Archives for posts with tag: Home birth

I once led a community service project for which middle schoolers baked cookies to deliver to a local shelter.  We brought out the ingredients and began giving instructions when one kid asked if they could eat some of the cookie dough.  Another kid immediately said eating cookie dough would give everyone salmonella.  Within seconds, we had two camps of shrieking middle schoolers, one with members who had eaten raw cookie dough all their lives and were just fine, and the other with members that insisted that eating raw cookie dough would lead straight to a week-long date with the toilet followed by certain death.

A Google search on the subject breaks into similar camps, from “Rejoice!  you Probably Won’t Get Salmonella from Eating Raw Cookie Dough” to “Eating Raw Cookie Dough Can Actually Be Deadly.”

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In fact, there is a tiny risk of contracting salmonella from eating anything with raw eggs in it, including cookie dough, but that risk is very small, and the risk of dying from salmonella is even smaller.  There is also a risk of choking on raw cookie dough, or having an unexpected allergic reaction to an ingredient, or eating too much of it and having a stomach rupture.  And there is a risk of getting salmonella from other foods, such as meat or salad greens–in fact, almost any food could be contaminated.

All of this is to say that everyone assesses risks differently, and that people can get very upset when others don’t assess risks the same way they do.

Enter home birth.

In the New York Times’ “Is Home Birth Ever a Safe Choice?” risk assessment is on everyone’s mind.  Two obstetricians who specifically address risk come to two very different conclusions.

In “Emergency Care Can Be Too Urgently Needed for Home Births,” John Jennings, the current president of the American Congress of Obstetricians and Gynecologists (ACOG) writes,

When women decide where to give birth, they should understand the potential risks involved with their options….evidence shows that although the overall risk of serious childbirth complications remains low, there is still a twofold to threefold increased risk of neonatal death associated with home birth.

This line is almost verbatim from ACOG’s 2011 Committee Opinion, “Planned Home Birth,” which says that “it respects the right of a woman to make a medically informed decision about delivery,” but goes on to say that the only risk obstetricians are obligated to share is the neonatal death death risk as determined by the Wax study.  The Wax study, a meta-analysis of a number of other studies, was widely criticized for drawing faulty conclusions from flawed methods (see e.g. herehere, and here).

Like OBs Grunebaum and Chervenak, who I critiqued in my previous post, Jennings, a professor at Texas Tech, suggests that hospitals strive for more home-like settings and partner more with nurse midwives (CNMs).  He also suggests working with patients to create “action plans”–aka birth plans.

Texas Tech OBs attend births at the Medical Center Health System’s Center for Women and Infants.  The hospital reports to the Leapfrog Group, which says that they have made progress on reducing episiotomies (current rate is 12.2%,), but have low adherence to clinical guidelines for high risk deliveries, which would seem to negate the purpose of having a high-risk birth at the hospital.  In their favor, they do appear to have one of the lower primary cesarean rates in the state for uncomplicated births at just over 12% (an uncomplicated or low-risk birth is generally defined as a healthy mother with a single, head-down, vertex fetus).

It’s hard to determine much from the website other than that they have a lot of nice rooms and that they appear not to do skin-to-skin contact at birth (the nurse takes the baby for suctioning).  They have a short video that shows a woman on a gurney with a nurse showing her what look like two English muffins on a headphone cord.  There is a long sequence on the Ronald McDonald Room where a towheaded boy eats cookies, and then a segment on “Family Centered Care,” which shows a nurse holding a baby in the hospital nursery.  Despite Jennings’ apparent promotion of CNMs, no midwives are listed as practicing there, and a search for midwives on the site yields nothing.  There is no information about developing or following an “action plan.”

OBs who say that hospitals should provide home-like setting, employ nurse midwives, and honor birth plans might want to begin at the hospitals where they themselves practice.

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Jennings also says, “As obstetrician-gynecologists, our goal with any delivery is a healthy mother and a healthy baby.” It’s not as if mothers’ and midwives’ goal is mothers and babies who are sick or dead. Jennings definition of “healthy” seems to be “alive.”  Superfluous slicing, dicing, and infections are not even noted.

The problem with assessing risk only in terms of neonatal death is that the risk of neonatal death is very small, while the risk of other birth complications is fairly large.  Jennings’ hospital aside, the national cesarean rate for low risk births is 26.9% (the overall rate is 32.7%).  This varies tremendously by hospital, with some achieving rates below 5% while others have rates that are over 80%.

Aaron Caughey, who is chair of the department of obstetrics and gynecology and the associate dean for Women’s Health Research and Policy at Oregon Health and Science University’s School of Medicine, does not assume that the risks in home birth are automatically unacceptable.  Instead he asks, “In Home Birth, What Risk is Acceptable?

In discussing a recent British report about home birth, Caughey acknowledges  “increased C-sections, episiotomies and epidurals as a reason to avoid in-hospital births”  and “[t]he tradeoff of an increased risk of C-section for a small decreased risk in neonatal morbidity and mortality is not worth it for some women.”  He goes on to emphasize neonatal death risks, but says that women should be educated and assess trade-offs for themselves.

Oregon Health and Science University actually does offer some of the options that other OBs said hospitals should provide.  They have midwives on staff attending births, tout their low C-section rates (which actually aren’t that low, but are below 30%), and offer waterbirth and vaginal breech births.  Even though Caughey chairs the department at a hospital with many “home-like” options, he is the most open to the idea that some women might still choose to birth at home.

Obstetricians are the people most likely to see the rare birth disaster, and understandably, such emergencies make an impression.  Because even a low-risk birth can go wrong, many OBs see low-risk home births as risky, and Caughey pretty obviously believes hospital births are the better choice–which is absolutely his prerogative.  At least he doesn’t imply that women who make different choices than he would simply don’t know what they are doing.

Home and hospital births, however, are often compared to each other with little consideration of circumstances.  For instance, home-to-hospital transfer rates for women who have had a previous birth are far lower than they are for women having a first birth–in the largest home birth study done in the United States, transfers were three times more common among first time mothers–22.9%–vs. 7.5 % for women who had birthed before.  As mentioned above, the risk of an unnecessary C-section is very high at some hospitals and almost unheard of at others.  Some hospitals are not even equipped to do on-the-spot emergency cesareans, resulting in bans on vaginal birth after cesarean.  Thus, a woman might want to consider more than just home vs. hospital, but individual circumstances–does her pregnancy have elevated risk?  Does the hospital available to her offer evidence-based care?  What are the skill levels of the various practitioners available at the hospital or at home?

Even the Wax report acknowledges

Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery. These women were less likely to experience lacerations, hemorrhage, and infections. Neonatal outcomes of planned home births revealed less frequent prematurity, low birthweight, and assisted newborn ventilation.

It is presumptuous for obstetricians to offer only neonatal death rates when giving women information about risks of home vs. hospital births. While the risk of neonatal death is a very serious one, it hardly ever happens.  Wax estimates the risk to be about 2/1,000 for home births vs. a little less than 1/1,000 for hospital birth.  On the other hand, a hospital with an 80% cesarean rate for low-risk births would give a woman an 800/1,000 chance of having a cesarean vs around 50/1,000 if she births at home.

Women take the lives of their babies very, very seriously.  It is almost certain that every mother loves her baby more than any obstetrician does.  With accurate facts about all aspects of birth, women are capable of doing their own risk assessments, and they have the right to choose even high risk home births, despite the opinion of you, an obstetrician, or anyone else who doesn’t agree with her choice.

For the record, I have eaten raw cookie dough all my life and am just fine, but you don’t have to have any.  As for the service project, we had bought pasteurized eggs, and all of the kids enjoyed cookie dough to their heart’s content.

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In February, the New York Times ran six short pieces on home birth in its “Room for Debate” online feature.  I am going to discuss each of the pieces in posts over the next few days.

One of the featured pieces is titled “Home Birth is Not Safe,” written by two doctors who have made a number of anti-home-birth contributions to the medical literature.  Their NYT bio line says,

Amos Grunebaum is the director of obstetrics and Frank Chervenak is the obstetrician and gynecologist-in-chief at New York-Presbyterian Hospital, Weill Medical College of Cornell University.

Their work brings up a number of interesting issues to consider about home birth safety, but they also appear to conduct their research with an anti-home-birth agenda–Chervenak has written articles stating that it is unethical for MDs to participate in home births in any way and that it is the professional responsibility of all health workers to forcefully persuade women to birth in hospitals.  All birth data in the United States has limits, but Grunebaum and Chervenak’s use of vital records data to draw sweeping conclusions about home birth outcomes has been broadly criticized (e.g. here, here, and here).

Grunebaum and Chervenak say,

[i]n our research we have found that in the United States at least 30 percent of home births are not low-risk and that two thirds of home births are delivered by midwives who are not properly credentialed.

While I have argued that a woman has the right to birth wherever she chooses, regardless of risk, one might ask why a woman at high risk would choose to give birth at home when she has a hospital as an alternative.  Some women may be compelled to do so for religious reasons (and may not have full control of their choices), but it is also true that some well-educated, well-informed women also make the choice to have high-risk births at home.

Grunebaum and Chervenak acknowledge some of the problems with hospital-based obstetrical care that drive women to seek out home births even when their medical profiles indicate that they may need the kinds of medical interventions that are only available in a hospital-based setting.  They particularly note high numbers of “unnecessary C-sections” and lack of “compassionate care” in hospital births.

They propose as a solution that “the profession [of obstetrics] should strive for home-like hospital births.”

We know from his bio that Chervenak is in charge of the obstetrics unit at NY Presbyterian-Weill Cornell Medical College (NYP-WC).  If women are to shun home birth in favor of hospital birth, a good hospital environment must already be in place.  Let’s take a look at what he and his colleagues are doing to reduce unnecessary C-sections, provide compassionate care, and strive for home-like settings.

New York state now requires hospitals to report certain data, including C-section rates.  NYP-WC’s is 31.6%, a smidge below the national average, but hardly indicative of a culture that is eschewing unnecessary C-sections.  For the last year reported, there were only 38 VBACS at NYP-WC.

NYP-WC’s episiotomy rate is a whopping 25.7%.  Episiotomy is rarely necessary, and this rate is far, far above the home birth rate of under 2%.  According to a 2005 JAMA review by Katherine Hartmann and her colleagues, a national episiotomy rate of less than 15% should be “immediately within reach”–10 years later, NYP-WC is not on board, even though the national rate was already close to 15% by 2010.  Nearby Bellevue Hospital has a rate around 2%.   Compassionate care should not include cutting gashes in women’s vaginas for no reason.

Planned home births are generally attended by midwives.  Both certified professional midwives (who cannot attend hospital births) and certified nurse midwives (who most commonly work in hospitals) subscribe to “The Midwives Model of Care.”  The American College of Nurse Midwives summarizes this philosophy of care on its website–some notable components include:

  • Complete and accurate information to make informed health care decisions
  • Self-determination and active participation in health care decisions
  • Acknowledg[ing] a person’s life experiences and knowledge
  • […] therapeutic use of human presence and skillful communication
  • Watchful waiting and non-intervention in normal processes
  • Appropriate use of interventions and technology for current or potential health problems

Grunebaum and Chervenak brag that “we have a midwife teach our residents at NewYork-Presbyterian.”  However, they do not employ midwives to attend births.  Zero births at NYP-WC are attended by a midwife.  In addition, because they are a teaching hospital, NYP-WC has many births attended by residents whom the woman may not even know.  No one invites complete strangers into their home to attend their births.  Most women who have home births are seeking the Midwives Model of Care, but though Grunebaum and Chervenak acknowledge that CNMs can safely attend hospital births, they choose not to offer this option.

The hospital’s maternity unit has a “Patient and Visitor Guide: During Your Stay” that lays out standard processes and procedures on the unit, gives prospective patients an overview of what to expect, and lays out hospital and maternity unit policies.

The guide begins by saying that the hospital offers “Family Centered Care,” though what this means is not explained other than to say that rooming-in with the baby is encouraged.

They proceed to say that the woman’s care team may involve “your attending obstetrician, who is often your personal obstetrician or the doctor who admitted you, …[and] other medical or surgical specialists, as well as fellows or residents…[and] a pediatrician.”  But that’s just the doctors!  They say that the nursing staff is “constantly present” and indicate that there will be many nurses involved in care.  Other people involved in the hospital birth experience are care coordinators, unit clerks, physician assistants, lactation consultants, social workers, dieticians, nutrition assistants, housekeepers, patient escorts, and volunteers.  There is also a Rapid Response Team for emergencies.

I don’t know about you, but I’m not sure that many people could fit in my house.

The Labor and Delivery Unit is described as “comfortable, family-friendly, [and] private with soothing natural light.”  The birthing rooms are

spacious and light-filled birthing rooms [that] combine comfort with leading-edge technology. All suites are private and equipped with a special multi-positioned birthing bed, as well as state-of-the-art equipment for monitoring and delivering your baby. Your progress will be monitored regularly throughout labor, and your nurses will help you explore which comfort measures work best for you.

My home has a queen sized bed.  The most leading-edge technology in it is my iPhone.

Then we move on to pain management, and the real trouble starts.  Many women choose home birth because they want to be able to access a wide variety of non-pharmacological pain management strategies.  In my research, a frequent complaint from women who were not interested in epidurals was the pressure from hospital staff to have an epidural.  Here is what the guide says about pain management (emphasis mine):

The intensity of discomfort during labor and delivery varies from person to person. Some women may manage well with relaxation and breathing techniques. However, most women choose some type of pain relief. The majority of women receive analgesia (relief from pain without losing consciousness) from an anesthesiologist….The most effective methods for relief of labor pain are regional anesthetics in which medications are placed near the nerves that carry the painful impulses from the uterus and cervix, lessening pain and facilitating your participation in your delivery. Our anesthesiologists commonly use an epidural, spinal, or combined spinal-epidural to minimize pain.

Nothing is mentioned other than relaxation, breathing, and calling the anesthesiologist.  However, in home settings (and even at other hospitals) many women choose “pain relief” from any number of options that do not require an anesthesiologist, such as walking, changing position frequently, sitting on a birth ball, taking a warm shower, or submerging in warm water.  They may also get pain relief assistance from massage or from non-drug-based interventions such as acupuncture.  This is not a complete list.  It should be noted that all of these other options could be made available at home–the only one that could not is the anesthesiologist.  No mention is made of the risks of anesthesia nor of what can be done in the event that the epidural or spinal doesn’t work.  Choosing pain relief does NOT have to mean choosing an epidural–unless you are at this hospital, where according to the state more than 85% of women have epidurals (and that doesn’t include spinals and other medical methods).

Many of NYP-WC’s policies and standard procedures would preclude use of most pain relief options anyway.  Here’s what happens once a women is admitted to her birthing room:

your nurse will assess your blood pressure, pulse, and temperature, and place you on a fetal monitor. The nurse will monitor you throughout your labor and help you explore which comfort measures work best for you. An intravenous line may be placed to give you medication and fluids. You may also receive ice chips to help quench your thirst. Do not eat any food without your physician’s permission.

Not only are these policies not home-like, they aren’t even evidence based:

  • According to the Cochrane Reviews, continuous electronic fetal monitoring (EFM) in low-risk births increases a woman’s risk of an unnecessary C-section. Because the risks-benefits ratios of EFM and intermittent auscultation, in which a health care provider listens to the fetal heart rate with a Doppler or fetoscope at regular intervals, are similar, Cochrane recommends that women be given information and then choose for themselves.
  • IV fluids can also lead to complications, such as too much fluid in the mother or newborn.  In addition, having an IV in place is conducive to starting a cascade of interventions, as having the IV in place makes it easier to begin a Pitocin drip.
  • The Cochrane Review on eating and drinking in labor concludes, “Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications.”

cascade of interventions

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Only two people can be with the woman in labor.  Last I checked, I was allowed to have whoever the heck I want in my house.

The hospital does not allow videorecording of the birth.  At home, you could live stream your birth if you were so inclined.

Rooming in is offered but not required.  Obviously at home, there is no nursery staffed by nurses.  In addition, rooming in is the standard for Baby Friendly Hospitals, as non-medically necessary separations can negatively impact breastfeeding.

One of the things many women appreciate most about their home births is the freedom to move around and to birth in any position they choose.  An acquaintance of mine who had an accidental home birth said that although she hadn’t planned it, she liked the experience, especially because “no one made me get on the little table.”  Another acquaintance said that as she was birthing, her OB asked that she get on her back for each contraction because, the OB said, “that’s the way I prefer to deliver.” Still another friend said that although there was a squat bar available in her birthing room, her OB refused to let her use it and threatened to leave if she would not lie on her back.

Notably, NOTHING is said in the guide about freedom of movement or position during labor or birth.  If a woman is tethered to a monitor and has an epidural, her movement would be curtailed even if hospital policy did not restrict her.

Finally, in the “Patient Responsibilities” section, the guide lists this “responsibility” (all emphasis mine):

Follow the treatment plan recommended by the health care team responsible for your care and the care of your baby. This group may include doctors, nurses, and allied health personnel who are carrying out the coordinated plan of care, implementing your doctor’s orders, and enforcing the applicable Hospital rules and regulations.

In your own home, you make the rules.

If Grunebaum and Chervenak want women to choose their hospital’s maternity care over a home birth, they’ve got a lot of work to do.

Cosmopolitan (really!) has published an amazing interview with Dr. Katharine Morrison, the physician who worked with the abortion provider Dr. Barnett Slepian, who was murdered by “pro life” activist James Kopp in 1998.  She subsequently took over the Buffalo Women’s Clinic where they practiced.  In the intervening years, she developed an interest in homebirth as a women’s rights issue and decided to open a birth center so that her clinic would truly offer comprehensive reproductive services in a woman-centered environment.  It is only the second birth center in the entire state of New York (the other is in Brooklyn).

Unlike many obstetricians who vociferously oppose homebirth, Morrison has actually witnessed homebirths.  And as has happened with other obstetricians who have taken the initiative to learn about homebirth midwives and attend homebirths, she underwent a conversion.  She says that she went to a meeting led by Certified Nurse Midwife (CNM) Eileen Stewart, who was giving up her homebirth practice because she couldn’t find a collaborating physician.  Morrison recalls,

It occurred to me that, although I had delivered 2,000 to 3,000 women, I had never actually seen a natural birth.

Some obstetricians insist that it is ridiculous to say that OBs are not familiar with natural childbirth.  They will have to take this up with Dr. Morrison.  In any case, she asked Stewart to take on a few clients and agreed to be the collaborating OB.  Here is her response to the experience:

It’s a different culture of birth. A woman isn’t subjected to anything she doesn’t want. She doesn’t need an IV [for drugs or fluids]. She can eat and move around. No one’s checking her every hour. She can go at her own pace, and even have a water birth. There’s no rush to cut the umbilical cord as there is at a hospital. And if labor is progressing slowly, no one’s pressuring the patient to have a C-section, as can happen at a hospital. All of these things were part of my routine in my previous practice. But when I saw this woman-centered care, I was hooked.

Although Morisson is opening a freestanding birth center, not a homebirth service, she observes the similar reactions of those opposed to abortion and those opposed to homebirth:

The same contempt that people have for women choosing to terminate a pregnancy and the person providing that care, I’ve seen for women who want to have natural births and for the women providing them. It’s this idea that these women are selfish and insufficiently caring about these babies.

Women generally care passionately about being good mothers and having babies who will have all of the resources they need to grow to be thriving adults.  How and when to bring a child into the world are two sides of the same coin.  Women’s autonomy in deciding where and how to give birth is just as important as autonomy in deciding whether to give birth at all.

Read the whole interview: “Meet the Doctor Who Opened a Natural Birthing Center in Her Abortion Clinic

There is an interesting paradox in the arguments of some anti-homebirthers.  They argue both that homebirthing is an elitist practice driven by well-educated, wealthy feminists AND that these women do not know, understand, or have easy access to the “truth” about homebirth (because if they did, they would obviously come to the same conclusion as the anti-homebirthers).

Many of the women driving the rise in homebirth are the most capable of finding information on the risks and benefits of homebirth, and if they make a decision that goes against the anti-homebirthers’ beliefs, they certainly aren’t doing it because of a lack of information on risks.  A simple Google search on “home birth” pulls up many sites; some on the first page include a Wikipedia article that has a research review that indicates a higher rate of perinatal death in American homebirths, a Daily Beast story  called “Homebirth: Increasingly Popular, but Dangerous,” and the website Hurt by Homebirth.  It seems that rather than lacking access to the “truth,” some women simply have different interpretations of the evidence and/or different values than the anti-homebirth crowd.

There is, however, a different crowd of women who plan homebirths—or who have homebirths planned for them—who may or may not have accurate information about the risks of homebirth. If they do, it likely doesn’t matter.  Their choice is constrained by a subordination of their own autonomy to God, or in many cases, their husbands or their church leaders.

Some may have heard of the Quiverfull Movement and the Christian Patriarchy Movement.  The overlap between the two groups is substantial.  Those who are “Quiverfull” believe that they must gratefully accept as many children as God gives them, whenever He chooses to give them.  The Christian Patriarchy Movement believes in, well, patriarchy.  Women must always be under the authority of a man; generally this authority passes from father to husband.  The most well known Quiverfull family is the Duggar family of the TV show “19 Kids and Counting.” Kathryn Joyce has an excellent book on the movements, Quiverfull: Inside the Christian Patriarchy Movement.  Two excellent blogs that discuss the ramifications of Quiverfull and Christian Patriarchy are Love, Joy, Feminism, by Libby Anne, who grew up the oldest of 12 in a Quiverfull family; and No Longer Quivering, by Vickie Garrison, who had seven children before leaving the movement.

Because of the movements’ distrust of secular institutions, some in the movements eschew traditional medical care.  In addition, in part because they start families young and have so many children, many of these families are low income but do not believe in using government programs such as Medicaid.  Of course, many members of the movement go to doctors or licensed midwives anyway, and some even sign up for Medicaid.  But many don’t.  In many cases, it is the husband who makes the final decision about the healthcare of his pregnant wife and the circumstances of her labor and birth.  Sometimes these decisions are in response to the guidance of church leadership.

Amy Chasteen Miller, who conducted a study of unassisted childbirth published in Sociological Inquiry, points out that “women make choices about birth within a web of larger social influences.”  For educated, independent women, these choices may come from a feminist sensibility that leads them to reject a paternalistic and technological model of birth.  For other women, birth choices may be “driven by God.”  In some religious communities,

women see childbirth as fully ‘in God’s hands.’  For these women, seeking medical help for pregnancy and birth reflects a breach of faith and an unwillingness to fully trust ‘God’s will.’

In such circumstances, it is unlikely that women are familiar with the scientific literature regarding risks associated with homebirth, but it is also unlikely that knowing and understanding the risks would have any impact on their decision making–if they had any control over the decision.  Miller writes, “For some women, part of surrendering to God is also deferring to their husbands…”  One woman writes, “I asked [my husband] where we should have the baby.”  Another says, “[My husband] knew we needed to do this baby on our own without a professional birth attendant.”  In these families, Miller notes, husbands “played an active role in monitoring, directing, and evaluating the birth process.”

In her article “My Womb for His Purpose,” Kathryn Joyce tells the story of Carri Chmielewski, a self-described “Homeschooler, Homebirther, Homechurcher,” who had an unassisted childbirth after a complicated pregnancy and suffered an amniotic fluid embolism.  Her baby died.  According to Joyce,

Chmielewski’s husband, who critics charge has erased or hidden much of his wife’s past writing, described her survival as a miracle of God, who spared her even as He took their son.

Melissa, a former Quiverfull daughter who blogs at Permission to Live, was a submissive wife who was active in the web group of Above Rubies, a forum for Quiverfull/Christian Patriarchy mothers.  She says of her prenatal care in the U.S., “I had limited my checkups to only a handful to keep costs down.”  She also got only one of the two recommended shots for her rh-negative blood type and had her children at home.  She could have had comprehensive prenatal care, but her family did not believe in accepting government “welfare” and so went without any insurance at all:

I believed that welfare programs were unnecessary because if every woman just got married to one man and he supported her and her kids there would never be a need for welfare, I believed that Christian rights and privacy were being violated by the government on a regular basis…I remember being on a mommy chat board during my first and second pregnancies and someone started a thread on costs of prenatal care and childbirth. I mentioned that my uninsured home births had cost between six and seven thousand dollars each and felt proud that my costs were so low…
She never mentions anything about her knowledge of homebirth risks, only the “risk” of accepting government assistance.
Anonymous left the following comment at a Recovering Grace post on Quiverfull (ATI is the Advanced Training Institute, a Christian Patriarchy group):
I was an ATI mom for quite a few years and embraced the Quiverfull teachings. After a number of children we had a close call. A home birth and heavy hemorrhaging nearly claimed my life. I was ready to end the child bearing and focus on the children we had, but my husband didn’t agree. Within nine months I was pregnant again. We actually had insurance and I wanted to have the next birth in a hospital, but it was more important to my husband to have a home birth and “prove” his faith. I asked him, “What are you going to do if I bleed to death?” His answer amazed me. “Get a new one.”
This women knew first hand that there were risks to homebirth, ones she did not wish to accept.  Her religion, however, would not allow her to exercise her own autonomy.
According to Birth Junkie, “Born in Zion is a book by Christian ‘childbirth minister’ Carol Balizet, who ‘ministers’ to women during their home births” (I wanted to verify what Birth Junkie writes, but the book is now out of print and is currently selling for $200 per copy, so we’re going to take Birth Junkie’s word for it). She writes of Balizet:

[W]hatever Balizet’s ministry may be, it is certainly not midwifery….her teachings on childbirth are thoroughly unbiblical and even dangerous.  As if all this weren’t bad enough, Balizet believes that to receive any medical care whatsoever is a sin. It is yielding to the “world system” (167) and to the “arm of flesh” (84). Furthermore, taking any drug for any reason is sorcery according to Balizet (171). She refers to people who have never ingested drugs of any kind as “undefiled” and “virgins” (174)….Balizet believes that getting a Caesarean Section is a particularly abominable sin. All women who have had Caesareans have “the same spirit,” the “spirit of Caesar,” who is one and the same with “the Strong Man, the Satanic high prince over the organization and sphere of humanism” because they have “rendered their babies unto Caesar” rather than to God (48). In other words, women with Caesarean scars are idol-worshipers who are demon possessed.

Followers of such a philosophy are likely to be frightened into not seeking appropriate medical care–or bullied into not seeking it by church or family “authorities.”

Vyckie Garrison tells the harrowing story (long but fascinating if you want to read the whole thing) of her belief in her husband’s and God’s authority, and how it impacted her prenatal care and birth.  First she was betrayed by the conventional medical system.  A doctor told her a bone spur made vaginal birth impossible.  When she found out that wasn’t true:

‘Then why have I had three c-sections?’ I wanted to know. Well, it turns out that there really was no good reason–only that the first doctor had run out of patience so declared me to be ‘too small’ to give birth. And because of the first cesarean ~ I had automatically scheduled repeat c-sections for my next two babies.”

Her Christian OB offered severe limitations on VBAC and laughed at her wish for vaginal birth.  Having embraced the Quiverfull lifestyle, she decided to deliver with Judy Jones, an unlicensed midwife and devout Christian.  Because Vyckie had many complications in her pregnancy (for which she did not seek other care), Judy was at their house frequently.  Vyckie writes,

As ‘part of the family,’ Judy was around to witness the way that Warren dealt with the children…She spent a lot of time talking to me about the importance of upholding my husband’s authority…she always backed him up as ‘head of the home’….the wife should pray for the father of her children–but it’s essential that she never contradict him or do anything which might undermine his rightful authority as protector, provider–and priest in the home.

As the pregnancy progressed, Vyckie’s health worsened:

I was feeling particularly horrible…I told Judy that I really needed help–I really needed to go to the doctor. Judy drove to my house and did the usual check and assured me that–although I was still spilling sugar in my urine (+1,000)–I was okay and the baby was fine….Even though we really didn’t have the money for it, I insisted that I needed to go to the OB/GYN. ‘I can’t handle this anymore–I feel like I’m dying!’  I was laying on the couch and Judy got down on her knees beside me and did what she called a ‘diaphragmatic release,’ in which she put one hand under my lower back and her other hand on my lower abdomen and then waited patiently while the uterine muscles relaxed. It did calm me down, and while we waited, Judy told me a bible story…about the time when the children of Israel were wandering in the desert, and the Lord was providing for their every need…[b]ut the Israelites grew…greedy. ‘They had meat in abundance,’ Judy explained, ‘but they suffered leanness of the soul.’  Leanness of the soul … that’s what happens to those who don’t trust the Lord through their trials–those who seek “worldly” remedies and don’t have the faith to believe that God will never give us more than we can handle.

Eventually, after months of complications and a harrowing labor, she had a hospital transfer and an emergency cesarean.  Her recovery was lengthy, and her mother urged her not to have more children.  Vyckie writes,

But what about God? What did He want? His word made it very plain ~ He wanted to bless us and to use our family for His glory. Who was I to say, “No. Sorry, Lord–but it’s just too difficult for me”?

Now that she has left the movement, Vyckie offers the following reflections on her experience:

Because I had made the commitment to welcome every pregnancy as an unmitigated gift from the Lord, and because I also believed that accepting government assistance in the form of Medicaid was tantamount to trusting Caesar to provide for the health and wellbeing of my babies, I desperately sought an alternative to the expensive surgical deliveries.  I know now that it was absurd for a woman with my health issues and high-risk status to eschew all medical care and trust myself and my unborn baby to an unlicensed ‘lay midwife’ – but I was idealistically motivated, and it made perfect sense to me at the time. In fact, I was absolutely certain that it was God Himself who put the idea in my head and lead me to Judy Jones….Judy’s incompetent, negligent, and abusive pre- and post-natal care…seriously endangered my life and my baby’s life, and left me so physically, emotionally, and spiritually traumatized that I suffered severe PTSD for over a year and still sometimes have nightmares almost seventeen years later.

Rebekah Pearl Anast, the daughter of Christian Patriarchy couple Michael and Debi Pearl, married Gabe, a man who quit his job to study the Bible.  The family lived in a rural home outside Gallup, New Mexico, where their electricity has been turned off because they can’t afford to pay the bill.   Rebekah has 6 homebirths assisted only by Gabe.  She does seem to have enjoyed them (at least the first 4):
Now, I have had 4 “unassisted” homebirths. It did save us 20,000 dollars all told, and has been a thrilling and bonding experience for both my husband and I.
However, she has so subsumed her own desires to those of her husband that it is unclear whether she knows how to have her own feelings.  Of her relationship to God, her home, and her husband, she says (DH means Dear Husband),
[I]f your worship of God IN ANY WAY short-changes your husband or son, or makes them feel shut out, then IMO, it is not in spirit and in truth….Remember that your husband is your lord….It really helped me to remind myself ‘this kitchen belongs to DH, the food belongs to DH, the meal is all about DH, and both me and our daughter are helpers for DH…’
Rebekah’s entire life is dictated by the whims and desires of her husband, so whatever knowledge she has of the risks of unassisted childbirth are likely to be irrelevant.
There definitely appears to be a group of women homebirthing under questionable circumstances regarding their knowledge and autonomy–but it isn’t privileged feminists beholden to misinformation campaigns of hippie websites.

There is a sense in the United States that a woman has a right to give birth in the hospital.  In fact, most people can’t imagine giving birth anywhere else.  Fewer than 2% of births in the U.S. occur outside of a hospital.  Hospitals are required to accept birthing women–even undocumented immigrant women receive emergency Medicaid to cover the cost of a hospital birth.  Insurance policies often do not cover homebirth but they are required to cover hospital birth.  While some state Medicaid programs cover homebirth (e.g. Washington), most do not.  But does a woman have the same right to birth at home that she does to birth at a hospital?

Working through ACOG and its journal, Obstetrics and Gynecology (aka The Green Journal), obstetricians vociferously push their view that homebirth is dangerous.  While there certainly may be dangers in birthing at home, recent studies have relied on birth certificate data to indicate dangers.  Marian McDorman, a senior statistician with the National Center for Vital Statistics, has said repeatedly (most recently in the Daily Beast) that vital records data are not appropriate for research: “There are quite a few limitations in using that data for that kind of analysis.”  Vital Statistics reports are descriptive in nature for this reason.

In a recent workshop I attended on linking Vital Statistics data with Medicaid claims, the statistician leading the workshop pointed out  flaws in a recent study of Apgar scores and neonatal seizures in home, hospital, and birth center births.  Among the flaws:  hospital birth certificates are generally filled out within 24 hours (while for home births, they are generally filled out later), thus truncating the time during which a seizure could  be reported for a hospital birth.  A senior statistician for the state of Washington also pointed out that homebirth midwives reliably fill out every field in the birth certificate while most hospitals rarely do.

It is hard to tell whether hospital birth is really safer than homebirth (or vice versa) for low risk births.  Politics take over the debate, and women are left with rhetoric rather than information.  For high risk births, however, there is some agreement from both sides that the intrapartum and neonatal death rates* are higher when a woman births at home.

High risk births include breech presentation, vaginal birth after cesarean (VBAC), maternal complications such as preeclampsia or gestational diabetes, and multiple gestations (e.g. twins).  While women in these circumstances are more likely to be subjected to interventions in the hospital that may be unnecessary, they and their babies have a lower risk of dying in the hospital.  These high risk conditions sometimes result in complications that simply cannot be handled adequately at home and may not present in such a way that a hospital transfer can occur in time.

Death is the ultimate negative outcome in medicine.  Long term disability for the infant or woman is also  a poor outcome.  While medicine acknowledges short term morbidities such as maternal hemorrhage or neonatal respiratory distress, these are generally not taken particularly seriously as long as everyone appears to be all right in the long run.

The question is then, should women who are well informed of the risks and benefits of home vs. hospital birth be allowed to choose where to birth?

At the Institute of Medicine Birth Settings Workshop, I chatted with a number of Certified Professional Midwives (CPMs), the kind of midwives who generally attend births only outside of a hospital.  I asked if they were willing to attend high risk home births, such as breech births.  They replied that the choice of birth setting was entirely up to the woman.  They explain the risks thoroughly, and if the woman still chooses to birth at home, they will attend her.

ACOG’s official position is remarkably similar: a woman may make choices that entail risk, even if the doctor does not agree, and should not be prosecuted or persecuted for her choices (though that doesn’t mean the doctor should provide the care). Among their recommendations in their Committee Opinion, “Maternal Decision Making, Ethics, and Law,” is

Pregnant women’s autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman’s broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman’s autonomy.

ACOG’s Committee opinion, “Planned Home Birth” even reluctantly acknowledges a woman’s right to birth at home:   “Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery.”  (Though they do not support physicians’ attending home births.)

In an ironic twist, ACOG supports physicians who actively act in ways they believe are not in the best interests of a woman’s health as long as they explain the risks to the woman and she still wants the procedure.  While they are not obligated to perform the procedure, ACOG’s Committee Opinion, “Elective Surgery and Patient Choice,” says it is ethical for the physician to perform operations such as ovary removal or cesarean section on patient request.

In addition, as Marian McDorman has pointed out, even in high risk situations, the absolute risk of a bad outcome from homebirth is very small.  I would point out that in contrast, the absolute risk of unnecessary clinical intervention in hospitals (and associated morbidities), including administration of high alert medications such as Pitocin and unnecessary cesarean surgery, is very, very high.  In the case of a woman wishing to have a VBAC, the chance of of cesarean in a given hospital may be 100%, even if the woman meets ACOG criteria for safe VBAC.

Personally, I would choose to birth at the hospital if my pregnancy indicated that my birth would be high risk.  But that is my choice.  I would not want someone to force me to birth at home because that person thought that the relative risk of morbidity at the hospital was higher than that of death at home, or because hospital birth in the U.S. is outrageously (and unnecessarily) expensive, or because some hospitals cannot be trusted to act in the woman’s best interests as a matter of policy, or because U.S. hospital births have among the worst maternal and infant outcomes in the developed world.

A practitioner does not have to attend a high-risk homebirth (or any homebirth), just as a practitioner is not obligated to perform a maternal request cesarean.  But if it is not wrong to put a woman and infant at risk from unnecessary surgery because the woman believes that is the best decision for herself, then why is it wrong to support a woman in homebirth if she believes that is the right decision?

We need to separate ethics, which are often personal, from the law, which is universal.  As long as a woman’s body is her own, she has the right to determine where it should be, when she is giving birth, and always.

*The intrapartum rate refers to deaths during labor and delivery; the neonatal rate technically refers to the first 28 days, but it is often truncated to refer to the first 24 or 48 hours.  A study should explain which definition it is using.

The debate is on.

At long last, the Midwives Alliance of North America’s (MANA) homebirth data has been published in a peer reviewed academic journal, the Journal of Midwifery and Women’s Health.

The study is descriptive, meaning it can only speak to the women included in the data and cannot be generalized to the population at large.*  That being said, the data indicates that homebirth for LOW RISK women (no prior cesarean;  no gestational diabetes or pre-eclampsia; a singleton, vertex, term fetus) is not only safe regarding mortality, but is much, much safer regarding sources of maternal morbidity such as cesarean, instrumental delivery, administration of Pitocin, epidural use, and episiotomy.  Here is a summary from Citizens for Midwifery that includes all of the births, not just the low risk ones.  I have highlighted some notable points:

  • High rate of completed home birth (89.1%): Primary reason for transport was “failure to progress.” Transfer for urgent reasons, such as “fetal distress” was rare.
  • High rate of vaginal birth (93.6%)
  • High rate of completed vaginal birth after cesarean (VBAC; 87.0%)
  • Low intrapartum and neonatal fetal death rate overall: 2.06 per 1000 intended home births (includes all births); 1.61 per 1000 intended home births excluding breech, vbac, twins, gestational diabetes, and preeclampsia. 
  • Cesarean section rate of 5.2% 
  • Less than 5% used pitocin or epidural anesthesia
  • Low rate of low APGAR scores
  • Extremely high rate of breastfeeding (97.7%) at 6 weeks

Even for those in the “healthy baby is all that matters” club, the data don’t have much to condemn low risk homebirths.  And for those of us who think that a woman’s physical and mental health are crucial measure of the “success” of a birth, the data indicate that low-risk women who want to birth at home, for the most part, may be better off doing so.  

It is important to note that most of the births in the MANA registry are attended by Certified Professional Midwives (CPMs).  While many obstetricians accept the professional capacities of Certified Nurse Midwives (CNMs) (who usually practice in hospitals), they generally disparage the credentials of CPMs, even when they don’t know what the requirements are for earning the CPM title. (See information on the different kinds of midwives here.)

As reported in the Huffington Post, Dr. Jeff Chapa, director of maternal fetal medicine at the Cleveland Clinic, who reviewed the new study, said that low-risk women having a home birth “can feel good in that they’re probably going to be OK,” but that the study had not affected his views on home birth because “the bottom line in all of this is you can’t predict who is going to have an issue or a complication.”

The silly thing about Chapa’s comment is that if the maternal, infant, and fetal death rates among low risk women are more or less the same for hospital or home birth, there is no indication that a fatal “issue or complication” could be avoided by going to the hospital.  It is possible that some complications are unavoidable regardless of the setting.  It is also possible that the hospital could prevent some complications while causing others–thus there is no overall advantage to birthing in either setting.

Given that the homebirthing women avoided many procedures that result in complications, it seems that the argument could be made that the hospital is actually less safe for low risk births.  When obstetricians discuss birth outcomes, they often focus on a healthy baby and sometimes a healthy mother.  But what does this mean?  Is a baby who spends a week in the NICU “healthy” if it goes home healthy?  Is a mother “healthy” if she develops post-traumatic stress disorder from a forced cesarean?

Many morbidities don’t enter into calculations of the risks of hospital birth.  In many cases, unnecessary procedures conducted in hospitals are touted as positive, even when they have no positive effect.  Few acknowledge that doctors sometimes cause the problems that a heroic intervention solves, as evidenced by the horrifying practice of “pit to distress.”  Pit to distress NEVER happens at a home birth.

As Melissa Cheyney, a medical anthropologist and lead author of the study, said

 We need to start focusing on who might be a good candidate for a home or birth center birth and stop debating whether women should be allowed to choose these options.

On the other hand, as Miriam Perez, the Radical Doula, points out, very few women birth at home–fewer than 1%, and we should be far more focused on the outcomes in U.S. hospital births:

Whether you think midwifery and home birth are viable alternatives or not, it’s hard to ignore the statistics that say what we’re currently doing isn’t working. We should be able to guarantee better (not perfect, but better) outcomes for parents and children. If I were to play the blame game, I’m going to look to where almost everyone is giving birth — the hospital.

She concludes,

Let’s focus our scrutiny on the system that is failing us, and figure out how we can make it better. A few things that would help greatly in this matter: transparency about c-section rates from hospitals, an independent body investigating deaths from pregnancy-related causes, and real pressure on the obstetrics community to follow their own advice on practicing evidence-based medicine.

If obstetricians and the medical community really care about maternal child health, then rather than railing against homebirths, they should focus on making birth as safe as possible for women and infants, wherever the woman chooses to birth.

To paraphrase Jesus, who had a lot of great things to say if you actually pay attention to them, it is always wise to remove the plank from your own eye before you go after the speck in your neighbor’s.

*In order to say something about homebirth for all women, the women in the sample would have had to be selected randomly.  They were not.  All of them chose homebirth.  In addition, they are not representative of all women who homebirth–only women whose midwives submitted data to MANA are included, which means 70-80% of homebirths are NOT included in this data.

Dr. Paul Burcher has responded to my post “Is This OB Ethical” with a comment.  I would like to thank Dr. Burcher, and before I go on, here is the entire (verbatim) text of his comment:

This is Paul Burcher. You reference me in your blog, and I think you have made some incorrect pre-judgments about who I am. I am a practicing Ob/Gyn (true) and a PhD ethicist (also true) but I am no fan of Frank Chervenak’s position on home birth (if you google me you will see that I have collaborated extensively with, and defended midwives and home birth. I quoted Chervenak on a completely separate topic where I am with him–that talking with woman before labor, about labor, can reduce or eliminate misunderstandings and conflict. The “maybe” category that I wrote about is not a bait and switch as you suggest. As I wrote about in the Journal of Medical Ethics, how would you respond to a birth plan where the woman insists that no matter what happens in labor, and even if she requests it, that I must refuse her an epidural? As you know labor (and life) are fluid, and sometimes we don’t know “till we get there.” So maybe is maybe, and it means just that. The “non-starter” category is for me both real and small. I value patient autonomy, but it isn’t the only value in the room, and physicians also have values that must be respected by patients. If I say I can’t participate in what a patient requests, that is also my right. I rarely just say no, and I bend a lot even pushing beyond comfort zones at times.But physicians must be also be able to make rational and value laden choices–they must also be autonomous. These words don’t really express how it has played out in my practice, but I have 18 years in practice with almost no conflict with my patients, because I am respectful (and because I worked with midwives I have had strong-willed, conscientious women with alternative values as patients for much of this time).

I am honestly touched that Dr. Burcher cared enough to read and comment on my post, which I think gives much credence to what he says here about his respect for women.  If he didn’t care very much about his integrity and that of his practice, I’m sure he would not have bothered.  His “full biography” on the Albany Medical Center website states, “Dr. Paul Burcher specializes in general obstetrics and gynecology and women’s health. As an ethicist, he has a particular interest in the doctor/patient relationship and physician empathy.”  My post might have been more fair minded had I spent some more time researching his background.

For instance, I tied Burcher to Frank Chervenak because he begins his column by citing Chervenak’s idea of preventive ethics.  Dr. Chervenak’s attitude toward homebirth and midwifery is uninformed and patronizing, and because of the citation, I tarred Burcher with the same brush.  Burcher is not anti-homebirth, as evidenced by this piece about a woman who had a stillbirth while attended by unlicensed midwives.  This piece was co-written with Colleen Forbes, a licensed midwife (who is not a CNM, the kind of midwife who usually practices in hospitals–you can read a description of the various kinds of midwives here) and does not condemn homebirth.  He was also quoted in this piece in the New York TImes about the risks associated with episiotomies and the importance of women making informed decisions.  I think Burcher and I probably agree about many–even most–aspects of obstetric care.

I think some of the issues I have with Burcher’s column have more to do with audience than anything else.  In writing for other obstetricians, Burcher certainly had to appeal to them.  And defending the right of women to have birth plans and encouraging obstetricians to take them seriously is an important and noble undertaking.  I should have been less glib in my introduction and offered him more respect for his efforts.  I, on the other hand, am writing as a passionate advocate for women’s autonomy and agency, and my audience is those who are interested in that perspective.  I do not wish to imply that Burcher does not value women’s agency and autonomy, but we may approach the concept differently.

I do have problems with preventive ethics, at least as they are conceived by Chervenak.  I mentioned in particular Chervenak et al’s  piece “Obstetric Ethics: An Essential Dimension of Planned Homebirth” in which he states strongly that it is an obstetrician’s duty to convince women not to birth at home and to birth at a hospital.  Chervenak carries his ideas about obstetrical judgement based in beneficence to the conclusion that the obstetrician must convince a woman to do what the obstetrician thinks is best.

However, a woman may have vastly different values that lead her assessment on a very different path.  Anne Faidman’s wonderful book The Spirit Catches You and You Fall Down offers numerous examples of this conflict between the values of doctors and those of their patients.  While the book is primarily about the care of an epileptic child in a Hmong family, there are also a number of examples given about childbirth.  One section noted that many of the Hmong women in the book preferred to give birth with a little-respected family physician because he did not “cut” (meaning episiotomies and other surgical procedures–cutting the body is anathema to traditional Hmong beliefs) and because he would hand over the placenta to the family (the placenta was used in important post-birth rituals).  The more highly respected obstetricians held their own clinical judgment in higher esteem than the beliefs and values of their Hmong patients, and the patients sought care elsewhere.

Burcher, it seems, has a different approach to the idea of “preventive ethics” than Chervenak, one that is a true exchange involving shared decision making.  He is right to be honest with women about what is not possible, either because of structural constraints (the hospital will not allow it) or ethical ones (the doctor believes s/he cannot in good conscience provide what the woman requests).  I said in my original post that I though he had a reasonable approach to “non starters.”  I might even go further than he did on the “refuse me an epidural no matter what” question.  I would not be willing to work with a woman who gave up her autonomy and made me the gatekeeper of her care.  That is not shared decision making.

My issue with the “maybes” had more to do with Burcher’s  concerns about his colleagues and their approaches to care.  I understand that “maybe” is circumstantial–my position was that really the maybes are either “of courses” or “non-starters,” depending on the emergent situation.  It’s impossible to go through every possibility in advance to know which would be which.  While Burcher himself might be working with his patients to make sound decisions in the moment on the “maybes,” I do worry that many practitioners view the “maybe” as a way to placate women, with the situations in which the “maybe” becomes an “of course” so limited that the “maybe” is more accurately categorized as a “non starter.”  In my original post, I gave the example of the way many practitioners approach VBAC requests.  Again, if there is an evidence-based reason to do something, what would be the justification for removing that possibility based on a practitioner’s “comfort zone”?  Is the practice evidence based or not?  Is it safe or not?  It seems there are very limited situations in which the practitioner herself/himself would be the determinant (for example, an exception would be vaginal breech birth, which many practitioners no longer know how to attend safely).

Albany Medical Center, where Burcher practices, has a cesarean rate over 40%, indicating that much of the time, Burcher’s colleagues are not adhering to evidence based practice.  I am concerned that many doctors are happy to follow women’s non-evidence based requests when it suits them — for instance, performing non-medically indicated cesareans or inductions — but are not willing to comply with requests that are evidence based, such as eating during labor, laboring in water, or freedom of movement during labor.  I am also concerned that many physicians use non-evidence-based practices routinely, such as continuous electronic fetal monitoring for low risk women, routine oxytocin (Pitocin) augmentation,  routine amniotomy (breaking the bag of waters), or prophylactic cesarean for suspected macrosomia (big baby). Some practitioners view these practices as non-negotiable, and some hospitals institute them as protocol even though a woman’s request to forgo them is based in science while the practices themselves are not.

Burcher says, “If I say I can’t participate in what a patient requests, that is also my right.”  I agree with Burcher that the conflict between the rights of the patient vs. the rights of the practitioner are real and ethically complex.  I have written about conflicts in these rights here and here, and I am sure I will have future posts exploring this fraught issue.  It sounds as if Burcher’s decisions are generally based in evidence and ethics, but I do not have confidence that all practitioners abide by Burcher’s standards.  Is it ethical for a physician to refuse to provide evidence-based care because for some reason the evidence does not coincide with the physician’s “comfort zone”? Is it ethical for the physician to insist on non-evidence-based care, or care that has substantial evidence of harm, because it does fall within the “comfort zone”?  While I believe that physicians, like their patients, are autonomous beings, I would not want them to answer yes to these questions.

And thus I still ask if it is ethical for a colleague to refuse to follow a birth plan that Burcher has negotiated with a woman, and for Burcher to present that as acceptable.  “Maybe” should depend on the evidence and a shared decision making process, not on a nebulous, one-sided “comfort zone.”

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