The fatal error at the heart of homebirth midwifery

Imagine a bicycle helmet designer who never considered issue of safety. He gives a great deal of thought to style, takes the issue of comfort into account and consider how best to market bicycle helmets, but simply assumes that protecting the cyclist's head is irrelevant because cycling is inherently safe. That would be both foolish and bizarre, because in contrast to the designer's belief that there is no need to worry about safety, head injuries are the major cause of mortality for cyclists.

Now imagine a homebirth midwife who never considered the issue of safety. She gives a great deal of thought to style considerations, ponders the issue of comfort in labor and even considers how best to market her services to clients, but simply assumes that childbirth is inherently safe. That would be both foolish and bizarre, because in contrast to the homebirth midwife's belief that childbirth is inherently safe, it is actually inherently dangerous.

Nonetheless, homebirth midwives persist in the erroneous belief that childbirth is inherently safe. And that belief in something that is untrue renders the entire philosophy of homebirth midwifery incoherent and virtually nonsensical. Why do homebirth midwives persist in this belief? We can find insight in the chapter that I cited yesterday, The Dialectics of Disruption: Paradoxes of Nature and Professionalism in Contemporary American Childbearing by Northwestern University anthropologists Caroline Bledsoe and Rachel Scherrer.

Bledsoe and Scherrer explore the fundamental assumptions behind the philosophies of natural childbirth and homebirth. Bledsoe is a Professor of African American studies and the paper is in part of cross-cultural comparison of the bedrock assumptions that underlie beliefs about childbirth.

Homebirth midwives are obsessed with "disruptions" of the natural process of birth, because they lack a basic understanding of the purpose of and need for these "disruptions":

Whether we look at birth through an African cultural vision, our own historical impetus for the rise of obstetrics as a medical specialty, or even through the lenses of international metrics, what emerges is a vision of birth as an event of potentially mortal consequence. The conviction among middle-class US women that birth is an event to be experienced to the full, freed from any external attempts to regulate or disrupt it, inverts this image. As we turn to the disruptions that preoccupy US middle-class women as they contemplate the birth of a child, it is vital to keep in mind both the dangers that reproduction can entail and the science that has allowed us to imagine as common sense a safe, uninterrupted. reproductive life trajectory. (my emphasis)

Simply put, the understanding of what is natural, and therefore the understanding of what is disruptive to the natural process is based on a false premise.

American women's assumptions of a healthy, surviving mother and child make the possibility of apprehending birth as a pathological event a challenging stretch. The popular sources now overwhelmingly depict birth as a peak life experience of physicality for women, bringing a sense of achievement at fulfilling a natural act, so much so that the baby seems to play a secondary role. The failure to achieve all the elements of this experience is viewed as personal failure...

In fact, homebirth midwives know so little about childbirth that they actually believe that efforts to prevent "disruptions" are what makes childbirth safe.

... In the US, where the default assumption of pregnancy and birth is normality, a natural lifestyle during pregnancy and an intervention-free, natural birth are often described as the cause of a normal outcome: healthy mother and baby.

Since the safety of childbirth is assumed, NCB and homebirth advocates turn their attention to "disruptions" that they believe can lead to the two most feared outcomes.

1. The "suppressed birth experience"

While birth is seen as a natural process that should transpire at a pace and in a manner set by a birthing woman ... birth is removed to the hospital, where ... birth becomes subjected to ... systematic management... [W]hat [NCB and homebirth advocates] most fear is losing control over the birth event and with it, the chance of achieving what they see as a natural birth... In this context, then, disruptions refer less to unpredictable events that can spell health risk ... than to the disruptions that the loss of control to medical authority may spawn.

2. The failure to bond with the baby

Bonding has a deep emotional pull in the contemporary US... [Homebirth and NCB advocates believe that] [t]he faster the mother and baby ... can establish dose contact-the mother receiving the infant immediately after birth, wet and crying, umbilical cord attached, placing it on her chest and beginning to breast feed-the better the chances of selling the child securely on a healthy emotional course in life ... [T]he loss of the smallest window of bonding opportunity after the birth may set the stage for future pathology for both the infant and the new family unit.

Unbeknown to homebirth midwives, it is the "disruptions" that have allowed homebirth midwives the luxury of pretending that facilitating experience of childbirth and "meaning making" about childbirth are the most important services that can and should be offered.

... the explicit goal of childbearing in the us in the past was health normality. and in much of the developing world it remains the same. Today in the US, as long as health normality remains the predicted outcome, the goal shifts to the experience itself of childbirth, and the interventions that can save lives are [barely mentioned] in pursuit of the goal of naturalism and the control that is seen as the key to achieving it.

One of the most remarkable things about Melissa Cheyney's paper Reinscribing the Birthing Body: Homebirth as Ritual Performance (discussed here) is the virtual absence of any discussion on safety, either of homebirth or of birth itself. The paper has 156 mentions of midwives/midwifery/providers, but only 13 of safe/safety. Safety is assumed to be a given. It is precisely this assumption, belied by everything we know about childbirth in nature, that is the fatal error at the heart of homebirth midwifery. Fatal because it renders the entire philosophy incoherent and nonsensical and fatal to the babies whose mothers have been misled by an incoherent and nonsensical philosophy.