The Business of Being Misled

I loved the movie The Business of Being Born after I watched it a few years ago. I thought it was amazing. I even went to a showing of it up in LA and got to meet and take a photo with Ricki Lake.

I was obsessed and convinced that every mom-to-be needed to watch that movie. Hello, we need to know what we're getting into at hospitals! Or even better, opt out of a hospital and give birth at home, because it's (apparently) safer!

It wasn't just the film. But it was a starting point for me. I started reading Ina May's books (for example) and doing all kinds of research on childbirth and on home birth - everything I could get my hands on. I hadn't given birth in a hospital... how was I supposed to know what it's like? That movie played a part in making me fear giving birth in a hospital. Big time. Yes, I knew family and friends that had obviously had babies in hospitals... but I didn't really know what their experiences were like and I came to believe after watching this movie that if they didn't admit to how horrible their birth experience likely was, then it was because they just didn't know how horrible their experience likely was.

If you've read other posts on my blog, then obviously you know that I've changed my tune.

I had to go back to the movie.... I needed to figure out what it was that resonated so vibrantly with me now that made me feel so upset with the film. I decided to watch it again. And take notes. 

I realized what made me feel so upset: I find the film very misleading. And it's misleading about such an intimate topic: childbirth. And once I learned the truth, I almost felt violated for believing so much in this film. So I want to share with all of you the parts of the film that I found to be misleading.

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• Two minutes into the film, shortly after a midwife arrives at the home of a woman in labor, this pops up on the screen: "Midwives attend over 70% of births in Europe and Japan. In the United States they attend less than 8%." This comes up in the film more than once - twice in just the first 10 minutes.

It leads you to believe that if you want a birth like other women of developed countries, then you should do it at home with a home birth midwife. It doesn't talk about midwives in hospitals. It just talks about midwives out of hospitals, even though majority of births in developed countries take place in hospitals, with a midwife, OB or other doctor. Yes, you are more likely to have a midwife in other parts of the world - but the birth is taking place in a hospital. The Netherlands has the highest rate of home births, with approximately 20% of women who choose home birth with a midwife - women who are carefully screened so that only low risk women have the option. Every other developed country? It's a fringe practice, just like it is here in the USA, with a home birth rate around 1%. (Update March 1, 2017 - home birth rate in the Netherlands continues to drop and is now at 13%)

So let's talk midwives. This film is obviously very pro-midwife. Which I love because I love the midwifery model of care and have oodles of respect for Certified Nurse Midwives (CNM). But in the US, if you're having a home birth, you are likely not seeing a CNM (you might be, but you are not in the majority if you are).

Yes, in other developed countries, midwives are more popular. But they are also very different from what we have here in the United States. 

For example, in the Netherlands, the midwife candidate must first be accepted into one of four higher education academies, which is a very competitive process. Each academy follows a strict four-year curriculum and is for full-time students only. Approximately half of the curriculum is practical internships and the other half is studying science-based medicine. Low-risk pregnant women have an option of home birth or hospital birth with a midwife but if the woman becomes high-risk or if complications arise during pregnancy, labor or delivery, she is referred (or transferred) to an obstetrician. Twins, VBACs, breech, etc are transferred to the care of an OB in a hospital. One type of midwife in the Netherlands. That's it.

In the US, it is very different. There are three types of midwives in the US: 
1. AMCB-certified midwives
2. NARM-certified midwives
3. Lay midwives

The American Midwifery Certification Board (AMCB) is the Gold Standard for midwifery certification and it certifies Certified Nurse Midwives (CNMs) and Certified Midwives (CMs). The North American Registry of Midwives (NARM) certifies Certified Professional Midwives (CPMs) and Licensed Midwife (LMs; essentially a CPM that has been licensed to work in a particular state). Lay midwives have no certification, education or training requirements - technically anyone can call themselves a midwife.

You can read a full breakdown of the different types and their standards/training requirements by clicking here.

For an easy-to-read fast facts sheet about home birth in the USA, click here.

Though some CNMs attend home births, most work in hospitals - the training and education of a CNM is more similar to the training and education of a midwife in other developed countries.

Mass majority of home births in the US are attended by a NARM-certified midwife (a CPM or LM). The typical route to become a CPM or LM (and most popular route of all currently practicing CPMs) is the Portfolio Evaluation Process which consists of an apprenticeship program and passing a skills assessment and one written exam. The time length to become a CPM or LM varies on an individual basis. CPM standards do not meet the standards of the International Confederation of Midwives (ICM). No other developed country allows midwives to attain certification through the types of program that NARM allows.

If a CNM has current hospital privileges, then she may be able to continue care alongside the hospital staff in the event of a transfer. CPMs and LMs do not have hospital privileges and are legally regulated in only 26 states.

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• "They're surgeons (obstetricians). They should be doing surgery... they should not be doing normal births." This is a quote made by Elan Vital McAllister. This sentiment has been echoed many, many times by home birth advocates. 

Yes, surgery is one aspect of the job of an obstetrician. It doesn't mean that every OB prefers surgery or even likes surgery. It just means they are able to perform surgery when needed. To lump all obstetricians together like that is just stereotyping. Yes, I'm sure there are going to be some OBs out there who prefer to attend c-sections... there are going to be some who prefer to attend vaginal births. There are also going to be some with awesome bedside manner, some that could use a lesson in TLC, some that would get down on their hands and knees in a delivery room to accommodate a mom in labor, some that only want mom to delivery in one position, some that insist on use of continuous EFM, some that are prefer intermittent EFM or even a doppler, etc.... in any profession you are going to have some good, some bad, some that do it this way, some that do it another way, and some that might seem horrible to you but are precisely what another person prefers. 

This sentiment and skewed view of OBs really tainted my view of OBs. But then... I had my first baby and delivered with the on-call doctor that I'd never met before and she was great to me, as was my nurse... and  I became a doula and saw more OBs in action (even random on-call docs and Laborists).... and I started to hear more about the birth experiences of my sisters and cousins and friends (women I know and trust.... women with no hidden agenda)... the good I was experiencing and hearing was much more than the bad. 

Now, I'm not saying the bad doesn't exist. But I do think it's misleading and a scare tactic to say that OBs are surgeons and should only be doing surgery. A lot of women and a lot of OBs would disagree with that.

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• This caption pops up on the screen: "The United States has the second worst newborn death rate in the developed world." Then you hear the voice of Eugene Declerq saying "The United States is ranked poorly in terms of infant mortality."

Totally misleading and something I completely fell for when we watched this. Infant mortality is not the correct mortality rate for assessing whether or not childbirth in a country is safe. The correct rate to look at is perinatal mortality. Here's the difference: 

Infant mortality refers to the death of a baby within the entire first year of life. (reference is linked) Infant mortality does not include fetal or intrapartum deaths. Again, infant mortality refers only to babies born alive that die before they turn one. If a baby dies at 4 days old or 364 days old it will affect the infant mortality rate. So yes, it includes pregnancy and birth-related issues that may later cause a death like birth defects, low birth weight and neonatal hemorrhage but also includes things like accidents, disease, and SIDS… those are all encompassed (and more) in the infant mortality rate. According to the CDC, in the United States, SIDS is actually the leading cause of death of infants 1-12 months of age.

Perinatal mortality is the most accurate way to assess the outcomes of pregnancy and childbirth (even the World Health Organization acknowledges this). It includes prematurity, fetal mortality (death of baby in utero of at least 20 weeks gestation), intrapartum mortality (death of baby during labor and delivery) and neonatal mortality (death of baby during first 27 days of life). (reference is linked)

So, how does the US compare to other countries in this regard? The United States perinatal mortality rate is one of the lowest in the world. Our rate tied with countries like France and Japan and is actually lower than the Netherlands and the UK, surprisingly enough. (reference is linked)

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Edited to add: I quickly want to address maternal mortality. In the film it is brought up about the high rate for maternal mortality in the USA. As far as that goes, the real issue in our country is health of pregnant women. Maternal death is very rare (which is why it's measured per 100,000). And it's even more rare for healthy, low risk women.

Our number one pregnancy-related killer for women in the USA is cardiovascular disease.

Some important information to read/consider:

"In the U.S., deaths from hemorrhage, sepsis (infection) and abortion (the medical definition of which includes ectopic pregnancy, miscarriage and induced abortion) are on the decline.... But deaths from medical complications that were either exacerbated by pregnancy or started during pregnancy -- things like congenital heart disease, diabetes, obesity and kidney problems, are on the rise." (my emphasis; quote from Maternal Mortality Article << this link includes a recent study on maternal mortality around the globe)

In other words, mass majority of the women dying due to pregnancy-related issues in the USA need more intervention, not less.

And here's more food for thought on maternal mortality: Chronic Disease and Maternal Health

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• Cara Muhlhahn is the home birth midwife featured in this film. At one point she lists all of her education and training and it sounds awesome. 

She definitely sounds like she is qualified to deliver a baby. She is a CNM. She's been to nursing school and has several years under her belt delivering babies in and out of hospitals. BUT.... did you also know she has had two lawsuits against her? One for a stillborn baby and one for a baby born partially paralyzed both born at home under her care. You can read more about that here. She also does not have hospital privileges and is known for not risking out women and referring them to OB care if they become high risk (breech, twins, etc), even though in the film she talks about how important it is to screen women to make sure they are good candidates for home birth. 

The baby that was partially paralyzed was born in 2003. This film was made in 2008. I found that interesting.

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• At 27 minutes in, Cara Muhlhahn assists a woman in her water birth... she has her hands in the water and appears to be applying counterpressure presumably to help the woman from tearing... I'm not exactly sure though but in any case, she has her hands down there on the woman's vulva and then helps the mother catch the baby.

What's my issue here? SHE ISN'T WEARING ANY GLOVES!!!!!!!!!! If a midwife or doctor or nurse ever has their hands any where near my vulva and/or my brand new baby, they most certainly will have gloves on. Come ON. So unsanitary.

Can you just imagine if a MALE doctor put his ungloved hand on his patient's vulva? Did this woman in the film give consent to that? Was she aware that it happened? This just blows my mind.

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• Around 35 minutes in, they discuss c-sections. And basically, we are led to believe that c-sections happen b/c either doctors want to go home for the day or because they are afraid of getting sued. C-sections are "extremely doctor-friendly."  That's their whole spiel on c-sections. How unnecessary and scary they are for women, yet convenient for doctors.

C-sections are also life-saving. And they aren't all scary. There are some beautiful c-section stories out there of women who peacefully birth their babies into this world via cesarean. I know there is a whole slew of people out there who believe that most of the c-sections done in our country are unnecessary c-sections (or "unnecesareans"). I'm sure there have been cases when a c-section has been performed for the wrong reasons - and I'm sure that happens in a lot of developed countries, not just the US. How do we know what's unnecessary and what's not if we don't have the details on each individual case? If they are unnecessary in the moment, then why aren't women saying no to the procedure? If they are only unnecessary in hindsight (in someone's opinion), then how do we know the doctor doesn't feel the same way? How do we know the doctor that performed a c-section isn't thinking "maybe I could have let her labor longer but I was worried about her baby and I truly did what I felt was best in that moment for the health of that baby and mother." Or does it not matter what the doctors thoughts are about it? Once deemed unnecessary by someone - someone that may or may not have any medical expertise in obstetrics - then it becomes the doctors fault and he or she is evil for that potentially unnecessary c-section. The doctor had no good intention in their actions. It was purely out of convenience.

For those who were coerced into a c-section they did not want when there was truly no medical need for it, when labor could have continued on without the mother or baby in danger, then that is horrible. And I don't dismiss those. B/c I know that has happened (and continues to happen). I think sometimes there is more to the story that I don't know, or maybe that even the mother doesn't know - but not always. Sometimes yes, convenience may be the driving factor in a woman getting a c-section. And I do not believe that is OK. At all.

However, I do not believe this overall negative attitude toward c-sections is serving women well. It's filling them with fear and doubt and a sense of failure for those that need c-sections. Empower women with information, such as evidence based practices that have been proven to lower a woman's chances of a c-section. Don't just make sweeping and negative generalizations about c-sections being scary, unnecessary and extremely doctor-friendly. 

Fast forward for a moment to the end of the film when the on-screen producer, Abby Epstein, needs a c-section for her breech, pre-term baby (she says she is about 35-36 weeks pregnant)... what does Ricki Lake say to her afterwards (8 months later) when they are discussing her birth? She so kindly asks "Do you feel cheated? Do you feel like you missed out?"

Nice.

I can understand wanting and desiring the birth to go one way, then having it go another and feeling upset about it. It could have been a totally terrifying experience for her and if it was, hopefully she has found a way to sort through that. But this was evidence based care that she received. I don't think she needs someone poking at her to see if she feels like she "missed out," making her feel guilty and insinuating that she was cheated in some way. How about asking "how do you feel about the way that it all happened?"

Abby Epstein then goes on to say that her son "probably would have survived" a vaginal birth... and then talks about how they had a hard time bonding and a hard time breastfeeding. And she thinks this is from the C-section??!!!

The C-section is what is blamed here for her "lack of bonding" and the breastfeeding issues? How about the fact that her baby was in the NICU for a few weeks? How about the fact that her baby was very underweight due to IUGR, weighing only 3 pounds 5 ounces? How about the fact that he was pre-term? Why is the C-section getting the blame for her postpartum issues?? The C-section SAVED her baby. She would not have a child to bond with or breastfeed at all if that baby wouldn't have survived birth - which is completely possible given the state of her baby and his presentation.

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• What makes homebirth safe? According to Eugene Declerq, outcomes for home birth are very good when "the people there are trained, that there's backup, that they can transfer to the hospital quickly." 

There are other studies that have been done in other countries that show that home birth, under those circumstances, can certainly be a reasonably safe option. But again, those are different types of midwives with different health care systems. You cannot use studies done in other countries to try to demonstrate the safety of home birth in the United States. You're comparing apples to oranges.

What we know about home birth in the USA is that the outcomes are much worse than hospital births. Every study we have demonstrates this. And I'm not referring to the Wax study. I'm talking about:
The 2015 New England Journal of Medicine study
The 2014 Midwives Alliance of North America (MANA) study
The 2014 Cornell study
The 2013 Grunebaum study
The 2013 Cheng study
The 2005 BMJ study

These home birth outcomes are not good:

 (image from the 2014 Cornell study published in AJOG)

Notes from the above chart:
NNM = neonatal mortality
BC = birth center
Home "Other" refers to accidental home births (a woman intends to give birth at hospital or birth center but accidentally gives birth at home unattended) or planned, unattended childbirth (a woman purposely gives birth without a professional care giver present).

Home births in the USA aren't just more dangerous than USA hospitals, home births here are more dangerous than home births in other developed countries. Here's some food for thought regarding our awful home birth outcomes from this piece by the Coalition for Safer Home Birth (fully referenced, follow link for the studies used):

"Looking at combined intrapartum plus early neonatal mortality rates (early neonatal death means the baby was born alive but died sometime in the first seven days), a baby is three times more likely to die at a home birth in the USA with a mortality rate of 1.71/1000 versus only 0.64/1000 babies dying in the Netherlands.
        Let’s give a little context to what these numbers mean: for every 10,000 babies born at home in the Netherlands, only 6-7 babies will die; for every 10,000 babies born at home in the USA, 17-18 babies will die. That is an excess of 10-12 babies that die per 10,000 births. According to the CDC Wonder Database9, in 2013 (the most recent year available) in the USA there were over 40,000 births that took place in a non-hospital setting (home or freestanding birth center) with a midwife in attendance, which means, within a single year, 40-48 babies died who would have lived in a safer home birth system like that of the Netherlands."

And also, when Eugene Declerq mentions being "trained" I have to wonder what he means by that? Does he mean the training of a CNM? CM? CPM/LM? Lay midwife? The training varies greatly from one midwife to the next in the US - to which is he referring? If you'd like to see an interesting breakdown on the qualifications so you can see just how little it potentially takes in order for one to get the title Certified Professional Midwife or Licensed Midwife, check out this post at the Safer Midwifery for Michigan blog.

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• "Today in the United States, we know that there is serious increase in minimal neurological problems in children and in attention deficit disorders, in autism, and all these things are increasing at the same period of time that we're increasing all these obstetric interventions," says Marsden Wagner

What a horrible way to try and scare women away from childbirth interventions. No studies or evidence offered to support this nice little scare tactic. This is called correlation (not to be confused with causation). These things could be completely unrelated! Let me explain.... take this graph below, for example. It represents data for organic food sales compared to autism rates. It clearly shows that the rate of individuals diagnosed with autism increased at the same time and same rate that organic food sales increased. One look at it and one might think "organic food causes autism!!" 

Image from io9: On Correlation, Causation and the Real Cause of Autism

But can we really conclude that autism is caused by organic food? Of course not. But that is exactly what Marsden Wagner is doing: using correlation and trying to convince people that it means causation. Don't fall for it! This is just a crappy scare tactic. Beware the correlations and cherry-picked data, my friends.

This next and final part disgusts me. DISGUSTS me.

• Michel Odent says this: "With mammals in general, there is immediately after birth, a short period of time which will never happen again and which is critical in mother/baby attachment. Until recently, in order to give birth, a woman, like all mammals, is supposed to release a complex cocktail of love hormones. As soon as baby is born, when mother and baby are together, both of them are under the effect of a sort-of morphine, an opiate, natural morphine endorphins. We know the properties; they create states of dependencies. Addiction. When mother and baby are close to eachother it is the beginning of an attachment." While he says this in the background, you are watching moms/babies shortly after birth at home births. They are over-the-moon with happiness, cuddling their sweet little gooey babies. 

He continues, "But today, most women have babies without releasing this flow of love hormones. I'll just give an example of animal experience. In general, if you disturb the hormonal balance of a female giving birth, it's simple, the mother does not take care of her baby. It's simple, if monkeys give birth by cesarean section, the mother is not interested in her baby. It's simple, easy to detect on an individual level. So you wonder but what about our civilization, what about the future of humanity, if most women have babies without releasing this cocktail of love hormones, can we survive without love?" While he's saying this in the background, you are watching epidurals being placed and c-sections and women who look disconnected from the process. 

Wow. He is reaching pretty far there. Really far. No love cocktail at birth = humanity doomed to try and exist without love. WHAT? Yes, ladies who have had or will have a c-section, you aren't going to feel bonded to your baby. Sorry, but you won't have that "love cocktail" that enables you to feel that bond. We're just like monkeys after all so you probably won't even feel interested in your baby. Moms who have had or will have interventions, please know that if our species stops surviving due to lack of love, it's your fault. For moms who adopted their children and experienced no pregnancy or birth hormones what-so-ever with their adopted child, well, yikes, according to Odent you are pretty much screwed!! All of humanity is!

What a load of nonsense. Horrible, offensive nonsense. 

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These are my main issues with the film, the things I found to be the most misleading. Does this mean I'm anti-home birth?? Nope. Read here to find out how I even got started writing about all of this. But this film is misinformation and full of scare tactics. They clearly want women to take with them the message that if you choose home birth, then you are empowered, you know how you want to do things, you are a go-getter (and it's not just insinuated, there are direct quotes, like this one from Marsden Wagner "If you really want a humanized birth, the best thing to do is to get the hell out of the hospital")... and the rest of us women who choose to give birth in the hospital? We are not empowered, we don't know how we want to do things, we don't desire a humanized birth, we are just willingly poked and prodded when we go to L&D, basically. Amiright, Ricki?

I suppose since it's a documentary it's bound to be biased. Clearly, this film is biased toward scaring women away from hospitals and childbirth interventions.

I remember discussing the film with my cousin a couple years ago. She was not impressed at all by the film and I couldn't understand how that could be possible! We went back and forth about it and just couldn't see eye to eye. I thought, maybe it's b/c she's a little younger than me or something, she just doesn't get it. 

Well, Juls, now I get it. :)


Edited to add: I was interviewed by the New York Times regarding this film. Click here to read about it.