Why women hire dangerous homebirth midwives and why preventable deaths are inevitable


Yesterday I wrote about the tragic death of homebirth advocate Caroline Lovell, who bled to death while a midwife blithely ignored her pleas to call an ambulance. That midwife, Gaye Demanuele did not relent until Lovell suffered a cardiorespiratory arrest and by then it was too late.

A number of homebirth advocates have insisted that Lovell did not die because of homebirth; they blame the midwife’s horrific negligence in ignoring basic safety measures. But Lovell hired Demanuele specifically because both believed that ignoring basic safety measures was critical to achieving the desired homebirth experience.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Preventable deaths are inevitable at homebirth because identity creation is the focus, not safety.[/pullquote]

Lovell was a high risk patient. Three different physicians told her that she was not a candidate for homebirth because of her history of retained placenta and postpartum hemorrhage. Lovell ignored the basic safety criteria that risked her out of homebirth and Demanuele attended her because she, too, believed that ignoring basic safety standards was completely acceptable.

Why would a pregnant woman and her midwife conspire to ignore safety standards?

If you want to understand homebirth, you need to understand this: homebirth is not about birth or about a baby; homebirth is about the creation of meaning and identity.

As Rutherford and Gallo-Cruz write in Great Expectations: Emotion as Central to the Experiential Consumption of Birth:

…[W]hen selecting alternative providers of birthing services, women are not simply purchasing health care, they are choosing and purchasing guides for and co-creating an event that is idealized and emotionally charged.

No less an authority than anthropologist and homebirth midwife Melissa Cheyney concurs. Cheyney explains in Reinscribing the Birthing Body: Homebirth as Ritual Performance:

As a socially performed act of differentiation, homebirths are constructed in opposition to dominant ways of giving birth …

In other words, homebirth has little to do with birth and virtually nothing to do with the baby or with safety. It is a piece of performance art whereby women signal an identity in opposition to medical authority.

A homebirth advocate hires a midwife not to catch the baby or even to support her through labor, though that is included. According to Rutherford and Gallo-Cruz:

Midwifery is not simply a service to be purchased, but is also an embodiment of cultural meaning; through its consumption women make the ordinary experience of childbirth a symbolically charged and extraordinary experience of “meaning transfer.” … [Campbell] argues that “the essential activity of consumption is…not the actual selection, purchase or use of the products, but the imaginative pleasure seeking to which the product image lends itself …

The choice of midwife is extremely important:

… [T]he midwife’s role is critical … because she is fluent in the alternative symbolic orientations to and understandings of natural birth … [She] also provides her association and emotional support either by sharing beliefs about the experience or by affirming the woman’s right to assign her own unique beliefs to birthing. This seemingly simple service of association and presence is a critical social need in the context of extraordinary experiences and rites of passage that depend a shared cultural consensus for their significance.

Had Lovell merely wanted a safe birth, she could have gone to the hospital where she undoubtedly would have survived. But Lovell wanted a homebirth because a safe birth was not the goal; the goal was the pleasure she found in anticipating her defiance of medical authority and the anticipation of pleasure she would experience boasting of her success in the face of being counseled that homebirth was too dangerous for her.

She hired Demanuele because Demanuele shared her belief in the symbolism of homebirth and affirmed her desire to ignore basic safety standards. Lovell wanted to create a piece of performance art and Demanuele understood that and was fully committed to helping her achieve the desired performance.

I cannot begin to imagine Caroline Lovell’s horror when she realized that Demanuele was willing to go further than she was to achieve the idealized birth they had agreed upon. Lovell was dying and she knew it. She was going to leave her children motherless and she knew it. She literally begged for her life and Demanuele ignored her pleas. She bled to death slowly, surrounded by people who could have helped her, but chose not to do so.

Of course by hiring a midwife instead of having an unassisted birth, Lovell was implicitly relying on Demanuele’s greater knowledge to recognize and treat an unforeseen serious complication. I doubt Lovell could have imagined that Demanuele would be willing to let her have a cardiac arrest before she would give up on an idealized birth experience they had planned. Who could imagine that?

But the difference between Demanuele and many other homebirth midwives is merely one of degree. Midwives who attend high risk homebirths, and there are many, do so because they share with their clients the belief that birth is an opportunity for meaning making and identity construction.

Or as Cheyney might say:

… It co-opts and restructures what Babcock has called “symbolic inversion,” where the gradual psychological opening to new messages characteristic of the liminal or transitional period of ritual is intensified by metaphorically turning elements of the normal belief system upside-down or inside-out.

It is inevitable that preventable deaths will occur at homebirth when symbolism is the focus instead of safety. Homebirth midwives and homebirth advocates “trust” that complications will not occur and, if they do, there will be plenty of time to deal with them. In waiting for complications to occur instead of acting preemptively to prevent them, homebirth midwives and their clients routinely risk death. It is much harder to treat a complication than to prevent one; it is much more dangerous, too. Inevitably, midwives will judge wrong and by the time they understand what is happening, the life of a baby or mother or both is forfeit.

The problem with homebirth isn’t merely structural (being far away from emergency personnel when an emergency occurs), it is philosophical. Nothing more clearly illustrates how viewing birth as an opportunity for identity creation leads inevitably to preventable death than the hideous experience of Caroline Lovell … who knew she was dying, begged for her life, and was ignored by the person she hired to help her make meaning from birth.