I recently read a great article on Science Based Medicine about acupuncture. Author Ben Kavoussi describes the way acupuncture studies imitate actual scientific inquiry but fail to control for the influences of physiological pain-response:
“Another example of cargo cult science is the plethora of two-arm acupuncture studies that compare a needling regimen using the traditional concepts, and compare it with a non-interventional placebo. These studies might have the appearance of clinical research, but they are inherently flawed and inconclusive, because they do not rule out the possibility that the observed results are mainly due to the painful stimulus and injury caused by a needle, which can occur regardless of the insertion point.”
I commented:
“I’ve often wondered if acupuncture carries the illusion of legitimacy because it’s penetrative in a way that other cam modalities are not.”
I suspect that the cargo cult metaphor would be a great paradigm for examining a variety of dubious alternative medical modalities and why lay people believe in them.
The problem is that in evaluating any alternative medical modality, the apparent intuitive knowledge “other/ancient ways of knowing” gives the impression of legitimacy. It’s the argument from antiquity. The ancient wisdom and spiritual-laden lore of natural, whole, organic ingredients and oils can offer calming, ritualistic alternatives to frightening and painful science-based treatments. Words that sound science-y and equipment that looks medical make some alternative claims very seductive. Add in the confirmation bias of self-limiting diseases, cancers going into spontaneous remission, or copious anecdotal evidence, and it all becomes terribly confusing.
It seems to me that homebirth in the US is often a form of cargo cult medicine. The survival of our species depends on more babies and mothers surviving birth than those who die, so it usually turns out okay no matter where the mother delivers. This feeds right into confirmation bias that homebirth in the US is as safe as hospital birth for low-risk women. The statistics tell a different story:
“While the risk of neonatal death is low overall, it may be higher at home births and that is a problem, said Dr. William Barth, Jr., chair of ACOG's committee on obstetrics practice and chief of the division of maternal-fetal medicine at Massachusetts General Hospital,
‘It's one of those situations where overall the risk is low, but it is increased two to three-fold," he said. "Even though it's a rare outcome, it is a catastrophic outcome. It's preventable in that it is less likely in the hospital.’
Explaining his stance, Barth cites a study presented by researchers from Maine Medical Center at the Society for Maternal-Fetal Medicine meeting in Chicago in early February. The study, a meta analysis of research from around the country comparing home births to hospital births, appeared to show a twofold increase in the rare event of neonatal death at a home births.”
Modern obstectics offers early diagnosis of problems, pain management, and surgical birth in the event of an emergency; however, we’ve all heard our mother’s horror stories about twighlight sleep, forceps, horrific vaginal tearing, and absolute lack of information and consent. Although modern obstetrical care is vastly different than those dark days, legends from that time percolate through the oral histories of women and misinform contemporary mothers. Add to this the fact that some OBs are paternalistic jerks, and I can understand why lots of women flee. Many women, informed by such pop-culture sources as Mothering, seek midwife-assisted homebirth as a way to forcibly avoid any medical intervention during birth. According to the ABC News story I linked above, almost 50,000 home births took place in the US in 2005-2006.
I have previously addressed the ways I think childbirth becomes a litmus for status among a certain type of mothering peer group. I think this is an important phenomenon that adds social pressure to decisions surrounding childbirth. Briefly, mothers share birth stories as a bonding ritual as well as an assessment tool. There seems to be an inverse correlation between status and use of standard medical practices in childbirth, where C-section is the ultimate failure and homebirth is the ultimate ideal:
“The ideology surrounding natural childbirth is so powerful that consenting to medical intervention may lead mothers to deep disappointment and regret. My obstetrician reports that many women are harmed by such attitudes. Instead of experiencing joy at the arrival of a healthy child, they feel as if they have abjectly failed the first litmus test of motherhood. These mothers question every decision: maybe if they had waited at home longer, maybe if they had refused monitoring, maybe if they had refused an IV and so on. They wonder how they can possibly go on to become good mothers. The reality is that unmedicated childbirth can be incredibly difficult. My obstetrician actively supports natural childbirth and anecdotally reports that few natural childbirth patients maintain the calm and focus necessary for unmedicated birth.”
It’s heartbreaking that misinformation, unfair judgement and dogmatic attitudes rob so many women of the joy of birth and make adoptive mothers feel inferior. I have been reading Dr. Amy Tuteur’s various blogs about chilbirth for years. Her primary sources are usually very solid, and most of what I think I know about homebirth in the US comes from her.
Individual midwives obviously fall along a continuum of competency, but here’s the general overview as I understand it. European countries have strict standards for midwife education, licensing and oversight. These midwives follow conservative transfer of care protocols and have reliable emergency transportation. In the US there are basically two types of midwives: Direct-Entry (DEM) also known as Certified Professional Midwife (CPM); and Certified Nurse Midwives (CNM). (Notice how similar the abbreviations CPM and CNM are.)
CNMs are registered nurses who have additional specialized obstetrical and pediatric training. They work in tandem with obstetricians and hospitals. They are supervised and follow a standard of care that attempts to err on the side of caution. They offer alternatives to the medical hospital childbirth experience by providing unmedicated alternatives at birthing centers attached to hospitals. In my mind this is the best of both worlds: it feels homey and cozy, you can bring your lavendar oil and iPod (just like in a hospital), the default mode is natural childbirth if that’s what you want, and yet there are surgeons and emergency equipment down the hall. It’s my understanding that CNMs don’t typically attend homebirths. I did read once about a physicians’ practice in the eastern US that supported homebirth with medical professionals.
A DEM is “A direct-entry midwife is an independent practitioner educated in the discipline of midwifery through self-study, apprenticeship, a midwifery school, or a college- or university-based program distinct from the discipline of nursing. A direct-entry midwife is trained to provide the Midwives Model of Care to healthy women and newborns throughout the childbearing cycle primarily in out-of-hospital settings.” These are the people who usually attend homebirth in the US. They often lack the safety net of OB supervision, transfer of care protocols, and reliable emergency transportation to hospital. But they call themselves midwives, and they appear legitimate. They speak the cloying language of self-empowerment and carry real medical equipment.
Anyone can purchase a “birth kit.” Expectant mothers go to a site like this and buy the kit their midwife recommends. It looks like real medical equipment to me. In fact I saw most of these items when I gave birth in the hospital.
I know several women who had fantastic homebirths and I know a handful of women and children who would not have survived outside of the hospital. Unfortunately when things do go awry, the DEMs are often not equipped to deal with childbirth emergencies. Dr. Tuteur has published many accounts of preventable homebirth death or severe damage that end with the midwife abandoning the family. The Daily Beast ran a recent piece about homebirth nightmares. There’s a story today (10.24) in the Guardian that describes the scene of a hombirth with an independent midwife. I love how the author sets the scene with all the cargo of homebirth:
“We had candles, mood music, a birthing pool. We knew how to breathe. We had massage oils. We were ready. My waters broke at night and I went into labour. My contractions were fierce. I was soon 10cm dilated. The contractions came every 30 seconds, pain grinding down my lower back. I felt I would crack open. My baby did not slip out like the Brazilian woman's. I laboured for 36 hours. There is no describing the agony. The midwife put her hand inside me to turn the head, but still the baby did not come. I didn't want candles or massage or music. I just lay on the bathroom floor and wanted to die.
My husband told me that the midwife had stood in the kitchen at a loss. By midnight on the second night, he insisted we went to hospital. Within three minutes of arriving, I had been given an epidural. Fifteen minutes later, the duty doctor told me that the birth was not progressing and I was exhausted. He would deliver the baby by emergency caesarean.
The independent midwife didn't stay. This would not be a natural birth.”
As a veteran of two Pitocin freight-train births, it’s astonishing to me that women’s bodies don’t just go into shock and start shutting down. I can totally understand the allure of natural childbirth, but I don’t quite understand why women don’t just opt for that in the hospital or birth center where emergency help is a moment away. DEMs carry the cargo of legitimacy, speak of nature and empowerment, and represent themselves as medically competent professionals. I think women are seduced by that.
TIP:
Enter the amount, and click "Tip" to submit!
Nikki Stern
Greg Correll
Amanda Gulledge
marytkelly
Indiana_Joe
Lainey
Salon.com
Comments