A few weeks ago Dr. Amy Tuteur wrote an opinion piece about home birth for the New York Times entitled “Why Is American Home Birth So Dangerous?” and the Internet did what it naturally does: exploded with outrage. Inflammatory! Judgmental! Incorrect! I have heard it all, but it’s that last claim that I’m really interested in: are Dr. Tuteur’s claims actually incorrect?
As a bit of background Dr. Amy Tuteur is a divisive figure in the birth community. She is a retired obstetrician who writes as The Skeptical OB and recently authored a book called Push Back, about the natural (sometimes known as “crunchy”) birth movement. Dr. Tuteur’s opinions are frequently controversial, her conclusions are often correct, and her communication style is commonly critiqued as incendiary.
I spent 32 years in the natural birth movement, first as a doula and then as a Certified Professional Midwife (CPM), although I am now retired. I know many people refuse to read a word Dr. Tuteur writes. But might Tuteur have something to say on home birth that is valid? Are those in the natural birth community sticking their heads in the sand about the matters of life and death that Tuteur raised in her OpEd?
Tuteur begins her OpEd by noting that an uncomplicated home birth in Canada and the Netherlands is statistically as safe as giving birth in a hospital. She’s not wrong about that. Many in the natural birth community have used those statistics to make the argument that home birth in the United States should be just as safe.
But it’s not.
Tuteur uses statistics from Oregon, which were published in the New England Journal Of Medicine, as her jumping off point for showing how dangerous home birth is in the U.S. But why does she only use these? Many have asked why she doesn’t she use statistics from the Midwives Alliance of North American (MANA) that are so beloved by many in the natural birth movement. Because the MANA Stats were done so incorrectly as to be considered completely unreliable.
The stats from MANA only included data points from self-reporting midwives, not from the entire profession. They also did not confirm that the self-reported statistics were accurate, so who can believe what they say? And even at that the MANA stats showed increase in death for babies in home births! The neonatal death rate climbs even higher for complicated home births like breech presentations, twins and VBACs.
So why can’t we take the statistics from the Netherlands, the UK and Canada and apply them to the U.S.? Those statistics are absolutely irrelevant here in the U.S. because CPMs in the US do not go through the same rigorous and strenuous training and education as midwives in those countries. When CPMs have hospital privileges, learn pharmacology in school, and a standardized education, only then can we compare those countries’ stats with our own. And I say this as a retired CPM!
Before I go on, I think it’s important to note that there is a difference between a CPM and a Certified Nurse Midwife (CNM). CPMs (what I was) don’t have formal medical training and train by apprenticeship. They are only allowed to catch babies (the word “deliver” is considered taboo for many midwives) outside of a hospital setting and aren’t overseen by a physician. CNMs are registered nurses that also receive training in midwifery. They are required to have a master’s degree, can catch babies in hospitals and birth centers as well as at home in some states and, depending on local laws, may or may not need physician oversight. Many CNMs can also write prescriptions, whereas CPMs can’t.
I have only read three rebuttals so far from the home birth midwifery community. The first was from MANA, which addressed why women in the U.S. choose home birth, it doesn’t actually rebut Tuteur’s statements. I agree with some points in MANA’s rebuttal, the medical model does suck a lot and women do want more autonomy during childbirth, but that doesn’t mean that home birth in the U.S. is as safe as hospital birth. One of Tuteur’s main points in the OpEd is that U.S. CPMs don’t pass muster with the International Confederation of Midwives’ standards for midwives around the world. MANA even concedes in its response that U.S. CPMs don’t meet the minimum standards of what midwives around the world should be providing.
Criminy! This is completely unacceptable.
The second rebuttal comes from Faith Gibson, LM, CPM in California and someone I’ve known for years. Faith fought tirelessly years for a woman’s right to home birth and then for licensing for CPMs in California so, when I saw she’d written a rebuttal, I thought, “Finally! Someone might be able to argue cogently!” But, oh, how very wrong I was.
I was so disappointed to see that Faith resorted to name-calling and pre-school-like taunting. We can disagree, but we don’t need to resort to those tactics. Additionally, Faith claims: “I’ve had more than one delicious fantasy of tying her to a chair and making her watch 48 straight hours of Sponge Bob-Square Pants cartoons.“ This may sound like an attempt at being cute, but many women who choose midwives do-so because they’ve experienced physical trauma. Claiming to want to tie someone up against their will, even in jest, is at best unprofessional and offensive to the women who seek our services because they fear losing their bodily autonomy in birth.
In terms of evidence Faith quite oddly picked statistics from Sweden to use as proof of the safety of home birth. Again, a totally different system of education and midwifery which is all completely irrelevant to the conversation about home birth in the U.S. She then discussed maternity care from the late 1800’s through the 1940s, but that doesn’t address any of Tuteur’s claims.
The final response came from Brilliant Bodies, which is the most frustrating because it included information which is patently false. Their response falsely claimed there is no difference in mortality rates between births attended by CNMs and CPMs. They also falsely claimed that CPMs work with disadvantaged and rural populations, which are to blame for the higher mortality rates. I cannot stress enough that these claims are completely untrue.
The CDC tracked statistics and trends in births from 1990-2012 and the data (the dataset is open to the public) show: “The uptick in home births began in 2004, and, so far, the majority of these have been among non-Hispanic white women.” The CDC also says, “In 2012, 1 in 49 births to non-Hispanic white women were out-of-hospital births.”
One last note from this response is something that really hit a nerve. The response says, “And none of us (including Tuteur) have been through C.P.M [sic] training so we have no right to speak to the quality of the education involved.”
Well, I have been through the CPM training and have every right to say how inadequate it is. So much needs to be done to fix this CPM mess we’re finding ourselves in. There are answers.
Where I disagree with Dr. Tuteur’s OpEd is in how to fix the mess. In her piece Tuteur calls for the CPM designation to be abolished, allowing only CNMs to catch babies outside of the hospital. I don’t think this is the answer. I disagree with this as a viable solution and instead would like to see CPMs brought up to the standards outlined by the International Conference of Midwives.
Some women will always choose to give birth outside of a hospital for reasons that are deeply personal and home birth can and should be safer than it is now. We need to fix the holes, and fix them now.
A version of this post originally appeared on Barbara’s blog The Navelgazing Midwife.