On Homebirth

Planning a homebirth in the United States means constantly dealing with medical professionals who think you’re the scientific and moral equivalent of an anti-vaxxer.

I’ve come to the conclusion that while some doctors do take an active interest in the medical literature, others view themselves mainly as technicians. Unfortunately, most seem to fall into the latter category. Not that I blame them for it. With all they do, how can the average doctor be expected to keep up with current research as well? But the very structure of American medicine seems to encourage an over-reliance on the official positions of the various medical associations (even when they differ quite significantly from international medical opinion). “What do I think about homebirth? I don’t know, what does the ACOG say about it?”

Several weeks ago, we were told by one particularly condescending doctor:

I just want healthy babies and healthy mothers. There’s no reason for anyone to die in childbirth anymore and the hospital is really the safest place. You’re taking a big risk.

Uh, no we’re not. Read the literature.

The United States has a 32.2% C-section rate, much higher than medical necessity might dictate (and even higher among poor women of color). While the American College of Obstetricians and Gynecologists (ACOG) discourages homebirth, insisting that “hospitals and birthing centers are the safest setting for birth,” they nevertheless note that “planned home births are associated with fewer maternal interventions, including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, operative vaginal delivery, and cesarean delivery.” (This still hasn’t stopped them from distributing anti-homebirth bumper stickers: Home Deliveries are for Pizza, not Babies.”)

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Both babies and pizzas.

Given the mind-boggling numbers, the statistical possibility of one’s pregnancy ending in a C-section should in itself raise alarm. In addition to the standard risks associated with major abdominal surgery, women who undergo C-section are four times more likely to die from complications during or after childbirth. It is for this reason the World Health Organization (WHO) says the overall C-section rate should not rise above 10-15%.  When rates exceed this level, there is no indication that health outcomes improve. Yet C-section rates continue to climb… and women are dying.

Only about half the states bother to collect data on maternal death and there is no corresponding national effort. The World Health Organization estimates somewhere around 12-28 deaths in the United States per 100,000 mothers—or about 1200 annually. This is an astonishingly high figure for a technologically advanced country; higher than Iran, Turkey, or pre-revolutionary Libya.

Yet numerous studies show that an uncomplicated pregnancy is as safe or even safer at home than in a hospital, where one is much more likely to face medical intervention and its attendant problems.

recent study on planned homebirth indicates a very slightly higher rick of perinatal death compared to in-hospital births but a significantly lower chance of unwanted medical inventions:

Perinatal mortality was higher with planned out-of-hospital birth than with planned in-hospital birth, but the absolute risk of death was low in both settings.

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This study is just the latest installment in a solid body of evidence that out-of-hospital births attended by qualified midwives are a safe option for women with uncomplicated pregnancies. So the argument that hospitals are the “safest setting” is certainly not as obvious as ACOG would like to suggest and the emphasis on risk tends to obscure the fact that, for the vast majority of women, childbirth is a normal physiological process—one for which their body has been well-equipped by the forces of human evolution. The cult of risk strips women of bodily agency. It presents a pregnant woman first of all as an emergency or at least a potential emergency. As City University of New York sociologist Barbara Katz Rothman writes:

Virtually any house can be struck by lightning: Do you care to think of where you live as being ‘low-risk’ for lightning? This is just what contemporary medicine has done to pregnancy. It has distinguished between ‘low-risk’ and ‘high-risk’ pregnancies, with the emphasis always on risk, and then gone on to define an ever-increasing proportion of pregnancies as ‘high-risk.’

Perhaps more than anything else, the obsession with risk is one expression of our deep cultural desire for scientific and technological mastery, for the attainment of absolute certainty over matters of life and limb—even to the point of irrationality and skyrocketing C-section rates. But whether at home or in a hospital, there is no such thing as “risk-free” childbirth. It’s likely there never will be such a thing.

This is not an argument against either hospitals or modern medicine. Hospitals are ideal for medical emergencies and the psychological comfort that provides makes hospital birth a no-brainer for many women. But pregnancy is not an illness. It’s not an emergency. Our midwife knows what she is doing and it’s really getting to be a drag constantly dealing with practitioners clearly less interested in keeping up with the scientific literature than in chastising us for defying the hospital monopoly. 

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Uterine Mysteries

Our daughter is due on March 11th.

It’s a peculiar way to discuss the arrival of a baby: to be “due.” Like a homework assignment. Or a debt. Still, babies are themselves usually reluctant to comply. A mere 4% of children are born on their predicted due date. Whether they come earlier or later, the rest are rebels even before extra-uterine life commences. 20% miss the mark altogether and opt to stay in the womb for at least another week before finally being evicted, which is probably a good thing considering the cognitive benefits demonstrated by children of longer pregnancies.

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Whither shall I wander?

The uterus defies the pretense of schedules, predictions, forecasts, or prophesies. Scientists still don’t know exactly when or how a woman’s body comes to conclude it’s time to eject its infantile occupant. The mysteries of the uterus and its purported powers have troubled scholars for centuries. Few other organs have caused quite as much contention, grief, speculation, and superstition.

As early as 1900 BCE, we learn from Egyptian papyrus that if a woman is “ill in seeing,” her womb is likely starved or dislocated (Not to worry! A poultice of dried human feces and beer froth will clean the problem right up). Other examples describe a range of symptoms the Greeks, more than 1000 years later, would associate with hysteria, after their word for the uterus, ὑστέρα.

In the Timaeus, Plato writes that an “unproductive” womb “gets irritated and fretful” and travels about a woman’s body “generating all sorts of ailments, including potentially fatal problems, if it blocks up the air-channels and makes breathing impossible.” Aristotle concurred and in his Nichomachean Ethics cites the deleterious emotional impact of uterine defiance (especially menstruation) to justify excluding women from politics.

It was Hippocrates, the “Father of Western Medicine,” who first coined the term hysteria. He postulated the theory of the “wandering womb” and suggested the uterus could literally float around a woman’s body causing mischief. To coax it back into place, he recommended sniffing acrid and foul odors.

Aretaeus of Cappadocia, an advocate of Hippocratic principles, described the doctrine’s basic tenets:

In the middle of the flanks of women lies the womb, a female viscous, closely resembling an animal; for it moves itself hither and thither in the flanks, also upwards in a direct line to below the cartilage of the thorax, and also obliquely to the right or to the left, either to the liver or the spleen; and it likewise is subject to prolapsus downwards, and, in a word, it is altogether erratic. It delights, also, in fragrant smells, and advances towards them; and it had an aversion to fetid smells and flees from them; and, on the whole the womb is like an animal within an animal.

And the Roman physician Galen continued his work centuries later:

I have examined many hysterical women, some stuporous, others with anxiety attacks […]: the disease [hysteria] manifests itself with different symptoms, but always refers to the uterus.

The solution? Hellebore, mint, laudanum, belladonna extract, valerian root and other herbal remedies. Marriage also seemed to work wonders, as it frequently resulted in a guaranteed cure: pregnancy and childbirth.

Helen King explains this apparently “pharmacological interpretation” of  “the social processes of marriage and motherhood”:

Not only does intercourse moisten the womb, thus discouraging it from moving elsewhere in the body to seek moisture, but it also agitates the body and thus facilitates the passage of blood within it. Furthermore, childbirth breaks down the flesh throughout the body and, by making extra spaces within which excess blood can rest, reduces the pain caused by the movement of blood between parts of the body. […] Since all disorders of women ultimately result from their soft and spongy flesh and excess blood, all disorders of women may be cured by intercourse and/or childbirth, to which marriage and pregnancy are the necessary precursors.

The myth of female hysteria persisted into the 20th century, making bloody detours along the way through so many inquisitions and witch-burnings. The Aristotelian belief that “the woman is a failed man” found advocates among the Patristic theologians and later in the work of thinkers like Thomas Aquinas. The 17th century English physician William Harvey claimed women were “slaves to their own biology” and described the uterus as “insatiable, ferocious, animal-like.”

Even as late as the Victorian era, women embraced Hippocratic remedies. A sick woman was said to be “womby” or suffering from “wombiness.” To combat this epidemic, it was common practice to carry a bottle of smelling salts with which to tempt the “wandering womb” back to its proper anatomical locale.

Fortunately, modern uteri tend to be rather less troublesome that their unruly predecessors and, by this time next week, a cocktail of hormones will trigger a succession of biological impulses in my partner’s body that will ultimately result in the birth of our daughter. It is a meeting we have anticipated patiently for 40 weeks. Whatever the womb’s mysteries, real or imagined, it’s hard to believe anything might surpass the sheer wonder and anxiety of impending fatherhood. 

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