a hospital birth. The NCB community clings to the past while painting a horror story of hospital birth. I was hell bent on a homebirth with my first, but my husband did not feel comfortable and with our insurance a hospital birth was more affordable. I went into the experience totally on the defense, expecting to be harassed around every corner… instead I found friendly accommodating staff members who treated us with respect. My OB welcomed all of my questions with great answers and didn’t treat me like I was sick ( something all my NCB studies assured me would happen) I could eat and drink lightly during labor, I didn’t have to have an IV as long as I was gbs negative, etc and the list goes on. Now 4 babies later birthing at 2 different hospitals I’ve had beautiful births with 2 of them completely unmediated. Are there bad hospitals? Yes. Are there some crappy doctors? Yes. But the homebirth community needs to stop painting the medical community with such a broad brush.

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