dear prudence

The first thing that happens when you get pregnant — or get somebody pregnant — is that everybody you know becomes an expert on fetal health. Also, everybody on the internet. Basically, everybody in the universe will tell you what to do.

  • Don’t eat fish — it’s full of mercury, and your baby will be a ‘tard.
  • Don’t eat peanuts — your baby will get asthma.
  • Don’t work out too hard or get in a jacuzzi — your baby will boil inside you.
  • Don’t eat soft cheese — you’ll get listeria and your baby will turn French.
  • Don’t drink wine — your baby will grow up to be a playwright.
  • Take your folic acid and your DHA — or your baby will never get into Harvard.

And on it goes. The hippie midwife tells your wife she shouldn’t eat more than one slice of bread per day. Your friend with the tortoise warns you never to let a pregnant woman touch the reptile, and that’s not a euphemism. And perhaps most annoyingly, every parking garage, every apartment building, every office, every stereo, and every cheap flashlight you encounter would like to warn you that it may contain things which ARE KNOWN TO THE STATE OF CALIFORNIA TO CAUSE BIRTH DEFECTS.

Here’s a typical sign, available at complianceposters.com:

Reproductive_harm

This is the kind of sign you frequently see at the entrance to buildings and parking garages. What does it mean? Well, possibly it means, “This is a parking garage, so naturally there’s some exhaust in here — don’t huff it or anything.” On the other hand, maybe it means, “Somewhere in your office there’s an unsecured drum of spent nuclear fuel rods. Perhaps we’ve disguised it as a water cooler. Good luck with that fetus, sucker!”


My wife comes from family of jolly, carefree hippies who lived on an actual commune. I, on the other hand, come from a family of people who probably wanted to be jolly, carefree hippies when they were young, but were too blue-collar to really relax about money, and got jobs at the Days’ Inn instead. Sure, my parents compost and garden and buy grass-fed beef from a nearby farm, and my dad didn’t bother getting a driver’s license until he was nearly 40, but when it comes to medical decision-making… I’m saying that I don’t come from people who know much about things like home birth. My mom had Demerol and was glad of it.

Which is not to say Elana is a believer in all things wacky and patchouli-scented. In fact, before we became Parents-To-Be, our hobbies included Eating Meat and Sniggering About Pseudoscience. We are crotchety urban skeptics who like to roll our eyes at not only proponents of homeopathy, but also potbellied 40-year-olds with no social skills who like to spin elaborate evo-psych theories that always begin with phrases like “Well, you see, our savannah ancestors needed visual cues…” and usually end with “…and that’s why I feel I should be able to sleep with 15-year-olds.”

So if my wife, who loves science and has a quite sensitive nose for the woo, thought home birth was a good idea, I was willing to look into it. We talked in depth about the hospital model of birth, which tends toward standardization and intervention. We talked about iatrogenic complications arising from that model, and the risks to mother and child associated with those complications. We talked about the psychological discomfort that arises from having strangers come into your brightly-lit room and look at your hoo-hah every twenty minutes, which leads to physical stress, which leads to prolonged labor, which leads to the administration of Pitocin to induce, which leads to terribly painful contractions, which leads to an epidural, which leads to failure to progress and a dip in fetal heart rate, which leads to a C-section.

Elana felt, and I agreed, that the risk of major abdominal surgery — for, in many cases, no better reason than that the American practice of obstetrics couldn’t really get it together to treat women more like autonomous human beings and less like malfunctioning Chevys — was too high for us to be comfortable with. So we started meeting midwives.


There are two kinds of midwives in California — Certified Nurse Midwives and Licensed Midwives. CNMs are registered nurses who receive special training in obstetric care and are licensed by the American College of Nurse-Midwives. LMs are not nurses, but according to the Medical Board of California, “Candidates must complete a three-year postsecondary education program in an accredited midwifery school approved by the board,” or else satisfy the board that they have sufficient clinical experience through a “challenge mechanism.” In either case, they must still pass a licensing exam also approved by the medical board. Three years, by the way, is about the same as or a little longer than it takes to become an RN.

I share this information because it will be useful later.


So we were going along, meeting midwives and seeing if we can make this home birth thing work, and I was doing all this googling, when one day I came across the following terrifying headline:

HOMEBIRTH KILLS BABIES

My initial reaction was annoyance, because every single aspect of birth seems to attract crackpot weirdos who are convinced that you’re killing your baby (or scarring him for life, or whatever). But you know how these things go. It’s like if you’re an Obama voter, and you see a link claiming that he’s actually a Kenyan sleeper agent, or if you’re a Christian and you see a link claiming Jesus got everything from the Egyptians/alien overlords.

You invest in something, and then it turns out there’s an opposition viewpoint, only you never read the opposition viewpoint if it’s couched in moderate, thoughtful language — you only go a-clicking if it’s a website by some hairy-eyed loon who writes inflammatory things to pick fights with people on the internet.

I went a-clicking.

And found the terrifying headline, an aggressively sentimental picture of a pregnant belly, and the following chart:

national_neonatal_mortality

And accompanying all that, some text by Dr. Amy Tuteur, an OB/GYN, explaining why this chart shows incontrovertibly that HOMEBIRTH IS DEATH TO THE INNOCENTS!

At first, of course, I laughed it off. I showed it to my wife, who also laughed it off. We are, after all, not stupid, and this chart, by itself, shows nothing of the kind. In fact what it shows is that in a two-year period, births attended by “Direct Entry Midwives” (itself not a terribly useful designation, since midwife accreditation varies wildly from state to state, with some states flat outlawing non-nurse midwives and others requiring a substantial level of schooling) had a slightly higher, but still nearly infinitesimal, risk of neo-natal death than those attended by physicians or nurse midwives.

Many factors make this statistic an inadequate measure of the absolute safety of home birth — everything from the above-mentioned non-uniformity of midwife training and legality to the fact that homebirth rates are higher in mostly rural states (leading, potentially, to long drives to the hospital should a problem arise) to the fact that there’s no information in this chart on homebirths attended by CNMs or physicians compared to hospital births attended to the same caregivers.

(And if we’re going to be perfectly cold-hearted about this, there’s no information given about how many babies are “saved” by the miracles of modern science in the hospital even though they’re destined for a few months of unpleasant life followed by a not-particularly-meaningful death. I wouldn’t mind seeing a side-by-side comparison of infant death rates in the first year of life. Some infants may well die in a home birth situation because of the incompetence of a midwife or the lack of available medical resources, but it’s entirely possible that some die because they’re meant to die: they’ve developed in a manner incompatible with life. I understand some people may find this view intolerable — comments on this point should be directed to Dr. Leonidas, Sparta Presbyterian Hospital, Hellas.)

So this chart gives us, really, no information. It’s a single number designed to terrify parents considering home birth, or at least to cow home birth advocates.

Which is not to say Dr. Amy is a terrible person, or even a bad scientist. After all, she went to Harvard, as she goes to some pains to tell you in her profile, and we all know that everybody who goes to Harvard exhibits terrific judgement later in life. (Sorry. That was a dig. I went to the University of Chicago, and sometimes we get a little insecure and competitive. Seriously — Harvard alumni are usually very sound of mind. Usually.)

No, the problem with Dr. Amy is the problem with everybody when it comes to birth, babies, children, and acceptable risk. To wit: WE’RE ALL FUCKING NUTS. We’re all terrified — people who don’t even HAVE kids are eager to tell you everything you need to do to make your baby turn out whole and healthy and beautiful and three times smarter than everyone else’s baby. And if a baby or a child or a teenager turns out to be unsatisfactory, it’s your terrible parenting choices that are responsible. Jenny McCarthy will tell you that vaccines give you autism, even though we’ve been getting the same vaccines for decades, while the rise in autism is a relatively recent phenomenon. These wackos will tell you that your lousy sex life is because you were circumcised, though, to be fair, these wackos would like to encourage you to get circumcised as an adult, because you’re really missing out on the spiritual purification made available by whacking off the end of your doodad.

Here is a forum discussion, partly amusing but mostly sad, about whether it’s “safe” to continue practicing aikido (not a particularly high-impact martial art) while you’re pregnant. It starts off fairly sane, with people saying things like “No high falls” and “No strikes to hit the stomach.” And then you get a loooong post by a fellow who takes umbrage when OB/GYNs tell women that the fetus is “well padded.” He’s obviously an engineer, because he says fantastic things like,

If you want to convince an engineer that the statement about the fetus being well padded and protected is true, you’ll probably need to come up with the Structural Damage Capacity and the Impact Dilution rating of the fetus’ padding/protection given the various stages of pregnancy, positions of a fetus, and different points of impact. There is no way that they will be able to describe the energy absorption mechanisms.

Which is all very technical-sounding, and indeed he seems to be taking the scientific high road, noting that

The typical response, however seems to be a bunch of anecdotal evidence, terrible statistical comparisons, and overall junk science from the people who just really want their personal belief systems validated…. [P]eople generally make decisions based on emotions and then try to rationalize them with logic after the fact — even OB/GYNs.

Fair enough. But then, a few paragraphs later:

To try to make the case about it being dangerous, I openly admit that all I could offer would be my own anecdotal evidence and supporting logic.

Which, indeed, he does. I leave it to the reader to slog through the musings about “staircase abortions,” but a bit further down, the engineer-aikidoist finally comes out with what’s really driving all this terror about women he doesn’t know doing aikido in dojos he will never visit:

On a personal level, the reason I am concerned about this is that my wife had a little fender bender (someone cut her off in traffic) while she was 7.5 months pregnant. She wasn’t driving fast and taking chances. She was carefully driving in town, nice and easy, and two cars that were in a hurry coming from the other direction both decided to take left hand turns into a gas station one after another infont of on-coming traffic. Sunny was in the wrong place at the wrong time. At this point in the pregnancy, my son’s (my eventual son’s, if that matters to you) head was engaged in her pelvis. Immediately after the minor impact, Sunny went into labor. They gave her drugs and she went on bed rest until the baby was born a couple months later – with an injured jaw.

I don’t care if my son was not considered an official “baby” prior to being born or not. All that matters is that “whatever he was” got injured prior to birth, and when he was born (and everyone could now agree on what to call him) he had a injury from that impact prior to birth. It snowballed because when he was born he couldn’t latch to nurse since his chin couldn’t move forward enough. We ended up having to take him to a baby chiropractor to get him straightened out after months of suffering.

This was obviously quite upsetting for this man, and of course everyone feels for the poor mom and kid who were injured. But let me point out two things:

  • No one expects pregnant women to stop driving because of this story.
  • This story has nothing to do with aikido practice.
  • I think this kind of experience, or fear of this kind of experience, causes us to search high and low for the means of perfect control. If we can just eliminate the right activities, the right foods, the right environmental toxins, then nothing bad will happen. This is clearly not at all the case, and not practical even should it be true, but all of us — I mean every single person — fall victim to this sort of magical thinking sooner or later. After all, as the engineer says, in what I consider to be a very honest declaration:

    When I last explained this, someone put forward the idea that “such injuries are rare.” …To me, rare does not have much to do with safe.


    I started to believe Dr. Amy. Even though I knew, rationally, that her statistic was fairly useless as a predictor of the success or failure of our particular home birth, the irrational ape brain started revving like Vin Diesel’s Dodge Charger. I held it together for a while; then I started redlining. We would have conversations like this:

    ME: How do you think you would feel if something happened during the birth and our baby died?

    ELANA: Ugh. Why are you asking me that?

    ME: Because ALL THESE HOME BIRTHS ARE KILLING OUR OFFSPRING!

    ELANA: Um… we don’t even have any offspring yet.

    ME: AND AT THIS RATE, WE NEVER WILL!! [grumble, grumble]

    We talked about this quite a bit. There was some crying — I won’t say on whose part. We decided to do further research. Here are our conclusions.


    If you consider even Dr. Amy’s numbers in isolation, the raw fact is that somewhere between 99.8 and 99.9% of births end with a live baby and a live mother — even if you choose to have a baby with a “direct entry midwife.” Those are pretty good starting odds — better than Powerball, anyway. Even if you have one of those (as Dr. Amy puts it in another post) “grossly undereducated” non-nurse midwives instead of a CNM or a physician, the statistics are overwhelmingly in your favor.

    On the other hand, the numbers from the California Medical Board’s 2007 annual report on Licensed Midwives provides a somewhat gloomier picture: out of 1,687 births that began in the home, 3 ended in fetal demise during labor or at delivery, and 5 infants were born live but subsequently died. This brings the total percentage of births which did not end in unexpected death down to a startling 99.5%. Startling, says I.

    But two of the infant mortality cases are ascribed to “Anomaly incompatible with life.” (At least, I think it was two — the numbers on the infant/fetal mortality chart don’t seem, to my layman’s eyes, to add up correctly.) Those cases are presumably not the midwives’ fault, leaving six (or, according to the faulty chart, four) that might be. Or, you know, might not be.

    If the case actually looks pretty good for non-nurse midwives attending out-of-hospital births, it looks amazing for nurse-midwives in a birth center attending to low-risk women with a good hospital standing by for emergencies. A 1994 review of births in the nurse-managed in-hospital birth center at Los Angeles County + University of Southern California Women’s Hospital, the total number of intrapartum maternal and fetal deaths between 1981 and 1992 was… zero. None at all. Clearly midwife care is incredibly safe under the right circumstances.

    Is there a way to split the difference? A recent massive study of birth statistics in the Netherlands, where about a third of women deliver at home, provides a glimpse of such a possibility. Studying over 500,000 births, researchers concluded that for low-risk women, a carefully planned home birth was just as safe as a hospital birth with a midwife.

    Of course, as Dr. Amy herself would be the first to point out, there are several factors that make home birth in the Netherlands as safe as it is. First, midwife training in the Netherlands is uniform and of very high quality. Dutch midwives have extensive medical knowledge that enables them to make correct judgements about edge cases that may be about to go south. And because so many Dutch women choose home birth and/or midwife care, Dutch midwives have an opportunity to see many, many cases. Call them the equivalent of a highly experienced American nurse-midwife.

    Second, the Netherlands has a relatively high population density — the transport time from the average Dutch house to emergency care is lower than it would be from, say, the average home in Wyoming.

    And third, the entire Dutch system is geared toward a seamless integration of various birth options, so there is no grinding of mental gears when a woman is transferred to hospital care, and no conflict between the midwives and hospital staff. Indeed, transfer rates in the Netherlands are quite high — about a third of home births are ultimately transferred. By comparison, the midwives we’ve interviewed have typically had transport rates of 5-10%, which in and of itself suggests to me a certain hesitancy on the part of both midwives and the kind of American women who choose home birth to engage with a potentially hostile medical system.

    America could, of course, create a uniformly trained and highly respectable class of home birth midwives, possibly by requiring all home birth midwives to become CNMs, or possibly by creating a non-nurse specialty that is legal and standardized across all fifty states. And we could, in time, transform the culture of maternity care so as to mend the divide between home birth midwives and home birth advocates on one side and the medical establishment on the other. But those two projects would require us, as a nation, to adopt the Dutch mindset, which is much less fearful and uptight about birth as a process, much less ideological and much more practical.


    Which brings me to my final point — my kids are on their own. That’s not to say I won’t teach them how to work the remote or show them where the peanut butter is, but basically, they’re going to have to assume some risk. I am not going to stop driving my car because some kids die in fiery crashes or stop going to the beach because some kids get bitten by sharks or stop poking wasps’ nests with a stick because some kids go into anaphylactic shock after a few dozen stings. If I ever get the opportunity to go to Egypt, I’m going, and I’m taking my kids with me, schistosomiasis and jihadism be damned.

    Hell, at this point, I’m tempted to choose home birth just because it might be more dangerous. Because the truth is that if you start out your life as a parent trying to play risk manager, I think you never stop. Life is full of peril — just watch Disney’s Earth if you have any illusions about the specialness of things which are small and helpless. We have less control than we think. Feed your kid; clothe your kid; educate your kid. Do not spend endless hours wondering if you’ve bought the right car seat or bike helmet or nannycam. You are not God. The whole world is not in your hands. Let your kid experience danger. Let him get into fights and look foolish in class and eat carrots off the floor and go in the bathroom by himself and climb a tree you know to be too high and pet strange dogs and watch slightly inappropriate foreign movies. Otherwise, I swear to God, he’ll grow up feeling like a pussy… and become a Navy SEAL.

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    8 responses to “dear prudence

    1. it was a very small amount of demerol and only lasted through
      transition labor. Yes i was glad of it because I had become disoriented and shaky, and your
      Da had had NO birth training. We couldn’t afford it.
      And I asked for it. They didn’t force anything.

    2. I’m with you all the way, except about the dogs. Never trust a dog completely. NEVER.
      And having your child’s face repaired waaaaaay worse than telling her to be careful.
      Really. Trust me on this one. I am the mama.

    3. thehandsomecamel

      Oh, yeah, man — we haven’t even started the whole birth class thing yet. Whew — so much stuff involved in all this!

    4. Well are you squeamish?
      There is usually a movie.

    5. thehandsomecamel

      Well, going to the midwives’ offices actually kind of prepares you for the, er, biological aspects of birth, because apparently one thing people like to do is take pictures of the process, make collages out of them, and hang them them up for the world to see in the lobby of their midwife’s practice. Apparently. We will probably not be doing that part.

    6. Cute blog! You guys have A LOT to say! Um, but um reptiles can have e coli and other nasty bacteria on them, in the same way that chicken eggs and raw meat can so handling them in a non-pregnant state means wash-your-hands but handling them in a pregnant state – well, the stakes are pretty high is all. It would be rare but it would be bad. So. That was actually pretty good advice. *cough*. That is all.

      • thehandsomecamel

        Hey Julie! Yeah, I know — I’m guessing there’s a lot of good advice lurking in the giant mound of OMIGOD SO MUCH ADVICE!!! This was more about, you know, our feeling overwhelmed by it all. We actually really appreciated your thoughts on parenting the other night — very sensible and useful! (And we always washed our hands, I swear!)

    7. Pingback: in the blink of an eye it can all go awry « Fighting Commies For Health Insurance!

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