Buried inside this week’s issue of New York magazine lies an inflammatory article called “Extreme Birth”. The article tracks a very well known midwife in New York, Cara Muhlhahn, who stared in The Business of Being Born. While the author diligently attempts to remain impartial, there are several issues with the rhetorical techniques she employs.
If you read the article carefully, it contends that Muhlhahn irresponsibly engages in high-risk home births because she is an ideologue. I do not know her personally and have only met her casually on a few occasions, such as the screening of The Business of Being Born. So I do not know what her protocols are or if they constitute irresponsible midwifery.
What I can say, from reading the article, is that it fails to dig deeply to address the fundamental issues that is raises:
1. When does the clinical data point to home birth as being the safest protocol leading to the best health outcomes?
2. When is an intervention needed and how successful are midwives in detecting this in such a way that a safe transfer happens and a successful birth occurs
3. What are the infant mortality rates of different populations –
a. Low risk mothers who start with a home-birth protocol
b. Low risk mothers who start with a conventional hospital birth protocol
c. High risk mothers who start with a home-birth protocol
d. High risk mothers who start with a conventional hospital birth protocol
I would be much more interested to see how the data stacks up to the practices of both OBs and midwives, including Muhlhahn, so that as a patient I can make better choices about the care I seek.
Long before the Business of Being Born was produced, Tara was working in a population that demanded home births, and this was not a hippie granola anti-establishment population as described in the article. A more accurate description would be a highly educated, highly proactive population, comfortable with making health decisions based upon their own evaluations. This is the same population that over-indexes for the purchase of generic drugs over brand names because they understand that they are paying for an active ingredient and not packaging.
And while the Business of Being Born may be one-sided, so to is the data. For low risk pregnancies, home birth leads to starkly better outcomes.
Now perhaps Muhlhahn does not practice like a typical midwife, as the article proclaims. But again, the issue is whether or not her patients are providing informed consent, and the operative word here being “informed.” If mothers are armed with the clinical data and choose to pursue a home birth when they are breech or as a VBAC, I do not see anything different than if I agree to take a drug that has such side effects such as:
Abdominal cramps, allergic rash, bloating, blood clots, breakthrough bleeding and spotting, breast secretions, change in menstrual flow, changes in the breast such as tenderness or enlargement, dark pigmentation of the skin, decreased milk production in nursing mothers, depression, emotional instability, gallbladder disease, headaches, heart attack, high blood pressure, intolerance to contact lenses, liver disease, liver tumors, migraine headaches, missed periods, nausea, problems with the ring, sinus inflammation, stroke, swelling, temporary infertility after discontinuing NuvaRing, upper respiratory tract infections, vaginal inflammation or discharge, vision problems, vomiting, weight gain or loss, yeast infections…
What drug is this? NuvaRing. And these are the “common” side effects. I wonder what the uncommon ones are. What are the incidences of these side effects: Hell if I know and I bet none of the people taking this drug know either. Is that informed consent?
So the question at hand, is whether or not having a breech birth at home constitutes informed consent or really, criminal irresponsibility and malpractice. How are the risks represented?
Call me a radical libertarian, but I like to think that I have the right to make informed choices about the health of myself and my unborn child. As a country, we are not going to mandate that everyone make health choices that optimize outcomes based upon the current clinical data. No we are not that draconian. And we have permission to do all sorts of things that have different risks to our health. If I know the risks are high, I still may choose to have a breech home birth. But do people making these choices know what the risks are? This is what the article raises; this is an interesting topic.
Well, what does the clinical data say?
An article was published in British Medical Journal*
in which 5418 home births were tracked in North America. The study finds that “among the 80 planned breeches at home there were two deaths and none among the 13 sets of twins.”
While the sample size was small, death in 1 in 40 births is quite high. I for one, would not feel comfortable pursuing a home birth under such circumstances. Were the parents pursuing these births aware of the risks? How were the risks represented?
The real issue, is about how such choices are made. How much is rooted in an ideological world-view versus data on outcomes. Patients and practitioners are often making decisions poorly. Practitioners, both in the hospital, and in the home-birth community, are making choices that perhaps are not simply based on data. And certainly most patients are making their health decisions “in collaboration with their health practitioner” not based upon data.
So why does this happen? Why do we choose to badly? Well there are lots of reasons, including simple cognitive biases like “anchoring” as described by Tversky and Khaneman.
Unfortunately, the article blurs its critique of Muhlhahn as a birth practitioner, and the home birth movement. This is a grave mistake and no different than if I found a wildly radical or even incompetent medical doctor and used this to dismiss the entire conventional medical community. And the article misses the most essential point, whether related to birth or any other event that may require some medical intervention. That most choices are ill-informed.