Response to critics of my homebirth piece in The New York Times


I was thrilled to write a piece on homebirth for The New York Times. As of this morning it was one of the most read opinion pieces of the last few days, and one of the most emailed articles of the entire paper. The comment section quickly grew to 337 comments before it was closed.

Positive comments might have had a slight edge over negative comments, but there were certainly many negative comments and they were entirely predictable. Today I’d like to address the main negative comments.

The NYTimes did not “let me” write about homebirth. They approached me to write a piece and this was the topic they chose.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Women have the right to refuse to go to the hospital for birth, but have no more right to an attended homebirth than to a home appendectomy.[/pullquote]

Many homebirth advocates complained that the piece had not been fact checked. I’ve written for many publications and I can tell you that not a single one has fact checkers as diligent as those of the Times. I had to provide a citation for nearly every sentence including the one about taxi drivers and children assisting at uncomplicated birth. Every scientific claim is supported by scientific citations and I often had to point out the specific language in the paper that supported my assertion.

Beyond those basics, criticism fell into two large camps. The first claimed that women choose homebirth because the maternity care system is in crisis. The truth is that hardly anyone chooses homebirth. Homebirth is a fringe practice representing only around 1% of births. Indeed, the vast majority of women are very happy with their maternity care. Every few years, the Childbirth Connection, a lobbying group for the natural childbirth industry, conducts a “Listening to Mothers” survey and every time they are forced to acknowledge that over 80% of women rate their maternity care as good or excellent, with no decrease from the prior survey. Only 2% rate the quality of care as poor.

Many critics cited infant and maternal mortality statistics as reasons for to reject hospital care. But infant mortality is a measure of pediatric care (deaths from birth to one year of age). The best statistic for assessing obstetric care is perinatal mortality and the US has one of the lowest rates in the world. If you look at maternal mortality you find that the women who died did so for LACK of high tech care, not medicalization of childbirth. Most women who die in childbirth have serious pre-existing medical conditions or major complications of pregnancy. Indeed the leading cause of maternal death in the US is heart complications. Homebirth is not the answer to improving maternal death rates.

The second camp of critics apparently believes that demanding measures to insure safe homebirth violates women’s autonomy. This reflects a profound misunderstanding of medical autonomy. Medical autonomy is a negative right, not a positive right. It means that you have the right to refuse care, but you do not have the right to demand that medical personnel give you medically unsafe care.

The classic example is that you have a right to refuse amputation of a gangrenous leg if your provider recommends it, but you do not have the right to demand amputation of a healthy leg.

Similarly women have the right to refuse to go to the hospital for birth. But women have no more right to demand a medical provider attend a homebirth than to demand a medical provider perform a home appendectomy. Mandating safety standards for healthcare providers is not a violation of anyone’s medical autonomy.

Moreover, even the right to refuse comes with caveats. An autonomous decision is not merely a wish, but a decision made with appropriate information and rational consideration of the outcomes. That’s why simply telling your doctor that you want him to amputate your healthy leg is not a sufficient reason for him to honor your request.

An example of a rational but deadly decision is the refusal of a Jehovah’s Witness to accept a desperately needed blood transfusion. The decision may be hard to fathom because it can lead to death, but it is rational because the individual values spiritual well being above health and even life itself.

Respecting the medical autonomy of a Jehovah’s Witness REQUIRES a determination that the individual understands the risk of death. Similarly, respecting a woman’s autonomy to refuse to give birth in a medical setting REQUIRES a determination that she understands the increased risk of death of her baby.

In other words, a doctor’s choice to refuse to attend a homebirth is not a violation of a woman’s autonomy. In contrast the failure of CPMs to disclose that they don’t meet international midwifery standards, that the safety of homebirth in other countries has no relevance to the safety of American homebirth, and that their death rates are dismal IS a violation of women’s autonomy.

The bottom line is that you may not like me or what I have to say, but:

  • My piece was zealously fact checked.
  • Homebirth is a fringe practice.
  • Our maternity system is not in crisis.
  • And safety standards for homebirth do not violate anyone’s autonomy.

I can’t wait to see how professional homebirth advocates address these issues.