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The Wax Home Birth Meta-Analysis: An Outsider’s Critique

October 23rd, 2012 by avatar

Today’s post is a fascinating interview that took place between Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth and Kyoung Suk Lee, PhD, MPH, RN, APRN. Rebecca asked Dr. Lee to provide a review of the Wax Home Birth Meta-Analysis, as an “unbiased outsider”, but highly skilled researcher.  Dr. Lee’s comments and critique are fascinating and provided me with many further thoughts.  Please enjoy Rebecca’s interview and share your comments. – SM

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http://www.flickr.com/photos/eyeliam/7353095052/

Shortly after starting my website, www.evidencebasedbirth.com, I had several people ask me if I could write an article about the research evidence on home birth. However, I was hesitant to do so for several reasons. Mainly, I was worried that I could not look at the evidence in an objective manner. My husband and I had recently chosen a home birth for our second child. I was worried that it would be difficult to objectively examine the research evidence on home birth, given my personal experience. The blogosphere is full of people who are strongly pro-home birth or anti-home birth, and their evaluations of the evidence are usually written through the lens of their own biases. I didn’t want to add to the plethora of biased articles already out there.

Then I had a sudden burst of inspiration. What if I asked one of my colleagues—who has no biases about childbirth—to review the home birth literature for me? In particular, I wanted to find someone who could review the Wax home birth meta-analysis (Wax, Lucas et al. 2010) and give me a fair assessment of its scientific value.

I chose the Wax meta-analysis for this review because in 2011, the American Congress of Obstetricians and Gynecologists emphasized the results of the Wax study in its official statement on home birth. Their statement said: “Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth.”(ACOG, 2011)

Dr. Kyoung Suk Lee, PhD, MPH, RN, APRN

It did not take me long to figure out who I would ask to review the Wax study. Dr. Kyoung Suk Lee is considered by her colleagues to be a rising star in the field of cardiovascular research. She recently graduated with a PhD in Nursing, and she just accepted a job at a research university. People who work with Dr. Lee say that she is extremely intelligent, hard-working, and a future leader in her field. Dr. Lee’s expertise has been recognized with research awards from the Heart Failure Society of America, the Society for Heart-Brain Medicine, and the Cleveland Clinic Heart-Brain Institute, among others. She has published her work in nursing and cardiology journals. Furthermore, I knew that Dr. Lee did not have any biases about childbirth, home birth, or hospital birth. I asked Dr. Lee if she would be willing to review the Wax meta-analysis for me, and she kindly agreed.

What follows is my interview of her about the study and its results (RD in bold, KSL unbolded).

Do you have any biases or conflicts of interest related to home or hospital birth?

I do not have any biases related to home or hospital birth.

Could you summarize the methods and results of the Wax study?

The purpose of this meta-analysis was to compare maternal and neonatal outcomes between planned home-and hospital-births.

Using an electronic database search and bibliography search, the authors retrieved 237 articles and included 12 articles in their meta-analyses. Of 12 articles included, 3 were conducted after 2000 while 9 were conducted before 2000. Of 12 articles, 2 were conducted in the US (one was a retrospective design) while 10 were conducted outside US.

Women in the planned home birth group had better maternal outcomes than women in the planned hospital group. They had fewer interventions such as epidurals and episiotomies, and lower morbidity (infection, 3rd or 4th degree lacerations, hemorrhages, and retained placenta). There were no differences in cord prolapse between the two groups.

For neonatal outcomes, babies born to women in the planned home birth group were less likely to experience prematurity and low birth weight. However, babies born to women in the planned home birth group were more likely to experience neonatal death compared to women in hospital birth.

What is the difference between neonatal and perinatal mortality? What does this have to do with the results?

Based on the definitions given by the authors, neonatal mortality was defined as “death of live born child within 28 days of birth.” This is a subset of an overall outcome– perinatal mortality, which was defined as “stillbirth (of at least 20 weeks or 500g) or death of live born child within 28 days of birth.”

According to the authors, there were no differences in perinatal death (the overall outcome) between planned home birth and hospital birth groups. However, homebirth was associated with 2 times higher risk for neonatal death (the subset of deaths occurring 28 days after birth) in all infants and 3 times higher risk for neonatal death in infants who did not have any congenital birth defects.

Interestingly, if you look at page 243.e3, the authors did a sensitivity analysis. In this analysis, they excluded the studies that had home births that were not attended by certified midwives or certified nurse midwives. In this analysis, they found that there were no differences in neonatal deaths between the home birth and hospital birth groups. This means that in the studies in which midwives with certification of some kind attended home births, the outcomes were the same except there was no increase in the neonatal death rate. In my opinion, we have to pay attention to results of sensitivity analyses because this allows us to see the results based on studies which were definitely known to be eligible or clearly described their methods and outcomes.

What is your opinion on the scientific rigor of this meta-analysis?

One thing that was strange to me is the odds ratios (ORs) in the tables. For example, in table 2, under morbidity, the percentages of infection between home births and hospital births were 0.7 vs. 2.6 (its OR was 0.27) while percentages of perineal laceration were 42.7 vs. 37.1 (its OR was 0.66). To a researcher, these numbers don’t make sense.

Many of the studies included were older (half of the studies were conducted more than 20 years ago) so results may not reflect the current practice at home births or hospital births.

The authors did not provide detailed information on how they evaluated the quality of studies included, although they cited a paper describing the method of study evaluation. This makes it difficult if not impossible to determine whether the studies they included were of good or poor quality.

The authors mentioned that women with high risks would prefer hospital births so that it would expect that home births have better outcomes than hospital births in some maternal and neonatal outcomes. If this was a concern, I wonder why the authors didn’t just focus on only the studies that used matching methods, in order to minimize confounding factors.

What is the difference between relative risk and absolute risk, and how does that apply to women who want to have a home birth?

Absolute risk is the probability of something occurring. They may be expressed as percentages or ratios. For example, neonatal mortality rate in the United States is 2.01 per 1,000 live births. This is .201 percent (2.01/1000 = .201/100).

http://www.flickr.com/photos/mikeporcenaluk/3789756395/

Relative risk is a comparison between different risk levels, such as the neonatal mortality rate of home birth compared to the neonatal mortality rate of hospital birth. The researchers found that there was a higher relative risk in neonatal mortality at home births compared to hospital births, but the overall absolute risk for both was small.

How can women know whether the Wax study results would be applicable to their own individual situation?

Meta analysis is one way to generalize findings from different studies. However, women and clinicians should interpret these results cautiously because the studies included were very different from one another and some of the studies included may not have been of good quality. Also, it would be important to note that the overall neonatal death rate that they report reflects home births that were attended by midwives as well as those that may not have had any kind of certified midwife present.

Because this study seems to have some flaws, the conclusion is tentative. I do not know if this article has any implications for pregnant women.

What do you think is the value of asking someone with no conflicts of interest to evaluate controversial research? Does Dr. Lee’s even-handed critique make you view the results of this study any differently? How do you feel about Dr Lee’s conclusion that the study’s results are tentative, and that the Wax study might not have any implications for pregnant women? Please share your thoughts and comments with other readers.

References

(2011). “ACOG Committee Opinion No. 476: Planned home birth.” Obstetrics and gynecology 117(2 Pt 1): 425-428.

Wax, J. R., F. L. Lucas, et al. (2010). “Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis.” Am J Obstet Gynecol 203(3): 243 e241-248.

About Rebecca Dekker

Rebecca Dekker, PhD, RN, APRN, is an Assistant Professor of Nursing at a research-intensive university and author of www.evidencebasedbirth.com. Rebecca’s vision is to promote evidence-based birth practices among consumers and clinicians worldwide. She publishes summaries of birth evidence using a Question and Answer style.

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Consider the Source: A new voice for maternity care reform, J.D. Kleinke

March 14th, 2011 by avatar

I get a particular kind of delight when I learn about someone who is willing to speak out about U.S. maternity care and yet isn’t the typical stakeholder. You might know the type I’m talking about: not a midwife or a doctor or an activist for any agenda, not someone who was harmed or transformed by their birth, not a spokesperson for a particular agency or professional society – just someone willing to look at our system, intelligently analyze its shortcomings, and be bold about how we could transform it into a system that reliably delivers humane, high-quality care.

A few months ago, I was introduced to J.D. Kleinke. It didn’t take me much time on Google to figure out that J.D. is exactly this kind of non-stakeholder. Turns out he’s a non-stakeholder with tremendous insight and influence. A health economist and health IT pioneer, he’s well known in health care reform and technology circles. He’s also an accomplished and prolific writer, with two health economics text books and articles in just about every major health care publication under his belt. But none of those publications has taken on maternity care specifically – until now.  And instead of writing a health economics text, he’s delivered a drama-packed, beautifully crafted novel, Catching Babies, published this month by Fourth Chapter Books. (Disclosure: I received a complimentary review copy.) I know the readers of this blog will be interested in the book. Even more so, I think you’ll be eager to hear more from this new voice for maternity care system reform.

Fortunately, there are plenty of opportunities to do so. J.D. will be making the rounds on the blogs this week – visiting The Unnecesarean, Birthing Beautiful Ideas, Birth Sense, and Mom’s Tinfoil Hat to discuss the themes in his book and the lessons it holds for “real life”. And next week, J.D. and I will be tackling the issues on stage together at the Health 2.0 conference. Watch for tweets, blogs and videos coming out of that meeting.

Let’s kick things off with an interview.

Amy Romano: J.D., in the author’s note at the beginning of Catching Babies, you say that you set out to write a non-fiction collection of case studies addressing conflicts and controversies in the field of women’s health. Instead, you ended up writing a novel about the personal and professional drama of a cadre of ob-gyn residents near the end of their training. How did this process unfold?

J.D. Kleinke: I was living among a group of OB/GYNs as they were going through their residency, right when the non-fiction rudiments of Catching Babies were coming together in my mind. As with many residents in any specialty, they would talk incessantly about their workloads, especially about their weirder cases. As they did, I could not help but notice that the most dramatic and interesting elements of each story were not the specific clinical details, but the emotional reactions of the physicians themselves. Fascination, revulsion, contempt, pathos, cynicism, wonder, ridicule, dread. The wide variety and raw intensity of their responses to what they were dealing with in the hospital every day were often counter-intuitive, sometimes shocking to me, and I noticed how these reactions started to pattern around the personalities and family histories of the physicians themselves. Some OBs tended to respond to the most emotionally difficult cases with fascination and compassion, others with a cynicism or blitheness that bordered on cruelty. After enough watching and listening, I started to notice a strange binomial distribution among the ones I knew most personally: one group were deeply empathic people making enormous sacrifices – they were what we would call heroes and, in a couple cases, martyrs. Another group were cold, mean, vindictive, really nasty – the sort of people who were plenty smart and technically capable – but I wouldn’t want them delivering my dog’s puppies. Oddest of all, there was no middle ground. This is the exact opposite of the bell curve of personality and temperament you tend to find within almost all other groups of professionals, including most other medical, if not surgical, specialties. And people who tend toward the extremes of heroism and callowness make for good drama!

Amy: Your novel begins during the main characters’ final year of residency and ends after they’ve all dispersed into private practice, fellowships, and other post-residency adventures. Why did you choose this particular time frame for your story?

J.D.: Great question. This precise year is the key inflection point in the life of any physician. It’s the moment of truth for everyone leaving years of school and facing their options out there in the big bad world. You’ve been studying, training, amassing debt, living on subsistence wages, and solidifying your ideals for 12 or more years – and now it’s go-time. And your competing choices are hugely different. Are you going to try to cash in as big as you can? Hunker down and try to advance the field? Try to take your already rarefied skills to the next level? Teach? Agitate? Or are you going to endure still another round of academic medicine to help the poor and desperate patients who stream without end into your teaching hospital? This is also the inflection point for doctors personally. Many have been postponing marriage, their own pregnancies, homeownership – in short, all the hallmarks of “growing up” – well into their 30s. And most of the OB/GYNs I’ve observed personally were hellbent on playing catch-up, often making terrible decisions and compromises in the process. This is also ripe for great drama: smart people with some of the most profoundly adult responsibilities in society who are, in a way, still arrested adolescents, thanks to 12 or more years of intense schooling and training.

Amy: One of your characters is an ob-gyn who wants to collaborate with home birth midwives to better integrate care during transfers. Just last month, ACOG released a new Committee Opinion that urges the development of integrated systems to optimize home birth outcomes. What do you see as the major opportunities or barriers when it comes to realizing the vision of integrated systems of care across birth settings?

J.D.: Let the record show – I thought of it first and I have drafts from Catching Babies going back to 2003 to prove it! Actually, it’s an idea whose time has been a long time coming. There is a groundswell of demand among American women to deliver at home – thanks in part to the hair-trigger interventions and often brutalizing processes I portray in Catching Babies – but thanks also to the same ethos emerging around the country regarding green energy, vegetarianism, organic food, recycling, local food sourcing, and generally trying to live a less toxic, less industrialized life – an enormous collective backlash against the technocratization of society. There is a growing number of women who believe that the traditional maternity care system has pathologized childbirth, and they want no part of it. Right or wrong, this is what they believe. There is, therefore, not just an opportunity, but an enormous responsibility for all of us to find ways to cope with their flight to homebirths, because homebirths are going to happen whether we like it or not. The barriers of course are enormous: medical, organizational, financial, legal, even criminal in some situations. Why? Because all elements of what is essentially not a health care system, but is really an “illness care system,” are elemental to the system for profound reasons, most of them ultimately economic. And they will not go away without an especially good fight because, in the home birth setting, the simple fact of the matter is that babies will die – a small number of babies who would not otherwise die had they been delivered in the hospitals, a few feet away from ventilators and the NICU. These cases are of course extreme outliers, as are those babies who die during delivery in the hospital. But we have a better safe than sorry system and culture, and that’s why homebirth will always be fighting a steep uphill battle. I am also just as aware of the thousands of other suboptimal birth outcomes of babies who are rushed through to delivery in the hospital who would have been just fine delivering at home. Unfortunately, the loudest sirens in our society – the lawyers, reporters, and politicians – don’t trade in population statistics, they don’t acknowledge trade-offs. They focus on the outlier, the tragedy of that one dead baby delivered at home – and probably would have died from the same problem in a hospital setting. But still, they focus on the reckless midwife, the random disaster that couldn’t have been prevented anyway. The biggest barrier to homebirth is the difficulty recognizing that the collective outcomes profile for homebirth – delivery complications, infection rates, rates of postpartum depression – is definitely different, and perhaps better for the population as a whole, but it will include an occasional travesty that a hospital setting may have avoided. Would the homebirth family have consented that? Will they honor their waiver of their right to sue? Doesn’t matter. There will always be an ambitious reporter, grandstanding local politician, or gutter-crawling attorney ready to re-write everyone’s intentions, and all the facts, when tragedy strikes.

Amy: You have been called “an advocate for a smarter, data-driven, post-partisan health care system.” What might this look like in the context of maternity care?

J.D.: Smarter and data-driven is easy, or at least easier than the “post-partisan” part! As applied to maternity care, a smarter, data-driven system would be fully armed from end-to-end with good clinical decision support systems specific to pregnancy, labor, delivery, and post-partum care. These systems would mobilize accurate, clinically detailed, risk-adjusted normative data about what works and doesn’t work for a very specific type of pregnancy – actually beginning with pre-pregnancy fertility, genomic and family data – and they would be parsable and analyzable up against accurate, clinically detailed, granular data about the pregnancy at hand. Hard as all that sounds to create and implement, we have now have systems like it in the ICU and for several medical specialties. Why not for maternity care? The “post-partisan” part – well, that is actually harder to imagine – because it would run headlong into much bigger problems than health care system problems. Look no further than the mindless screaming about birth control, abortion, gay marriage, or stem cell research, and you’ll realize that maternity care will never be free from the intrusions of partisan politics. This is actually one of the reasons I find the subject so interesting, and one of the reasons I wrote Catching Babies. Women’s health stands at ground zero for the entrenched ideology, zealotry, fear, and unconscious loathing of women’s sexuality that so clearly enrages many of America’s politicians and preachers. It is what drives people who otherwise claim to be “anti-Big Government” into all of our bedrooms, our marriages, and women’s health clinics, and they are not going to be off minding their own business any time soon.

Amy: Let’s close our eyes and imagine a time in the (hopefully not too distant) future when we can declare that the U.S. has achieved the 2020 Vision for a High Quality, High Value Maternity Care System. What was most critical to our success? What role did childbearing women themselves play in the transformation?

J.D.: I’m only a novelist – I don’t know if my imagination is that good! Everything that stands between us and that vision are precisely the same things standing between the rest of the American health care mess and a truly reformed, functional system. Maternity care is American health care in miniature, and fixing one on the most fundamental level is as hard as fixing the other. I suppose this is because, ultimately, the problems shared by the two are exactly the same. With childbirth, its just that much more maddening, because pregancy is not a disease, and yet the illness care system presumes that it is, and treats it like it is, and lo and behold, we end up with bad birth outcomes, many of which stem from nothing more than this erroneous orientation. That orientation is wrong in and of itself, whether it’s heart disease, mental illness, or maternity care, but that’s how the non-system was non-designed decades ago, when hospitals were places you went to die, not get better. Consistent with that tradition, our reimbursement is all wrong: providers are paid for more interventions, not better outcomes. And except in a few closed systems like Kaiser or Intermountain – and for only limited periods of time – we have no access to useful patient information, so many birth providers are either going on what the patient was able to report, or they are flying completely blind. What else? The tort system is a disaster and regardless of its actual direct impact, the perception of the size of this impact is caustic, divisive and counterproductive. And the evidence base for some of the most important things in maternity care is not great, and even where the evidence is great, findings are poorly disseminated or ignored. Certain practices are followed by birth providers for years – like the immediate cutting of the umbilical cord postpartum – when common sense and research has shown that delayed cutting is much better for the baby. Nonetheless, providers still do what they always did – because that’s how they always did it. The best ways to realize the vision you’re asking about is to stop treating maternity care – all medical care actually – like a folk art, arm all providers with better information, measure what they do, and radically realign the payment system to reflect those measurements. All else will fall into place. And to answer your last question, the single best way to make all that happen is to arm pregnant women with the same information. This is 2011 – we have the Internet now – no more excuses for paternalistic decision-making on behalf of passive patients. Patients should be encouraged to research and understand their bodies, pregnancies, birth choices, and intervention decision points – without interference, biases, or pressure from providers. Which brings us back to the home birth issue. This is a grassroots rebellion by women who are seeking to take back precisely this kind of control. Maybe they have over-corrected, if only because they felt so little control inside the traditional system, but their actions speak louder about maternity care in America than I ever could!

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An Interview with Stand and Deliver’s Rixa Freeze, Winner of Lamaze International’s 2009 Media Award

August 13th, 2009 by avatar

Earlier this year, I announced on this blog that, for the first time, bloggers would be eligible for Lamaze International’s Annual Media Award. The Media Award is intended for individuals or organizations shaping the public discourse about natural, safe and healthy choices for childbirth. With blogs and other social media now firmly on the scene, it was clear that restricting our award to “traditional media” would have been looking too narrowly.

Stand and DeliverThe response was tremendous, and we faced a difficult task of choosing from among many wonderful and informative blogs written by mothers, fathers, nurses, childbirth educators, doulas, midwives, and consumer advocates. But one blogger rose to the top. Rixa Freeze, MA, PhD, blogs at Stand and Deliver, and reaches over 30,000 readers a month. Known for her warm, thoughtful tone and expert critical analysis of all things birth- and mothering-related, Rixa has built a strong community of engaged readers who comment often, challenge Rixa and one another, and shape and shift a conversation about birth that very often trickles onto other blogs and online forums and, occasionally, even the mass media. Rixa will receive her award, along with the recipients of Lamaze International’s other prestigious awards (to be announced this Fall), on October 3 at the 2009 Lamaze International Annual Conference in Orlando.

Stand and Deliver, like many pregnancy and parenting blogs, started as a family affair. Rixa launched the blog as a way to explain to her family and friends why she was making certain pregnancy and birth choices, without the emotion involved in sharing these choices with unsupportive loved ones face-to-face. Over time, her blog has evolved to include a wider range of posts: research updates and analysis, guest posts, meditations on birth and mothering, academic essays, critiques of North American obstetric practices, links to blogs and news articles, birth stories, and book reviews. And, of course, updates and pictures of her beautiful family!

Rixa may be best known for her choice to have a planned, unassisted home birth, and later, to complete her doctoral dissertation (PDF) on the modern unassisted childbirth movement, the first analysis of its kind. Let’s be clear – Lamaze International does not endorse unassisted childbirth, and granting the Lamaze Media Award to Rixa should not be considered an endorsement of unassisted childbirth. But we feel that Rixa’s personal and academic journeys to explore the entire range of childbirth choices can help us better understand the practices that facilitate normal physiologic childbirth, and how to humanize childbirth in all settings.

Rixa agreed to answer some interview questions about her blog, her philosophy, and what she would like to see change in our maternity care system. We hope Science & Sensibility readers enjoy hearing from this powerful voice in the birth blogosphere.

Lamaze: Did you have an “a ha” moment about natural birth? How did you come to your beliefs about birth and our maternity care system?

Rixa: During my first year as a PhD student at the University of Iowa, a fellow graduate student had a baby. I had a few conversations with her about her pregnancy and birth. She initially wanted a home birth but was unable to find a midwife. (Direct-entry midwifery is currently illegal in Iowa, and there are very few nurse-midwives who attend home births. I knew next to nothing about midwifery, let alone that direct-entry midwifery was illegal in my state.) So she went with the CNM practice at the university hospital and was very disappointed with her experience there. She asked me if I had ever considered home birth, and I said something to the extent of: “Well, nurse-midwives in a hospital seem like a good idea, but I would NEVER give birth at home!”

Ha.

As it happened, I was also looking for a paper topic for a feminist research seminar I was taking. I decided that writing about home birth midwifery in Iowa would be really interesting, so I started reading. I checked out stacks of books. The first one I read was Peggy Vincent’s memoir Baby Catcher. I still remember the hallway and chair in the library where I read that book. It turned my worldview upside down and inside out. When I started reading, I imagined that when I had a baby I’d go to a hospital, have a nurse-midwife because they spend more time with you and are more personal than physicians, probably have an epidural, and that would be the end of my story. By time I finished the book, I was transformed. I knew deep in my soul that I would birth my babies at home.

Discovering the world of midwifery and home birth changed the way I think about birth. I used to see childbirth as disempowering and degrading. I resented that we as women had to go through such a horrible experience. And I felt that men definitely lucked out. Some of these attitudes came from a passive absorption of cultural images and beliefs about birth. In film, for example, giving birth is always horribly painful–the woman is screaming and sweating and out of control, swearing at her husband, and lying on her back with her legs spread open, exposed to the world. In addition, hearing stories of my own experience of being born certainly had an effect on me. My mom gave birth to me upside-down, strung up from the ceiling by her ankles, only her shoulder blades making contact with the bed. This was not her choice. Her physician believed that giving birth upside down would prevent hemorrhoids. My mother screamed to be let down, to no avail. (And she never had hemorrhoids, either, not with my older sister or any of my other siblings who were born more conventionally.) That was all I knew about birth until my graduate student years.

In a way, naming my blog “Stand and Deliver” brings the story of my own birth full circle. My mother was lain (upside) down and delivered of a baby. When I was in labor, I stood up and delivered both of my babies myself, with full autonomy over my body and my labor.

Lamaze: You have written extensively about both midwife-assisted and unassisted home birth, had an unassisted birth of your own followed by a midwife-assisted home birth for your second child, and for your doctoral dissertation examined the modern unassisted birth movement (PDF). Can you briefly discuss what you think the existence and apparent growth of the unassisted birth movement means for the broader maternity care reform movement?

Rixa: Although some women choose unassisted childbirth (UC) solely out of a desire to have an autonomous, undisturbed birth, many come to it from some sort of previous trauma, fear, or disappointment. Today’s obstetric climate pushes many women into considering alternatives, from birth centers to midwife-attended home birth to unassisted birth. Other women have had disappointing experiences with their home birth midwives–some traumatic, others highly disturbed and controlled–and they conclude that the only way to have a safe and satisfying birth is to have no one there to boss them around. Some women choose UC because all of their local hospitals have banned VBAC and they refuse to have an unnecessary repeat surgery. Whatever one’s perspective on unassisted birth, there is no question that the existence and growth of unassisted birth is, in large part, a vote of no-confidence in our maternity care system. Some women would still have a UC regardless of how many other options were available, but others would hire a midwife or perhaps even have a hospital birth if they felt that they would have control over what happened to them in labor. I was probably in the minority, because I choose an unassisted birth for my first baby. I had never had a traumatic birth experience that left me leery of all birth attendants. I wasn’t fighting for the right to have a VBAC. I choose UC freely, because I felt an intense need for privacy during this pregnancy and birth. I also came to UC from a deep background in midwifery. I had apprenticed with a home birth midwife for a year. I had read hundreds of books about birth. I had attended births in both home and hospital as a doula. I was certified in neonatal resuscitation.

The existence of UC has been used as a political tool to garner support for legalizing home birth midwifery. Advocates of home birth midwives argue that women will continue to choose home birth, and if midwives are not legal, they will choose “riskier” unassisted births rather than going to a hospital. While I’m not enthusiastic about this approach, it does seem to work.

I have mixed feelings about the increasing popularity and visibility of unassisted birth, because it is a choice that should never be made lightly. During the time that I have been following UC communities on internet discussion boards and forums, I have witnessed a trend devaluing education and preparation, dismissing midwives and physicians too quickly, and valuing intuition and the need to “trust birth” over everything else. Unlike other birth choices, unassisted birth carries a lot more responsibility on the parents’ end, as there is no one else there with birth skills or knowledge. I would almost prefer that UC remain invisible and “unpopular,” rather than the somewhat trendy thing it has become on the internet, to be sure that no one makes that choice for the wrong reasons.

Lamaze: You have written a lot about hospitals, and blogged about your experience touring local hospitals while pregnant with your son. What would you like to see change in hospitals? Do you think those changes are likely to happen?

Rixa: At a bare minimum, all hospitals should implement Baby-Friendly and Mother-Friendly protocols. US hospitals have shown remarkably slow progress in adopting the Baby-Friendly Hospital Initiative. It began in 1991 and was introduced in the US in 1997, yet as of July 2009, only 83 hospitals and birth centers have Baby-Friendly status. Contrast this to the 19,000+ facilities around the world that have become Baby-Friendly. Implementation of Mother-Friendly protocols, which share many of the same conclusions as the Six Lamaze Healthy Birth Practices, has been even more sluggish. Surely we can do better!

There is a great deal of resistance to changing institutional protocols, even when those changes would benefit both mother and child. I like to call it institutional inertia. It’s discouraging to see how long it takes for evidence to translate into practice. We’ve known for several decades that the supposed benefits of episiotomies are nonexistent and that they are more harmful than helpful. Still, somewhere around 25% of women still receive them, and almost three-quarters of those women were not asked for their consent before the cut. For example, the first birth I attended as a doula was with an OB who had an 80% episiotomy rate for first-time moms, and a 50% rate for multips. And he saw that as a good thing. At this birth, the mom pushed the baby out too quickly for him to cut an episiotomy–a fortunate thing, given she was a first-time mom and had a heavy epidural–and he told her afterwards in a regretful tone that he didn’t have time to do one. And another thing: this mom was adamant that she did NOT want an episiotomy. Did her OB know that? I don’t know, but I doubt it. Did she know about his episiotomy rate? Nope. Was the OB aware of the vast research showing that episiotomies cause more harm than good? Either he wasn’t aware of the research at all, or he knew about the research and chose to ignore it. I don’t know which of those two scenarios is more disturbing.

Another pressing issue is the widespread ban on VBACs. ICAN recently surveyed all maternity hospitals in the US and found that 49% banned VBAC, either through formal written policies or by a defacto ban (no doctors would do VBACs at that hospital, even though they were not officially banned). With the national cesarean rate at 31.8% and rising, VBAC bans affect a vast number of birthing women. It is unethical for the ACOG to support women’s right to choose elective cesarean section while maintaining policies that are directly responsible for the VBAC ban and the subsequent rise in the national cesarean rate. Cesarean sections are not without a host of risks, and each successive surgery becomes more and more dangerous.

I know this would be nearly impossible to implement in a country where only 2% of women give birth out-of-hospital, but I would love for every hospital-based provider (nurses, midwives, and physicians) to have experience witnessing out-of-hospital births. I think a lot of hospital-based providers would do things differently if they had sufficient exposure to women laboring without all the gadgets and protocols. If you’ve never seen a woman kneeling or squatting or standing up to give birth, you’ll probably stick to what’s comfortable and familiar: the woman lying down with her legs pulled back, her perineum in full view.

I would also love to see hospitals and care providers “giving” (as much as I hate that word, since it’s not really theirs to give in the first place) women more autonomy in their pregnancy and birth care. I personally know women whose OBs have dropped them from care for refusing certain prenatal tests or procedures (such as amniocentesis or prenatal Rhogam) or for making their home birth plans known. I’d guess that many women do not even know they can refuse hospital protocols–they are told they “have” to have IV access, they “cannot” eat or drink during labor, they “have” to have continuous monitoring. If women do not even know they can say no, we have taken away their ability to make crucial decisions about their care, their bodies, and their babies–decisions that may affect them for a lifetime.

Lamaze: Do you think blogs and bloggers have a role influencing the quality and safety of maternity care? If so, how?

Rixa Freeze, MA, PhD

Rixa Freeze, MA, PhD

Rixa: This is a question best answered by my readers! I would hope that I and other birth bloggers have made a difference. I imagine that blogging has helped individual women think more critically about their maternity care and their birth options. I am a little less optimistic that blogging has, or will be able to, dramatically affect maternity care on a systemic level. But who knows? Perhaps our message needs to reach a critical mass and then–wishful thinking here–changes will start occurring rapidly. Think of the impact that Dooce, the mother of all mommy bloggers, will have on birth after she wrote about her empowering natural birth (in three parts: Part 1, Part 2, and Part 3) and enthusiastically endorsed Ricki Lake’s and Abby Epstein’s documentary The Business of Being Born and book Your Best Birth.

Lamaze: Your blog strikes a remarkable balance among personal testimonial, comprehensive and nuanced analysis, sociopolitical commentary, and more light-hearted fare. It’s a balance that I think really resonates with your readers and sets your blog apart from many others. How do you determine this balance? And how do you decide when the personal is personal and when the personal is political (or “blogworthy”)?

Rixa: There’s no formula or pattern I try to follow; it’s how I avoid blogging boredom. I sometimes worry that my personal posts–you know, the everyday stuff like “we went the park and Dio spit up on me 5 times and Zari said something really funny”–are too mundane. But if I didn’t have those things about my everyday life, my blog would become too one-sided, too heavy-handed. What I post also depends on how much computer time I have. Reporting news or sharing interesting links is much faster than writing original essays or critiques. Since the birth of my second child, I’ve had much less free time to blog. I often need to put the computer down and spend more time with my family, especially my husband. My computer time is usually in the evenings once the kids are sleeping, but that’s also the only time my husband and I have to share with just the two of us.

Lamaze: What are some of your favorite posts?

Rixa: In rough chronological order:

Better is not good enough

My hospital rant

I am selfish

Cesarean sections and SUVs

Pregnant women are second-class citizens

Formative words

Is fat a moral failure?

Vision of Unity

10 Responses to ACOG’s statement on home birth

Let’s talk about pain (with links to earlier posts about pain)

On your back, please

More! Better! BirthTrack (TM)!

Mother who have lost children to death

Have patient’s rights undermined obstetrics?

Is brown the new green?

Biodynamism–Body and Soil

Conversation with the ultrasound tech

Working through some conflicted feelings and The root of my worries and midwife’s role at my birth: about hiring a midwife for my second pregnancy after having an unassisted birth

Not staying true to my word…whatever that means

Belly photos

What does giving birth feel like?

Litigation and the obstetric mindset

Burn the male midwife!

And, of course, the birth stories of my daughter (a planned unassisted birth) and my son (a midwife-attended home birth)

As I browsed through my blog to choose these posts, I was struck by the evolution in my writing and thinking. I’m still mostly the same person I was three years ago, but I see a definite maturation in my posts: more nuance, less emotion (although my passion for all things birth & breastfeeding still occasionally escapes), less dogmatism. I’m glad to see these changes; it means I am continuing to evolve as a blogger and as a mother.

Lamaze: What are some of your favorite blogs (birth-related or not)?

Rixa:

Taurus Rising: An Aussie who writes about food, sustainable living, gardening, and occasionally birth stuff

Balance: Chou writes all about food, food, and more food (and is a good friend of mine). She’s currently doing a PhD in food studies. Lots of great recipes and ideas.

Casaubon’s Book: food, peak oil, sustainability, gardening, farming

The Unnecesarean: sharp, sometimes biting, often funny blog about cesareans and VBAC.

Baby Makin(g) Machine: a future mama thinking hard about how she wants to mother

House Fairy: a fierce, honest mama of five

Keyboard Revolutionary: mama of 2, first born by c-section and second a HBAC, I love her birth posts

Feminist Childbirth Studies and The Feminist Breeder always give me things to think about

Nursing Birth and Reality Rounds are both fantastic L&D nurse blogs

The Happy Sad Mama: mother of three children; the first, Charlotte, was stillborn at term

Mom’s Tinfoil Hat: ob-gyn student who trained with midwives in a freestanding birth center before medical school

I am stopping here, otherwise the list will become too long! I have links on my sidebar to the many other fantastic blogs I visit regularly. (I’m still working on updating my breastfeeding links, so keep an eye out for them in the future.)

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