How did American birth become so controversial? A response to Dr. Amy Tuteur

It started as just another article that neighbors cut out and slip into my mailbox, or that comes up in small talk, “Oh, you’re a midwife, did you see the Times?”  Two weeks ago, the New York Times published an opinion piece by vocal opponent of home birth, Dr. Amy Tuteur.  It was followed up with a series of letters from readers, including a joint response from the presidents of ACNM and ACOG.  In the interim, the Washington Post also published Tuteur on a separate topic, the guilt and shame women sometimes feel after an unexpectedly complicated birth. Tuteur published a book on the topic last month.

As I tried to formulate a response to my neighbors and loved ones, I found myself wondering not, “Why is American Home Birth So Dangerous?” but rather, “How did American Birth Become So Controversial?”  After all, it should go without saying that each of us in the field is dedicated to preserving safety, regardless of the letters after our names or the setting in which we work.  But Tuteur expresses confidence that certain midwives are habitually reckless in their care of laboring women and newborns.  Even without getting into the muddy question of how she interprets the available research on these issues, which has been disputed elsewhere, her perspective and proposals are problematic.

The bulk of her argument is a critique of certified professional midwives, or CPMs, with focus on how their training and certification requirements differ from certified nurse-midwives (CNM) and obstetrician physicians (DO/MD).  I can’t claim to know why every woman who chooses CPM care does so, but I know from experience that, for some, it is to escape the medical system.  Physicians and nurse-midwives, regardless of our personal intentions, are part of a system fraught with medical errors and iatrogenic harm.  Obstetrics has a terrible record, from thalidomide to DES and beyond, of subjecting women and babies to interventions without considering the long-term effects. It’s not hard to imagine why a family may not want that as their child’s first experience of life outside the womb.

In her letter to the Times, the president of ACNM, Ginger Breedlove, cited the U.S. Midwifery Education, Regulation and Association work group.  The group is a joint effort of every major US midwifery organization, including CPMs, working actively to improve compliance with international standards and unify the profession.  With that in mind, we ought to move on from scapegoating or even “abolishing” the CPM, and consider what we, as part of the medical system, can improve.

Let us start by disposing of the notion that to be “an expert in normal birth” is somehow meaningless.  Yes, taxi drivers have handled uncomplicated birth, but the role of a midwife is larger than catching the baby.  Assessing maternal and fetal status throughout pregnancy, labor, and birth requires an intimate understanding of what normal looks like.  Tuteur neglects to realize that a responsible provider not only intervenes when complications arise, but must also avoid disruption of healthy processes.  Frequent cervical exams can cause infection in an otherwise normal labor, but an experienced midwife can read a woman’s progress by simply observing her.  Choosing to augment rather than accepting the normal ebb and flow of early labor can increase fetal distress and risk for cesarean.  Imagine how traumatic it could be to perform resuscitative measures on a baby who is already transitioning well.  Knowing normal is essential.

Tuteur summarizes her remaining proposal thus: “keep women at increased risk of complications from giving birth at home; insist on transfer to a hospital at the first hint of potential problems; and require that midwives have hospital privileges.” I suggest we look deeper into the issue of why women and midwives stay home, even when risk factors are present.

Hospitals and hospital-based practitioners must revisit how high-risk women are treated.  We must offer thorough counseling at every stage of care, enabling shared responsibility for all decisions or procedures.  This includes informed consent, but also informed refusal.  We should be certain that restrictions and routines are in place to protect safety, not just convenience.  In the Washington Post, Tuteur writes, “Birth is beautiful, no matter the room or the lighting or the drug regimen.”  I’ll agree with that.  But there are physiologic benefits to laboring in a quiet space with dim lighting and minimal disruption, so we should provide these things when they don’t compromise safety.

High-risk pregnancies do require additional monitoring and intervention, but hospitals could do much more to preserve the atmosphere of birth, even in the operating room.  If we can do that, fewer women will opt out of hospitals.

It is undeniable, however, that low-risk pregnancies can culminate in high-risk births, and carefully selected home birth candidates may require transfer.  In the US, I have seen such women met with disdain and judgment from hospital staff.  In contrast, I met a Canadian physician at a conference once who explained the process where he worked.  A midwife attending a labor at home would call into the hospital and give a quick report, and the patient information would be added to the board alongside all the admitted patients.  This served to facilitate more rapid care in cases of emergency, but also served to demystify home birth.  Rather than seeing only the cases that required transfer, it raised awareness of all the successful, uncomplicated cases as well.  This transparent, collaborative practice is exactly how we manage labors at the birth center where I currently practice, and it works well.  While I imagine there could be liability concerns if this were expanded to include home birth, it is worth consideration, for safety’s sake.

Finally, the issue of midwife admitting privileges is more complicated than Tuteur implies.  Hospitals and midwives must navigate the complex health care system that includes malpractice, reimbursement, risk management and beyond.  For these reasons, many state laws and hospital regulations currently restrict or prohibit admitting privileges for midwives, even those who practice exclusively in-hospital.  If we are truly to integrate the system of maternity care, these restrictions must be lifted.

Dr. Amy Tuteur has previously compared home birth to home appendectomy, implying that a patient’s hope for either is not only unsafe, but absurd.  Therein lies the basic failure of her perspective.  Appendectomy is the surgical removal of a diseased organ.  Framing birth in that manner is baseless and will inevitably lead to unjust abuses against women and children.  We must abandon the false assumption underlying all of her writing: that “healthy baby, healthy mother” justifies or even requires depersonalizing birth.  We can respect women and keep them safe simultaneously.  In fact, it is our professional obligation.

Amanda Alba is a Certified Nurse Midwife at the North Shore Birth Center