“The Business of Being Born” is a movie about midwives, home births, and hospital births in America. It’s a sort of kinder, gentler “Sicko” with onscreen births, gooey, bloody newborns and fat naked women. The message of the movie is that for an uncomplicated pregnancy, natural home births with midwives are better and safer than medicalized hospital births with obstetricians. It’s strong on sound bites, emotional appeals, and superficial arguments, but weak on substance, depth, and scientific evidence for its claims.
Obstetric care in America can certainly be improved. Our neonatal statistics are far from the best in the world, but when we look for reasons, I don’t think we can blame a deficiency of home births. We don’t have universal health care. Some women’s prenatal care is inadequate. We have more immigrants and a more diverse population than a country like, for instance, Norway, and that may skew our statistics. It is very tricky to compare neonatal and maternal death rates between countries.
We are doing too many C-sections. Midwives suggest that if women were allowed to ambulate, to deliver squatting rather than supine, and to avoid certain interventions like epidurals and fetal monitoring, some C-sections could be avoided. Most C-sections are done because obstetricians truly believe they are the safest option in that individual case, but I suspect that sometimes those decisions are subtly influenced by a fear of lawsuits and the doctor’s need to be able to show the court that he did everything possible to avoid a poor outcome for the baby. Some doctors are apparently inducing labor and performing C-sections on request for patient preference or so-called designer births. I personally consider that appalling.
Hospitals have tried to involve the family and offer home-like birthing suites, but they are still perceived as insensitive to the needs and wants of their patients. (I suspect that a few people have unreasonable wants and can never be really satisfied.) Birth has become overly medicalized and overly expensive. Again, the American legal system must bear part of the blame. No doctor wants to be on that witness stand explaining why he didn’t do an ultrasound or use a fetal monitor. Malpractice insurance is so exorbitant that it has led a lot of doctors to stop doing obstetrics.
The movie dealt more with feelings and opinions, and didn’t talk much about evidence from controlled studies. There are many unanswered questions about how to achieve the best outcomes for babies and mothers. If you don’t think doctors are constantly trying to reassess and improve their methods, just read any obstetric journal. When I was an intern, episiotomies were standard practice. I was chastised for not doing an episiotomy on one patient, a multigravida who begged me not to do one and who really didn’t need one. Now routine episiotomies are no longer recommended. Not because women complained, but because controlled scientific studies re-examined the outcomes. We stopped shaving the perineum and giving enemas a long time ago. Maybe we will stop delivering our patients in a supine position – but only when evidence clearly shows a safer option.
The whole home birth thing was entirely too touchy-feely to suit me. I got the feeling that if the woman had to pee during labor, the midwife might go along and hold her hand and tell her what a good job of peeing she was doing and ask her to notice how relaxed and empty her bladder felt now. Some women delivered under water, which doesn’t make a bit of sense to me. I personally wouldn’t want my home invaded, a tub set up in the living room, a bloody mess in my house, and my toddler watching. That’s a matter of personal taste, I suppose.
They kept harping on empowerment, and made it seem like a woman had to endure great pain so she could feel she’d accomplished something so wonderful that now she knew she could do anything. This is unnecessary. We can provide good pain relief during labor with minimal risk to the baby, and I see no reason to have women screaming “I can’t stand this!” with a midwife telling her she has to tough it out. Despite their protestations, I wasn’t convinced that the midwives’ attitude was kinder to their patients than my obstetricians who made my labors and deliveries almost pain-free.
They interviewed a man who said monkeys reject their babies when they have C-sections, and that C-sections and other hospital births are preventing babies and mothers from bonding, making them bring babies into the world “without the love” produced by the surge of oxytocin. A woman who required an emergency C-section implied that she felt like a failure and said that it had prevented her from bonding with her baby. This is pernicious nonsense. Human mothers bond perfectly well with their babies after C-sections, and there is no evidence for any emotional harm. I think there is more likely to be emotional harm from the attitudes fostered by the movie.
Obstetricians may tend to get bored with typical routine deliveries, and they may have to rush off to the clinic or surgery; midwives see routine deliveries as their raison d’etre, and they can usually stay and talk. Midwives are wonderful. I’ve worked with them and I’d love to see them attend most routine deliveries. But not at home.
Home births scare me witless, because I’ve seen a normal delivery turn to disaster in a heartbeat. As one doctor says in the movie, a woman can hemorrhage and bleed out in a matter of minutes. In one scene in the movie, a home birth is interrupted in mid-dilation because the baby is breech and premature, and there is a mad rush to the hospital in a taxi, with the mother screaming “My water broke!” and “I can’t take another contraction like that in this taxi!”
In a recent discussion on the Quackwatch Healthfraud discussion list, we heard personal stories of ideal home births with qualified midwives, assistants, oxygen at hand, and planned backup within a few minutes’ reach. We also heard about a disaster with a prolonged labor, a midwife who rejected the family’s and assistant’s requests to transfer to a hospital, a floppy blue baby, and the father’s conviction that his son would not have cerebral palsy if he had been born in a hospital.
Normal birth is not a medical problem, but it can turn into a life-threatening medical problem with no advance warning. Published safety statistics for home births are pretty good, but their validity has been questioned. Safety is going to vary with training, patient selection, and circumstances like geographical constraints. Comparisons are problematic. There is undeniably a small risk. The perception of the size of that risk and its acceptability boils down to personal attitudes and risk-taking behaviors.
Highly-paid obstetrical expertise is not needed for most births. There is no reason well-trained, well-equipped midwives could not deliver babies at home for those who prefer it and are willing to accept the small risk. There is also no reason midwives could not deliver most babies within the hospital in a patient-friendly homelike environment with expert emergency backup right next door. That would be the best of both worlds.
Optimum outcome for the health of mother and child is a science-based goal that can seek evidence to support every detail of practice. That doesn’t preclude an additional non-science-based goal: patient satisfaction, with personal attention to the feelings of the patient and leeway for individual preferences that don’t interfere with outcome.
We need to do more science, we need to listen to our patients, and we need to be open to suggestions from midwives. But that’s what good doctors do anyway.
This article was originally published in the Science-Based Medicine Blog.