The homebirth playbook for lobbying legislators

In Challenging Medicine: Law, Resistance, and the Cultural Politics of Childbirth (Law & Society Review, Volume 39, Number 1, 2005), Katherine Beckett and Bruce Hoffman explore the public face of the homebirth movement.

Homebirth midwives have set themselves some key tasks. No, not obtaining a better education, not monitoring their outcomes, and not instituting appropriate disciplinary measure for midwives who, through their lack of education and training, hurt patients. The key task they have set for themselves is obtaining more money. They want access to insurance company reimbursements, and they can only get that by becoming licensed.

You might think that homebirth midwives, including CPMs (certified professional midwives) face an up hill battle. After all, they are a second, inferior class of midwife; they have less education and training than any midwives in the first world; they are ineligible for licensure in any other industrialized country specifically because of their lack of education and training. But good PR can elide a multitude of sins, and playing fast and loose with the truth doesn’t hurt either.

Beckett and Hoffman (who are sympathetic to the homebirth movement) examine the rhetoric used in efforts to gain licensure for direct entry midwives. They note that alternative childbirth advocates have crafted their claims for public consumption, modifying them to appeal to legislators, and, when deemed necessary, concealing their true beliefs.

Homebirth lobbyists employ techniques that can be categorized as follows:

Birth activists located their claims and arguments in a narrative of tradition and continuity, depicting midwifery (like motherhood) as an age-old practice and long-honored profession …

They conveniently neglect to mention that certified nurse midwives are heir to that respected profession, not themselves, a bunch of high school graduates who can’t be bothered to get a college level degree or a real midwifery degree.

Birth activists have gone to great lengths to assure lawmakers that their primary concern is maternal – and especially infant- safety… One simply must be concerned about safety in order to be seen as credible. For this reason, many activists have stressed that midwives screen their clients carefully and serve only those deemed ‘‘low-risk.’’ In fact, one of midwives’ main concerns about licensure is that it necessarily limits the kinds of clients they may legally attend and requires them to refuse to serve a ‘‘high-risk’’ client … In this way, birth activists seeking midwifery licensure have been compelled to adopt a stance that many find objectionable.

This is simply a lie. If safety were their primary concern, they would get real midwifery degrees. Although when speaking for public consumption they stress screening, the reality is that they accept anyone who will pay. In reality, they ignore safety standards, and they make vigorous efforts to remove standards. Oregon is a perfect example. Melissa Cheyney, head of the Oregon Board of Direct Entry Midwifery, is on record insisting that any birth junkie who wants to call herself a “midwife” should be entitled to do so.

Midwives and their supporters have [attempted] to position themselves as the truly scientific ones. Toward this end, birth activists cite a seemingly endless supply of epidemiological studies that conclude that planned home births attended by trained birth attendants are ‘‘as safe or safer’’ than hospital birth for low-risk women. In fact, their lobbying materials consist largely of abstracts of such studies, occasionally accompanied by an article concerning high rates of cesarean section or rising medical costs.

That’s the homebirth canard du jour. What could sound more impressive that shouting from every hilltop that obstetricians ignore the scientific evidence, while homebirth midwives are slaves to scientific rigor? The fact that the claim is a lie is beside the point. Homebirth midwives neither know the truth, nor care.

If you say “obstetricians ignore the scientific evidence” fast enough, people won’t stop to consider if it makes sense. But if we do stop to consider it, we might amplify it as follows:

We are supposed to believe that obstetricians (with 8 years of higher education, extensive study of science and statistics, and four additional years of hands on experience caring for pregnant women), the people who actually DO the research that represents the corpus of scientific evidence, are ignoring their own findings while homebirth midwives (generally high school graduates with no background in college science or statistics, let alone advanced study of these subjects, and limited experience of caring for pregnant women), the people who NEVER do scientific research, are assiduously scouring the scientific literature, reading the main obstetric journals each month, and changing their practice based on the latest scientific evidence.

… [F]aith in technology is only part of the cultural story; discourses expressing fear of technology gone awry also abound, and many contemporary social movements -especially the environmental movement- highlight the risks associated with modern technology to great effect. The idiom of ‘‘the natural’’ has proliferated in this context, and the spread of natural foods, natural clothing, and natural medicine suggests that this rhetoric has significant cultural appeal. The importance of living and giving birth ‘‘naturally’’ has likewise been a key theme for the alternative birth movement…

Oh, the irony. Homebirth midwives will use any technology at their disposal: computers, the internet, e-books published on demand to rail against technology at birth.

This definition of professional midwifery is quite useful to those seeking licensure. First, it neatly distinguishes midwifery from medicine to bolster the case that midwives are neither medical practitioners nor para-professionals, but rather autonomous health care providers with a distinct area of expertise (i.e., out-of-hospital birth)…

Yet even as they tout their professional qualifications, midwives are (more quietly) modifying what it means to be a professional. Many in the midwifery community have been concerned that the extensive educational requirements associated with professionalization will exclude midwives already trained through apprenticeship, as well as aspiring midwives who are unable to relocate and/or pay for a formal education. In order to include such women, MANA acknowledges ‘‘multiple routes of entry’’ to the profession and allows applicants for the CPM degree to acquire their knowledge and skills through either formal education or apprenticeship; a woman whose education ends with high school can therefore be certified as a CPM. In public and political forums such as state capitol buildings, most midwives do not stress that they may be certified without extensive formal education …

In other words, as I have written repeatedly, homebirth midwifery is about letting any birth junkie call herself a “midwife” and bill for her services and has nothing to do with protecting babies and mothers.

Midwives and their supporters consistently frame this debate as one centrally about individual choice, arguing vigorously that women have the right to choose where and with whom they will give birth. As the legislative sponsor in California stated, ‘‘At the core of this issue are two simple beliefs: first, that childbirth is a natural process of the human body and not a disease. And second, that a parent has the responsibility and the right to give birth where and with whom the parent chooses . . .’

Choice is red herring. The reality is that women already have the right to give birth wherever they choose, and they already have to right to surround themselves with the friends, family and attendants they prefer. The “choice” that is at stake here is the homebirth midwife’s “choice” to charge money for her attendance.

Turf Battles
Birth activists further justify their emphasis on choice by arguing that planned home birth with a midwife is a safe choice for most women. As was discussed previously, the claim that midwife attended out-of-hospital birth is relatively safe is supported by references to scientific studies and to midwives’ professional qualifications and expertise. But it is also supported by the suggestion that the doctors who oppose midwife-attended births are engaged in a ‘‘turf battle,’’ and thus that medical claims about lack of safety are suspect…

Through such statements, birth activists invoked a kind of David and Goliath imagery, raising suspicions of opponents’ veracity by highlighting organized medicine’s professional and economic interests in the outcome of these debates.

As I wrote recently, framing the issue as one of “turf” has important advantages for homebirth advocates. At a deep (possibly unconscious) level, most homebirth advocates suspect that homebirth may be risky for babies. The few professional homebirth advocates who are familiar with the literature and statistics know that homebirth increases the risk of neonatal death. Moreover, the idea that being far from emergency personnel and equipment in the event of an emergency defies common sense. Therefore, they’ve chosen to frame the argument as doctors bullying midwives over “turf.”

These claims are the public face of the homebirth movement. I have made it my task to look beyond the public face to the reality: the shoddy training of homebirth midwives, the extensive efforts to stymie any regulation and, above all, the ever growing number of deaths and serious injuries that occur at the hands of homebirth midwives.

A version of this piece appeared on Homebirth Debate in January 2007.