The Perils of Skiing, the Value of Broccoli, and an Atypically Splenetic Rant from the Usually More Measured Jamie

When I spoke to those college students early last month about childbirth, I used an analogy that occurred to me during the Winter Olympics: I said that hospital birth is like ski-jumping and homebirth is like cross-country skiing. Ski-jumping is more dramatic than other events -- there are ambulances standing by for a reason. Cross-country skiing has its own risks. It's unusually hard work, and you could have a heart attack and die on the trail. But out there in the stillness some of us find an extraordinary beauty. A significant consideration, of course, is that in childbirth you've got a passenger along for the ride, dependent on you for protection. Your decisions matter, because we're talking about the potential for injury to or death of a baby. But I think most people hear "homebirth" and imagine ski-jumping solo, with no helmet and no EMTs, when it simply isn't like that. In both events you've got skis on your feet and you're heading to the finish line. But when you deliver a baby at home, the spiral of interventions that too frequently culminates in an emergency surgical delivery just doesn't get started. Why am I talking about skiing in April? Because Amie sent me a link to a blogging neonatologist's post on homebirth and I am frustrated. A few different MDs weighed in, asserting that homebirth is not safe, that last year's BMJ study was homebirth propaganda, that the problematic August 2002 Journal of Obstetrics and Gynecology study (critiqued here with additional links at the bottom of the page) was a landmark in homebirth research. My references were discounted (can't trust those Cochrane reviewers, you know); my requests for citations in support of dubious contentions have thus far been ignored. Which leads me, inexorably, to thoughts of broccoli. Let me explain. If you're an MD, you can probably diagnose cancer and prescribe narcotics. You can most likely explain whether a fluoxetine metabolite is psychoactive and how the Krebs cycle works. And hey -- more power to you. Somebody has to understand the Krebs cycle and it certainly isn't going to be me. If I were seized by a masked gunman who said, "Quick! Explain the Krebs cycle or I'll shoot!" -- well, tell my boys I loved them, folks, 'cause that's the end for me. But your MD degree doesn't qualify you to pronounce infallibly on the relative desirability of comparably safe options. Those decisions belong to patients. If you are skimming along here, thinking, "...skiing? ...broccoli? ...what?" this is the part where you need to pay attention. As far as I know, and I am not an expert but a curious layperson, there is no valid research to support the idea that hospital birth is safer than planned birth at home for low-risk women. If you have a full-term vertex baby and a qualified attendant, you won't increase your odds of a good outcome by going to the hospital. You will increase your odds of a surgical delivery, a cut or lacerated perineum, and a whole lot of hassle initiating breastfeeding, but probably that's not a constellation of facts the hospital's marketing department would choose to emphasize. I've heard a number of doctors say they're personally uncomfortable with homebirth. And that's fine by me: I would never suggest that anyone have a homebirth unless she's comfortable with the idea. But the doctors who say, "I'm an MD and no one should give birth at home" -- well, that's like saying, "I'm an MD and broccoli is icky." You're welcome to dislike broccoli. Maybe it gives you gas, or maybe you overcook it to drab sliminess every time because you get distracted thinking about the beauties of the Krebs cycle. Under certain circumstances broccoli can be indisputably icky -- or even dangerous, if you chop it up on the unwashed cutting board you just used for raw chicken. But an unqualified pronouncement that people who care about their families' health eat cabbage, and not broccoli, is ridiculous. When an MD says, "Homebirth is not safe," I'm skeptical. (Also irritated, but you probably figured that out by now.) When an epidemiologist says, "My analysis of a large number of homebirths leads me to conclude that..." -- then I'm all ears. That's exactly what happened with last year's BMJ study of homebirth safety (which confirmed that planned attended homebirth is a safe option for low-risk women and their full-term babies), and yet a commenter described it as pure propaganda passed off on an unsuspecting public as science. Ah, yes, the mighty homebirth lobby in action. Probably the entire BMJ editorial board quakes in its shoes at the thought of the powerful CPM contingent...or not.... I went back and forth a few times with one particular doctor, and our exchange left me highly exasperated. For one thing, she disagrees with me that homebirth can offer advantages to babies. But is it really best for babies when their mothers are pressured to use physiologically unsound positions (supine or lithotomy) for second-stage labor? Are routine pitocin augmentation and AROM good for babies? She disagrees that obstetric management can affect breastfeeding, though she offers no references to dispute the extensive bibliography of Kroeger and Smith. Most reprehensibly, she states in her final comment that fetal death is a feature of natural childbirth, not obstetrically managed childbirth. Maybe she works at the Fantasy Island Medical Center, where obstetric interventions have only benefits and no risks. But here in the real world, where I happen to live and give birth to my babies, there are unexplained IUFDs in the hospital as well as at home. There are HCPs who make mistakes in the hospital as well as at home. And, most troublingly, there are HCPs who do their level best to help babies arrive safely and still find themselves facing a bad outcome. It happens -- guess what? -- in the hospital as well as at home. To imply that good obstetricians don't see stillbirths is to demonstrate unbridled optimism -- or perhaps unbridled hubris. I was noodling around her website trying to find out more about her perspective, and came across this information on episiotomy: Episiotomy is one of the simplest and most common procedures performed in obstetrics today and, remarkably, one of the most controversial. It is difficult to understand why it is so controversial when you understand how and why an episiotomy is done. Episiotomy is designed to prevent uncontrolled, jagged tears during delivery.... Lately it has become fashionable for women to refuse episiotomy. There may be no harm in refusing an episiotomy, but it's important to understand that the consequences may very well include even more stitches and more postpartum discomfort than an episiotomy may cause. ...um...ooookaaay, maybe I shouldn't be holding my breath for references. Longtime readers will know, I hope, that I am not a commando homebirther. If either of my two homebirth attendants had said, "Jamie, we have to go to the hospital," I would have said, "Car or ambulance? Tell me more on the way." I have never intimated that homebirth is the best or purest or only right way to deliver a baby. But if I live to be a hundred, with the intervening 65 years crammed full of new and joyful experiences, I am certain that the days my sons were born into my living room floor will remain two of the four or five finest days of my life -- days when I was brimming with gladness at being alive in a woman's body, at being a mother to my boys. I am saddened that so few women in this country have the option of a legally attended homebirth. But! I have just learned from the good doctors that this is the viewpoint of a selfish woman preoccupied with having "an experience" at the expense of her baby's safety, and that I should have gone to dinner and a movie if I wanted "an experience" and bypassed the whole pregnancy/birth/motherhood thing. The things you learn in med school, I tell you. So these are my questions, gentle readers: one, should I call my confessor for an appointment tonight or can it wait until morning? Two, should homebirthing women be held to a higher standard with regard to informed consent? (By which I mean, if most women laboring in hospitals don't know that the shot of Nubain they gratefully accept can impede a baby's subsequent respiratory effort, should a woman at home be expected to be more conversant with the literature?) Three, Dr. Amy assures me she has a list of references as long as her arm to demonstrate the hazards of planned attended homebirth by low-risk women -- does this mean she is an amputee or just a person with unusually short arms? Four, would you consider a homebirth yourself, and why or why not? Talk to me. Regularly scheduled rant- and sarcasm-free blogging will resume shortly.