To the producers of “The Doctors”:

It is with great disappointment that I watched your show that aired on Wednesday, September 10, on the topic of home birth.  It was touted as a look at both sides of the issue, under the guide of helping an undecided couple in their sixth month of pregnancy to “make an informed choice” about whether to have their baby at home or in the hospital.  There were several gross overdramatizations, omissions, and outright mistruths that were displayed in this half-hour segment that deserve to be corrected.

In the intro segment, Dr. Ordon, a plastic surgeon, interrupted the host mid-sentence to confidently state right from the start that “there’s no question that you’re safer pre-, intra-, and post-pregnancy in the hospital.”  This is a common misunderstanding by doctors who haven’t read any of the research on home birth.  Many, many research studies over the past four decades have shown that for low-risk women with normal healthy pregnancies, there is no more risk at home than there is in the hospital.  The most recent study, published in the British Medical Journal in 2005 (1), studied over 5400 home births attended by Certified Professional Midwives and found that no more babies died at home than in the hospital, but there were far lower rates of medical intervention at home birth.  The belief that the hospital always equates to higher safety is a myth and it does not serve women to perpetuate it.

Also in the intro segment, Dr. Sears, who has four siblings who were born at home, explained that “the vast majority of home births don’t go bad.  It’s a really safe experience when done the right way, with a doctor present — my dad, who is a pediatrician — or a certified midwife…” (interrupted here by Dr. Masterson) “Most of those horror stories are uncertified midwives who are too afraid to seek medical help when something goes wrong.”

Dr. Sears is correct that the vast majority of homebirths go off without a hitch. According to the BMJ study (1), only 12% of women needed to go to the hospital in labor, and the majority of those were for pain relief or labor that had stalled out. In 17 states, midwives have no path to licensure (2) and often have to practice under the radar, so bringing a woman to the hospital can indeed be a tricky situation.  For this reason, amongst others, it is critical to advocate for midwifery licensure in all 50 states so that this process can occur more safely.  In states where midwives are licensed and legally practicing, there can often still be tremendous hostility from hospital staff when transporting in a homebirth patient who needs help.  This is where doctors, nurses and midwives need to work together for safe mothers and babies, not against each other.

After the commercial break, the only doctor chosen to talk with undecided parents-to-be Billy & Jenny was Dr. Masterson, who obviously had an anti-homebirth bias and did not try to hide it.  She assures them, “We’re here to help you make an informed choice.”  Unfortunately, her personal bias came through loud and clear for the rest of this segment, and the information that was given to this couple was anything but impartial or balanced.

Dr. Masterson’s main point was that “If something goes wrong, it can go wrong really fast, and really bad.”

This is not typically the case.  For low-risk women (the only kind that should have a home birth), most complications unfold slowly and can be remedied easily before they become actual problems.  Also, many medical interventions that can actually lead to complications simply are not done by midwives in the home setting.  When you’re an OB with 10 patients in labor at the same time and can’t give much attention to any of them, it probably does seem like problems happen “really fast and really bad.”  At home, midwives provide one-to-one support (and often there are two midwives) for the duration of labor, birth and several hours afterward.  Because of this intensive support and experience in recognizing potential problems early, only 3% of midwife-attended homebirths required emergency transport to the hospital in the 2005 BMJ study (1).

Deanna, an audience member who had her baby in a birth center, reported her horror story of her baby having a rare kidney disorder that had been missed, despite having had four ultrasounds during her pregnancy.  The baby was transported urgently to the hospital 45 minutes after the birth, where she reported that the doctors didn’t scrub in before inserting chest tubes in the baby (which in itself elevates the baby’s risk of serious infection!).  This story has absolutely nothing to do with having the baby in the birth center, but rather several poor ultrasounds.  It’s almost inconceivable that fetal kidneys that were the size of adult kidneys were missed on ultrasound — not once, but four times!  If this problem had been identified by one of those ultrasounds, this woman would likely have been risked out of a birth center birth by her midwives.  Why was this woman chosen to tell her story as part of a home birth vs. hospital debate?  It’s clearly more appropriate for a show on medical mistakes.

Dr. Masterson gave a very dramatic shoulder dystocia demonstration, explaining the following maneuvers:

• “sometimes we even have to break the shoulder” – it’s actually the baby’s clavicle or humerus that is broken, and this is close to a last-resort situation, but very dramatic for her to bring up so early
• “you have someone actually pushing down on this woman’s uterus to try to get the baby out” – this is absolutely never done because it can impact the baby’s shoulder even tighter into the pubic bone
• “then you actually cut through the rectum to try to get the baby out” – a shoulder dystocia is about the shoulder being stuck behind the pubic bone, not in the rectum
• “sometimes they cut right between the pubic bone” – the pubic bone is not actually “cut”, but rather dislocated at the ligament in the middle, which is another last-resort effort that disables the mother for months; the visualization brought to mind by Dr. Masterson’s comment was dramatic, though
• then she explains the Zavanelli maneuver, where the baby is pushed back up the vagina into the pelvis and removed by cesarean

It is important to note that with the exception of the Zavanelli maneuver, which is done only in the rarest situations, Certified and Licensed Midwives have been trained in the very same maneuvers as OBs for resolving a shoulder dystocia, sometimes more.  It is also important to understand that in a small level III trauma center, which most community hospitals are, a surgical team and anesthesiologist are not available 24/7 and must be called in from home to perform a cesarean, making it virtually no different than transporting a woman from the home setting to the hospital.

Jenny, our undecided mother-to-be. then asked a very prudent question: “What percentage of the births that you see in the hospital have an issue like this?”  Dr. Masterson quickly replied: “It can be like 10 to 15%, depends on the population.”

A standard obstetric text gives the incidence of shoulder dystocia as 0.15 to 1.7% of all vaginal deliveries (3).  A recent study in Obstetrics and Gynecology gives an incidence of 0.6% over a span of 14 years and over 80,000 deliveries (4).  Dr. Masterson’s answer was inflated by 20 times, which is outrageous.  This is not “informed choice” — this is fear-mongering and manipulation to convince Jenny to do what Dr. Masterson wanted her to do.  It is exactly the type of thing that drives smart women away from the medical system.

Dr. Masterson gave an equally dramatic description of fetal distress, saying “they can get distressed right at the very end, and we call that a CRASH!”; “…all of a sudden the baby can’t get any oxygen”; “…all of a sudden it dips down and it doesn’t come back up, and we call that a crash, and we run somebody back for a c-section to get that baby out, and you need to get that baby out in 5 minutes.”

Fetal distress of this sort rarely happens in the way that Dr. Masterson explains it (although it must seem that way to a doctor with 10 women in labor).  Healthy babies rarely “crash” at the end of labor, but rather tend to show us that they are distressed by heart rate decelerations during labor that may resolve with simple interventions like changing the mother’s position, or they persist and may get worse over time.  If you’re paying attention, you don’t have to get to a “CRASH” scenario to resolve it.  Midwives listen to the baby’s heart rate during labor according to evidence-based protocols and are trained to assess the problem and either attempt various ways to resolve it or transport the mother to the hospital for more intensive monitoring and appropriate intervention.

Also, remember that when this happens in the smaller hospitals, the surgeon and/or anesthesiologist often must be called in from home, or the mother has to be transported to another facility, which certainly does not facilitate a 5-minute cesarean.  Dr. Masterson’s dramatic description makes for good television, but not for appropriate informed choice to a couple who is trying to make an important decision.

Host Travis Stork then chimed in with “Things can happen to the mom too, like a postpartum hemorrhage where literally, the mom is bleeding to death from her uterus.  We’re just trying to cover all the bases here, give the arguments for and against home birth.”

What many people don’t understand is that Licensed Midwives are trained to handle postpartum hemorrhage in exactly the same way obstetricians do in the hospital, with the same medications that are available in the hospital.  The rate of maternal death in this country, while not the best in the world as we might expect it to be, is 0.013% or 13 in 100,000 (5).  While maternal deaths are extremely rare and are due to various reasons, the rate has actually increased in recent years, largely due to the rising number of cesareans that are performed, not because women are having babies at home.

Dr. Masterson showed a dramatic image of a baby with the umbilical cord wrapped around its neck, an occurrence that is actually quite common and rarely dangerous.  She explained that “sometimes you can just loop the cord around the neck, but other times, that’s what makes the baby crash, because it acts as a noose.”

It is important to remember that fetuses do not breathe air before they are born.  They are aquatic, living in amniotic fluid.  The baby receives its oxygen through the blood.  The cord could not “act as a noose” and cut off the baby’s air, because the baby is not breathing through the windpipe.  This is a common scare tactic.  In rare cases where the cord is extremely short or is wrapped around the neck several times, it can hinder the baby’s descent through the pelvis and the cord can be stretched and pinched.  There is no difference between the way a doctor would manage this situation in the hospital and the way a midwife would manage it at home, which would be to loop the cord over the baby’s head when it comes out, to somersault the baby out, or as a last resort, to cut the part of the cord that is around the baby’s neck and deliver the rest of the baby immediately.

Dr. Masterson explained that modern LDRs (labor/ delivery/ recovery rooms) are trying very hard to “mimic homes” with “rooms that are nicer than my bedroom at home!”  For most women, there is much more to being in the home environment than just a pretty shade of paint on the walls.  Women choose homebirth because they want more control over their own experience; because like the undecided couple on the show, they don’t feel that pregnancy and birth is a sickness that needs to be managed in the hospital; because they are afraid of hospitals and doctors who try to manipulate them and strip them of their identity; because they don’t want themselves or their newborn babies to be exposed to super-bacteria; because they don’t want their babies taken away from them after the birth for reasons that can be delayed until later (weighing, heel poke, shots and eye ointment); because they feel that a 1-in-3 chance of walking out of the hospital with a cesarean (or an episiotomy, or an epidural when they wanted a natural birth, or a number of other interventions) is just too high of a risk.  Hospitals can’t placate women with pretty pictures and mauve paint in the LDRs; listen to them!

Regarding the couple in the audience who had the “awesome” hospital birth, the woman credited it all to Hypnobabies, which is a method of childbirth preparation, not about the hospital or the doctor.  She also smartly hired a doula, which has been shown to reduce the incidence of hospital interventions and result in greater success of natural birth (6).

Back to our undecided couple.  Jenny asked, “There’s this feeling of fear around giving birth in the hospital that the doctor will rush you into something that’s not necessarily necessary, but kind of is more to their advantage to getting out of there faster, getting back home to their families… how much of that actually goes on inside a hospital?”  Dr. Masterson immediately replied “Zippo!  You do not go into obstetrics for a nice schedule.”

I would strongly encourage Dr. Masterson to read the “Listening to Mothers II” report (7) that was recently released by Childbirth Connection which states that over 40% of women had their labors induced by their care providers, both for medical and non-medical reasons; 55% of women received pitocin to speed up their labor once it had begun; and nearly 60% of women had their membranes broken, also to speed up labor.  A quote given by several mothers in the report was “I think they use Pitocin to hurry up your labor so that the doctor/staff can get done.”  Dozens of women writing in to this forum have described the same thing.  Perhaps Dr. Masterson does not do this sort of thing unnecessarily, but the statistics support it and the perception by the women who have their babies in the hospital is that it does indeed happen quite frequently, and this is another reason why more and more women are choosing homebirth.

Our host Dr. Stork concluded the segment by saying “I appreciate everyone for giving their side of the debate…”

There was only one side of the debate that was presented on this show.  Dr. Sears spoke for 35 seconds at the beginning of the show about the realities of home birth, only to be rudely interrupted and shouted down by the other two doctors (and obviously edited shorter as well).  The homebirth couple in the audience received a total of 55 seconds of air time before Dr. Masterson interrupted them as well and turned the focus back to her own views.  No midwives were represented on the show.  A total of 90 seconds of one side of the debate and 30 minutes of the other is hardly a fair look at the issue of home vs. hospital birth.  I think it’s clear that the intention was never to help anyone “make an informed choice.”

Wendy Gordon, CPM, LM

Certified Professional Midwife

Licensed Midwife

Portland, Oregon

References:

1. Johnson KC and Daviss BA. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. British Medical Journal, 330:1416-1422.
2. Direct-entry midwifery state-by-state legal status.  Midwives Alliance of North America.
3. Gabbe SG, Niebyl JR, Simpson JL. (2002). Obstetrics: Normal and problem pregnancies. Philadelphia: Churchill Livingstone.
4. MacKenzie IZ et al. (2007). Management of shoulder dystocia: trends in incidence and maternal and neonatal mortality. Obstetrics and Gynecology, 110:1059-1068.
5. Medical News Today. (2005). Maternal mortality rate in U.S. highest in decades, experts say. 
6. McGrath SK, Kennell JH. (2008). A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates. Birth, 35(2).
7. Declercq ER, Sakala C, Corry MP, Applebaum S. (2006). Listening to Mothers II: Report of the second national survey of women’s childbearing experiences. New York: Childbirth Connection.
   

Wendy, your detailed and factual critique is fantastic, and I hope “The Doctors” are listening! I have had both a hospital birth and a home birth, and the difference between the care and treatment I received for the two cannot be understated! In the hospital, I had to fight tooth and nail to avoid unnecessary interventions and have the natural birth that my OB had supposedly agreed to, and even had to fight off pressure to induce for no medical reason other than being “past” my arbitrary due date. I had no high risk factors or complications, and there was no reason for them to pressure me, other than outdated hospital policies to CYA. One doctor actually told me I’d hemmorhage if I didn’t get an IV. What the hell kind of thing is that to say to a laboring woman? I knew he was lying; that they could give me pitocin without an IV if needed, but I wanted to try and breastfeed my (drug-free) newborn to naturally raise my Oxytocin levels first. Disgusting scare tactics! I will never deliver in a hospital again! Dr. Masterson needs to get her facts straight and realize that educated women will not cave to misinformation and fear tactics anymore!

Wendy, thank you SO MUCH for breaking this show down to show the disservice that it does to women trying to gather information and make a choice. I agree with you 100% and am so glad that you cited all the latest research. How come the show didn’t do similar vetting before it aired? If they had, the show would have obviously had a different tenor. That is, of course, if they were intending to be fair and balanced. Women can go to www.mothersnaturally.com for more information.

Thank you! Thank you! Thank you!
I had 3 terrible hospital births full of unnessary interventions! When Dr. Masterson said ZIPPO!! I literally began to cry! I feel so assaulted by the doctors that attended my births and that word (ZIPPO) Just shattered me! How dare she use these scare Tactics. I can’t stand the Lies!
Your letter speaks the truth and I hope many many women read it!

Wow! Thank you so much for your post. It was very professional and very accurate, something the Doctors show should learn. Did you also send your letter to the producers of the show? You should also send your thoughts to Dr. Phil and Robin McGraw. Their son is producing the show.

Thank you again,

Lisa
Homebirth mom,Senior Midwife Student, Former NICU Respiratory Therapist.

WOW! thank you for such a detailed truly INFORMATIVE post. i wish more people would be willing to speak the TRUTH.
i’m not a homebirth mom BUT i fully support home as a safe choice.

Thank you wendycpm.  Your detailed factual rebuttal was very informative.

Thank you so much for your well thought out critique of the show. I just saw it today and was infuriated. I posted a question asking why the risks of hospital birthing were not presented, but the post was either deleted or never showed up for whatever reason.

I was floored when Dr Masterson said “zippo”. I actually yelled at the TV “Are you kidding me?” Talk to any mom that recently had a baby, cruise through some forums, heck, even my own personal experience with hospital birthing would argue otherwise.

Hi, all & Happy New Year! I (hopefully) can give you some insight as to why doctors are so negative about home births.  Doctors (and hospitals) are afraid of the potential malpractice suits. I work for a company that administers Structured Settlement payments to persons (and family members) who have been injured due to birth related injuries such as shoulder dystocia (among other personal injuries) and the doctors are petrified that if they (or their midwives within their practice) gave the green light to a mother to have a home delivery, they would be sued.  So they try to scare women into having their births in a hospital so their liability is lowered.  I believe that if a mother is at low risk, she should be able to dictate whether or not she wants to have a home delivery.  What the concern should be is for the comfort and well-being of the mother, since being in familiar surroundings can enable her to have a positive birthing experience.  Besides, I know some midwives who are better suited to help in the delivery than the doctor due to their compassion.  I am not knocking all obstertricians and/or OB-GYNs’, but it seems that some of them (and I have had this experience as well) tend to treat their patients as if you are on an assembly line with a time clock hung around your neck, while the midwife tends to take more time to explain procedures and experiences with you.

I was low risk but had a difficult birth and was very glad to have been in a hospital. I ended up with a blood transfusion. Might not have lived through it all if I had been at home.

Loved your post. Adding to your refernce list. Ricki Lake (who had her second baby at home) and Abby epstien (I hope I spelled her name right) produced a film called “The Business of Being Born”. It gives accurate insight into hospital and homebirths. www.thebusinessofbeingborn.com

KSandru, you make an excellent point, and I suspect that you are correct that the fears of liability often overshadow the advice given by OBs.  In an ideal world, care providers would be honest about this and own it for what it is, rather than displace that doubt and fear onto the woman regarding her body and her baby’s health.  Women deserve to be treated as adults and told the truth, and it comes off as rather unethical to scare them into making decisions that may not be in their own best interests, or that of the baby.