This is part 2 of our conversation with Skekptical OB, Dr. Amy Tuteur. Be sure to read Part 1 before you start reading this post.
DrAmy: I think it’s an enormous red flag and something that American women need to know about.
The Midwives Alliance of North America, as I said, is the trade organization that represents home birth midwives. They were the ones that collaborated with Johnson and Davis on that BMJ 2005 study. They gave them all the data for the year 2000, and after that study was finished, MANA continued collecting statistics, and has collected statistics to this day.
They are currently sitting on the largest single repository of American home births ever assembled. They have, by their own publicly stated numbers, they have in the range of 20,ooo+ home births. Over the years, in their publications and press releases, they kept promising that this data was going to be released and that it was going to show that home birth with a Certified Professional Midwife was safe.
It was due to be released in 2008; well, first it was going to be released any minute, but nobody could ever get it. Then they said they’d be all done collecting it in 2008, but even before that, they started offering the statistics publicly. According to the midwifery newsletters, you could get access to the statistics if you could prove that you would use it for the benefit for home birth midwifery. They have an elaborate application process, and you have to show who you are, and who you work with, and what you’re going to do with it…
Colin: and whether or not your name is Dr. Amy Tuteur
DrAmy: Yeah, well, I haven’t applied, but you can’t make it any more plain than they made it – you have to use it for the benefit of midwifery. Not for the benefit of patients, by the way, for the benefit of midwifery.
Colin: Has anybody leaked the data to you, have you seen it?
DrAmy: The icing on the cake of that whole thing is that once you’re approved to get the data, the last step is that you have to sign a confidentiality agreement with legal penalties if you let anyone else see the data.
Colin: So, you can’t answer my question…
DrAmy: I haven’t seen it, but I don’t think it takes a rocket scientist to figure out what’s in that data is pretty solid evidence that home birth increases the rate of neonatal death, and that’s why they can’t let it out. They’re pretty up front about the fact that they got it and nobody else can see it. In fact, they invoked something, and you have to give them points for cleverness, they announced that, in retrospect, they’ve decided that this is for “community-based research”.
Community-based research, typically, when that’s used is to get members of the community, the study subjects, to buy into the study. You tell people, for example, that you want to collect their DNA, but you’re not going to use it in any way that will harm them, and that’s why people come forward and be volunteers. But, you don’t ask the doctors. You don’t set it up so that it protects the researchers. You’re supposed to set it up so that it protects the subjects, but they say right in their own publication that they have a responsibility to the midwifery community to make sure that the data is used in ways that the midwifery community would approve of.
JohnP: There’s a lot of anecdotal discussion on blogs and board that have to do with home birth. One thing that is often is brought up is someone will say, “Well, my midwife has done a thousand births and never had a complication.” In your career as an OB, how many births do you think you attended?
DrAmy: Thousands. In OB, when I did a residency, I probably did 20, 30, 40 deliveries a week… for years. You see a massive number. This is the benefit of working in a hospital setting, even when I didn’t do the delivery myself, any interesting case was presented, so you learn a lot more than what you personally see. During the period of time that I was in training, my hospital probably did 30, 40, 50,000 deliveries. Anything that went wrong, or anything that was unusual, I knew about, I learned about it. So, you have an experience that cannot be captured in any other way.
Colin: Did you have home birth transfers? Did you see any issues with those?
DrAmy: Yes. Of course, if somebody transfers there’s always an issue. Home birth midwives are not licensed in Massachusetts and so anybody can call themselves a home birth midwife, and believe me, anybody did. I met people who announced that they were midwives after they had gone to eight births, and other women hired them.
They’re really completely misrepresenting their experience. They don’t even have a tiny fraction of the experience that Certified Nurse Midwives have. Certified Nurse Midwives, some of them, not many, some of them do home births, and they have better statistics on home birth than Direct Entry Midwives. Although, their home birth statistics show that they have double the neonatal mortality at home than they do when they’re working in the hospital. Which only stands to reason because obstetrics is basically preventive medicine. You know about a whole bunch of things that can go wrong, and you don’t want them to go wrong. And if they do go wrong, you want to make sure you know about it so that you can minimize the consequences. An emergency can happen from one second to the next.
I know that all obstetricians say that, and so it sounds kind of cliche, but it’s really really true. I always say that some people drive race cars for excitement and other people deliver babies…
JohnP: Could you give us an example of a situation where something could suddenly or unexpectedly happen that you would need to have training to deal with?
Colin: …A worst case scenario.
DrAmy: There are two major things that they have trouble with at home birth. One is fetal distress, all of a sudden the baby’s heart rate goes down and won’t come back up, and that baby needs to be delivered immediately. It can happen. Usually you have some warning, but every now and then, some baby, for whatever reason the bottom drops out and you need to deliver that baby immediately. In the hospital, you can do a C-section in 10 minutes, but at home, the average transfer time to the hospital is 45 minutes, and that’s before you even get anywhere in the hospital. So, you have serious fetal distress at home and that baby is going to die.
The other thing is that there are babies who are born who need an expert neonatal resuscitation with an incubation. Say there’s a shoulder dystocia, the baby gets stuck. The head comes out, but the shoulder gets stuck. And then it’s a long time before the rest of the body gets delivered. That baby can be really compromised by the time it’s delivered. Without an expert who has training in neonatal resuscitation and has done it many times, and by training I mean somebody who hasn’t just read it in a book or did it on a plastic doll, unless somebody has had training and has equipment and knows how to use it, the baby will die. It’s just that simple. If any of those kind of things go wrong, there’s just no way that the baby will make it to the hospital.
In the Wax study, the deaths that occurred in the home birth group are all related to things like that. The excess deaths are from what they call anoxic injuries when the baby, either for fetal distress or for whatever reasons isn’t getting enough oxygen, and therefore dies.
Colin: I wanted to ask you about more alternative birthing experiences. They seem like they’re more and more out there…
JohnP: Water birth!
Colin: Water birth would be the first one that I wanted to ask about. What is the deal with water birth?
Elyse: Women are crazy about water birth. I know women who are like, “I want to get pregnant just so I can have a water birth.”
DrAmy: I think water births are great for whales and dolphins.
Colin: It’s not natural for humans to have birth in water?
DrAmy: That’s the funny thing about alternative health. It’s supposed to be so natural, and then they do all this stuff that is not natural. For example, what’s so natural about acupuncture? How did that end up in alternative health? Steel needles?
It’s the same thing with water birth. Water birth has existed for 200 years. It was made up by somebody in Russia. Primates aren’t supposed to be born in water. It’s very simple.
Elyse: You mean, we didn’t blow up kiddie pools in the caves?
DrAmy: What’s even worse is that the explanations that are evoked as to why water birth should be safe are complete and utter bologna. One of the things that water birth proponents say is that when the baby is delivered, the baby won’t breathe because of the diving reflex. There is such a thing as the diving reflex. Most higher mammals have a diving reflex. When they’re immersed in very cold water, their heart rate slows down, they won’t gasp or do anything for a while… but ultimately they’ll drown. The diving reflex is elicited by cold water, and the whole thing about water birth is that it’s done in warm water, so it can’t even elicit the diving reflex.
So, that’s a bunch of baloney. If the baby is going to suck in water, it’s going to suck in water, and nothing’s going to stop it. The fact of the matter is that inside the uterus the baby has breathing movements. That’s how the baby’s lung develops. The baby sucks in amniotic fluid and pushes it out again. If there’s not enough amniotic fluid, the baby’s lungs will not develop properly. So the idea that babies don’t inspire, and won’t inspire until you bring them up in the air… that’s just baloney. That’s not true. It’s not surprising that babies have died at water birth because they have sucked in a lung-full of water, which is, by the way, toilet water…
Elyse: It’s filled with blood and poo right?
DrAmy: Exactly. Somebody did a study of what’s in the water at water birth, and it’s appalling. It’s basically toilet water. So, if a baby gets a lung-full of that, that’s bad news. The baby can get pneumonia and die from that. And the other thing is, even if the baby doesn’t suck the water in it’s lungs, if it swallows enough water (because babies are so tiny and because the water is fresh water and doesn’t have electrolytes in it) they will get hyponatremia, their electrolyte concentrations will drop so profoundly that they will die just from that. There are have been a number of water birth deaths related to that.
There are some women who say that laboring in water is very relaxing for them, and laboring in water is fine. Just don’t delivery the baby under water because… would you drop the baby in a toilet when you delivered it?
Elyse: I would, but I don’t really like my kids very much. I’m not a very good Mom.
DrAmy: All you have to do is think about it. What’s in that water? It can’t possibly be that good.
Colin: NO! I don’t want to think about it.
One of my friends had a lotus birth recently. I want to respect their decisions, but it seems really… different.
DrAmy: First of all, one of the things about the competition about child birth is that everybody is trying to one up everyone else. This happens in various areas: somebody says “I had a birth at the hospital”, and somebody else says “I had a better birth because I had a midwife”, and then somebody else says “I didn’t even go to the hospital. I had a home birth”.
The thing with the placenta and the cord is that it used to be “oh, my husband cut the cord”. That was the trump card that you could play at the playground. Then it became, “Oh, we waited to cut the cord so that all the blood could be transferred to the baby”. Now it’s, “We didn’t even cut the cord. We waited for it to rot off.”
Elyse: OH MY GOD!
DrAmy: That’s what they do! They don’t cut the cord, and they carry the baby around with the placenta attached. The reason that they call it “lotus birth” is because the placenta is like a flower, so beautiful.
Elyse: If you go to the hospital, it’s a bio-hazard, right? You can’t even leave with it from the delivery room.
DrAmy: Right. It is a bio-hazard.
Let’s go back to square one. Is it natural? Do you see any other animals with newborns dragging their placenta around? I haven’t seen that. So, it’s completely unnatural. It’s an incredible infection hazard for the baby because it’s dead. The placenta comes out, the blood leaves it – it’s dead. So, now you have this giant dead thing hanging off the baby. You just have to hope that it’s not going to get infected and make the baby really sick or kill it.
There’s a whole lot of that because there’s not only lotus birth; the new thing is unassisted birth. DIY Birth. Don’t have anybody there. That’s just a disaster waiting to happen.
In the area of pain relief, the progression is “I didn’t have an epidural”. And there’s people who say “Well, I didn’t have an epidural, but I didn’t even have any pain. My labor was painless”. And then there are the people who say “Not only was my labor painless, but I had an orgasm when the baby was born”.
Colin: OH NO! That’s not right!!!
DrAmy: Yes. YES!
So, if you step back, you can see the competitiveness of the whole thing. It’s very unfortunate. Saying that you had an orgasm during birth, that’s not going to hurt anybody; if you want to say that, go ahead and say that.
Elyse: It’s going to really really upset your child when they see you wrote it on the internet in fifteen years.
DrAmy: I can only imagine what’s going to happen down the road when people see this. It speaks much more about the competitive nature of mothers than it says anything about child birth. It has nothing to do with child birth; it’s about beating other mothers over the head about what a good mother you are.
Elyse: I’ve gotten into a lot of trouble. I wrote a post on skepchick about the things that pregnant women don’t tell you. I wrote about pooping during child birth, and that your genitals swell, and that you get kicked in the cervix. I got just angry angry responses that I would dare talk about such a thing. I got a lot of angry letters from dads.
I’ve seen the posts in the natural parenting boards that they’re talking about how I don’t understand what a beautiful experience child birth is, and that I’m mourning my birth experience. I just want to say that I’m perfectly happy with my over-medicalized “big pharma” hospital births.
DrAmy: There’s an unbelievable amount of “ostentatious sadness”. They’re always sad for you what a terrible birth you had. People write to my blog all the time and say, “You’re a horrible, terrible person. You must have had four c-sections”. Well, I didn’t. And, “Oh, you must have never had a child birth without anesthesia”. Well, actually, I had a couple of those. They just imagine that anybody who doesn’t make the choices they made are deficient in some way.
Elyse: For me, it was even that I dared say it was unpleasant. People accused me of sterilizing the human race with a blog post. Honestly, that would be an amazing accomplishment, and I kind of wish I did just to say that I did it!
DrAmy: If you think about it… it’ in the bible. It was so incredibly impressive, the agony that child birth is, and that is what it is… agony. There are some people who have easy labors, but they are few and far between. The rest of the people aren’t faking. They are screaming their heads off for a reason. It really really really really hurts. That was so impressive to the ancients that they decided it must be a punishment from god, otherwise how do you explain something so dreadful?
So, they have people turn around now and say, “Oh, it’s just fear that makes it painful.”
Elyse: No, it’s the contractions!
DrAmy: It’s just that baby’s head that makes it painful.
Colin: Do you have any advice for mothers who have decided to do a natural birth and are worried about the pain? Is there any evidence for hypnotism or lamaze?
DrAmy: I always told my patients, “Have an open mind”. Child birth is the only thing where people tell you to decide not to get pain medication before you feel the pain. That doesn’t make sense to me because shouldn’t you know how painful it is before you decide whether or not you’re going to need anything for pain relief? But, people make up their minds and say “I’m not going to have anything. I’m going to try hypno-birthing.”
Most of that stuff does not work. The only thing that works is an epidural. Some things help people. Some people find that the water is soothing. Other people hate it. Some people say that hypno-birthing works for them, but for most women it doesn’t work.
Colin: What about the idea of standing up? They say that lying down makes things harder for women.
DrAmy: There’s really no evidence of that either. If you think about it, if gravity were necessary to have a baby, babies would be falling on the floor all the time, every time a woman stood up. If only! If only standing up made your labor easier.
Which is not to say that you shouldn’t stand up. If you feel comfortable standing up, go ahead and do it. You should labor in whatever position makes you feel comfortable. But, the idea that moving around or standing up is somehow going to make your labor better or shorter… if only!
Colin: Let’s talk about some of the accusations that the alternative birthing advocates make that kind of ring true to me, or at least make me think twice. The first one is that doctors schedule c-sections out of convenience because they don’t want to be there all night long waiting on a baby to be squeezed out. Or that they schedule c-sections for reasons of profit, rather than safety.
DrAmy: In most places where doctors work for health organizations, they don’t make any more money by doing a c-section, and c-section rates are just as high in those places. In fact, if you look at systems like Canada or the UK, where the doctors are all on salary, they have skyrocketing c-sections too. So, it clearly is not the profit motive.
Do some people schedule things for their own convenience? I don’t think there’s any question over that, but I think more commonly women schedule c-sections for their own convenience. My feeling is that a c-section or an induction, those are medical procedures and they should be used for medical indications. And that’s actually what The American College for Obstetrics and Gynecologists says too. You need a medical reason, and convenience is not a medical reason.
Colin: What about the accusation that epidurals and pitocin have a cascading effect, or a domino effect? That one causes the other causes the other, and now… oops, you have a c-section?
Elyse: It’s not that the pitocin or the epidural end up with requiring a c-section, but now that you’ve gotten one intervention, your doctor thinks you now want a c-section.
DrAmy: It certainly can happen like that, but most women who get epidurals don’t get c-sections.
Does it increase your risk? There are big studies that say it doesn’t. What people don’t realize is that epidural is a technique. It depends on how much medication is put in it, and how often medication is put in it, and how often it’s refilled, or whether it’s done continuously. I do think those things have an impact on how labor goes, but you can change them. If somebody has no feeling when it’s time to push, you can turn down the epidural so they can get the feeling back. I always discuss that with my patients beforehand, if you’re not going to make progress with this epidural, we’ll talk about turning it down and you’ll get some of the pain back, but you’ll be able to push better. Those things can have an impact, but you can change the impact.
I will be the first person to say that the c-section rate is completely out of control. There’s absolutely no medical justification for a 33% c-section rate. But what’s driving it is for a large part the medical legal climate. People expect to get a perfect baby, and if they don’t get a perfect baby, they expect that it must be somebody’s fault and that somebody should have to pay for it. And when you’re the obstetrician and you’re looking at a monitor strip and you say, “Well, I don’t know. This baby could be doing OK, but there are some signs that are worrisome to me.” There are no downsides of doing a c-section because the obstetricians primary job is to present a healthy baby to a healthy mother, and a c-section is usually a guaranteed way of accomplishing that.
Colin: I want to ask you about birthing centers. I feel like they’re a good compromise for people who want the comfort of a home but don’t want to feel like they’re in a hospital.
Elyse: But with access to a hospital.
Colin: Right. They have access right there to a hospital but they feel like they’re at home. Are you down with birthing centers?
DrAmy: They have a good safety record. They have an excellent safety record. One of the things about birth centers or CNMs, they are very up to date on research on what is really going on, and what could happen, and they have real concrete plans on how to handle emergencies. The problem with home birth in the US is that they’re all about not having any plans. It’s about trusting birth. When you trust birth and don’t make any plans, the potential for disaster exists. Birth centers, they are a homey atmosphere, they’re much less technological, but the bottom line is that they don’t completely trust birth. They know that things can go wrong and they’re prepared when things do go wrong.
Colin: Thank you so much, Dr. Amy, for speaking with us!