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Controversy Over Home Birth Safety: What Is Really the Problem?

By HERWriter
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Controversy Over Home Birth Safety: What Is the  Real Problem? Halfpoint/Fotolia

Dr. Amy Tuteur published an article in the Opinion section of the New York Times on April 30, 2016, decrying the practice of home birth in the United States.

Tuteur was an OB/GYN for several years before becoming a writer. She is no longer a practicing physician, but manages a blog called Skeptical OB where she discusses birth practices, parenting choices and medical care.

In her recent article, Tuteur asserts that “childbirth is inherently dangerous.”

Her opinion is directly in contrast with much of the recent research published surrounding birth, including statements and statistics published by the CDC promoting midwife-attended, minimal intervention births. The CDC says that such birthing situations result in the best health outcomes for both infants and mothers. (3,4)

According to the CDC, midwife-attended, minimal intervention births can have better results than highly medicalized approaches based on the assumption that birth is an unnatural pathological event .(3,4)

The CDC reported that “in 2009, there were 29,650 home births in the United States (representing 0.72% of births), the highest level since data on this item began to be collected in 1989.It is estimated that 1 in every 90 births is done at home, mostly to non hispanic white women. (4)

In her editorial, Tuteur makes the case that home birth in the United States is unsafe. She reviewed infant mortality outcomes for various health providers and birth settings. She evaluated nurse-midwives and direct entry-midwives in a home or in the hospital.

Direct entry-midwives are also called lay midwives. They are birth professionals who typically receive their credentials and experience through apprenticeships and independent studies.

According to her research, infant death rate for home deliveries is about seven times higher than that of a hospital birth with a midwife.

She blames this disparity on incompetency of lay midwives. Lay midwives are the professionals who attend a majority of home births across the nation

Tuteur calls for an abolition of lay midwife participation as a solution to this problem. She believes that direct-entry midwives are not equipped to handle anything besides “normal” birth and that they don’t transfer clients who are in distress to a hospital setting early enough.

There are a few problems with her argument:

1) At no point in her article does Tuteur mention the factors that we know have much more significant impact on maternal and infant morbidity/mortality. Some of those are poverty, discrimination, education, insurance coverage, access to care (including prenatal) and community support.

Health care in the United States is rife with disparities, and low-income women of color are FAR more likely to experience complications and death in pregnancy. This is a hugely significant issue, but it's not incorporated into Tuteur’s account.

2) Tuteur neglects to compare the rates of mortality in home birth to births attended by OBs in a hospital. She only compares them to births attended by midwives in the hospital.

Similar studies that have attempted to compare safety of birth settings in other countries such as the Netherlands and Canada look at three groups of women — those who have planned to deliver at home with a midwife, in a hospital with a midwife, and in a hospital with a physician.

There are very few studies that compare these different groups in the United States, as birth certificate information is the main source for this data and reporting requirements vary from state to state. Tuteur should have made it clear that she was drawing conclusions without a full set of information.

3) Tuteur does not account for maternal mortality rates which are different than, but not separate from, infant mortality rates.

Recent studies and statements from public health groups like the CDC and WHO, physicians groups like ACOG and AAP, and nursing professionals like MANA agree that the midwife model of care and prevention of unnecessary medical interventions allow women to experience lower rates of morbidity and mortality. (5)

Statements from each of these groups align in their call for better-coordinated care and recognition of disparities in access, based on socioeconomic status, geographic location and state policies related to health care. (7)

Tuteur’s solution to the higher rate of infant death in home births is to ban lay midwives from practicing, a decree that elicited immediate and angry responses from birth experts around the country.

Many people wrote in to the New York Times to express alternative views and provide references that point to alternative outcomes. NYT published an assortment of these responses one week after the original was posted.

These people — midwives, nurses, anesthesiologists, doulas, and even other OBs — refuted her assertion on the grounds that it is an over-simplified statement of the problem.

They protested that banishing an entire group of professionals, in this case lay midwives, will PREVENT women from accessing high-quality care and from maintaining their voice in the process.

They stated that It will not result in lower rates of infant or maternal mortality.

They declared that it will not align with the research which demonstrates that coordinated, collaborative, client-centered approaches to caring for families during pregnancy is the best scenario.

Instead, we should be building a health care system that encourages ALL professionals to obtain certification that meets high-quality standards and practice evidence-based care.

I deeply support the discussion that has arisen out of this controversy. It is a conversation that needs to happen!

As a birth worker who is always looking for best evidence-based practices and highest standards of care for families, I believe careful scrutiny of data is critical.

We have struggled, and continue to fight, for women to have access to health care choices that fit their needs.

The last thing that reproductive justice advocates should be prescribing is limitations on a woman’s options for birthing.

It is only by working together and without judgment that we can ensure that people receive the care they should have, regardless of where they plan to deliver their children.

Let’s keep these conversations going, but let’s not point fingers of blame where they are not deserved.

Reviewed May 26, 2016
by Michele Blacksberg RN
Edited by Jody Smith

1) Original article by Amy Tuteur- “Why is American Home Birth So Dangerous.” New York Times. Website accessed: 5/2/16.

2) “Home birth with midwife just as safe as hospital.” The Star. Website accessed: 5/10/16.

3) “Midwife-led continuity models vs. other models of care for childbearing women.” Cochrane Database of Systematic Reviews. Website accessed: 5/10/16.

4) “Home Births in the US, 1990-2009.” National Center for Health Statistics. CDC. Website accessed: 5/10/16.

5) “Outcomes of Care for 16,924 Planned Home Births in the United States.” Journal of Midwifery and Women’s Health. Website accessed: 5/11/16.

6) “Study ties home births to higher infant death rates.” Web MD: Health and Pregnancy News. Website accessed: 5/11/16.

7) “Joint Statement of Practice Relations Between Obstetrician-Gynecologists and Certified Nurse-Midwives/Certified Midwives.” ACOG and ACNM. Website Accessed 5/20/16.

Add a Comment3 Comments

EmpowHER Guest

Dr. Amy is a blogger who spends enormous about of time and energy on bashing people and their views. She is part of the establishment. She downgrades people who embrace new trends and studies that are proven to work. Childbirth and choosing what/where to have that baby is up to the mother to be. Her views or the highway is how she works. And yet she will banish anyone on her blog who does not share her views. This, will be her downfall herself. She is vindictive!! A bot working to divorce people with their views from the medical leviathan. I would NOT recommend her as a viable source of info unless you risk getting chewed out by her and her followers on HER blog.

November 23, 2016 - 7:51pm
EmpowHER Guest

Yes, it is true that the leading causes of preventable bad birth outcomes are poverty and lack of access to care. However, the women in the USA who choose home birth tend to be relatively privileged! Approximately 90% of women who deliver at home with a midwife are white and approximately 90% are married, as per CDC figures. They are also less likely to have serious preexisting health problems, because women with known issues usually choose hospital care.

However, despite the fact that women who birth at home are healthier beforehand, they have worse outcomes. Much worse. The only possible explanation is that lay midwives do not provide good care.

Women deserve real health care, not lies. Poor health care is the opposite of empowering.

May 27, 2016 - 1:51pm
EmpowHER Guest

"Instead, we should be building a health care system that encourages ALL professionals to obtain certification that meets high-quality standards and practice evidence-based care."
So, you agree with doctor Dr. Amy. CPM's do not, by any measures , meet high-quality standards. Rather than saying essentially the same thing, but with a hug attached, how about forwarding pathways for lay midwives to obtain the certifications that lead to high-quality care? Nobody thinks these women are un-teachable or uninterested in the well being of mothers...a critique of competency is not a critique of character. Keep it simple: If these women want to support healthy birth in alternative settings, earn the nessesary credentails.

May 27, 2016 - 1:36pm
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