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The Home-Birth Debate Continues

As tragic as fetal loss is, it cannot be used in isolation as the only endpoint when determining models of care.

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Regarding “What Ricki Lake Doesn’t Tell You About Home Birth,” by Amy Tuteur, as a board certified and practicing obstetrician who has worked with both certified nurse midwives and licensed midwives, also called certified professional midwives, my experience is that they are both consummate professionals in their area of expertise. In California, all midwives are licensed by the Medical Board of California, the same agency that licenses physicians. They have extensive didactic education with accredited institutions and are trained in the care of normal birth through the mentoring and supervision process. The model of care they provide is based on prevention and nurturing and the trust that birthing a baby is a normal bodily function.

Dr. Tuteur believes that having a university degree and extensive in-hospital training is required to care for normal pregnant women. I would state, without reservation, that midwives do normal birth better than most obstetricians who are trained in surgical birth and rarely experience a normal labor from start to finish. In other developed nations, the model of care of collaboration between midwife and doctor is the norm.

When Dr. Tuteur writes, “All the existing scientific studies … show that American planned home birth has triple the risk of neonatal death,” this is an exaggeration. A study in the British Medical Journal published in 2005 found comparable outcomes for low risk home and hospital birthing. It also noted greater patient satisfaction in home birth and a higher C-section rate in hospital births. The journal Nature published a review in 2011 of the controversial paper touting a tripling of the neonatal death rate, citing many experts who find the study was flawed and excluded a large Dutch paper from 2009 that did not find an increase in neonatal death rates in home birth.

Dr. Tuteur cites a Netherlands study in the 2010 British Medical Journal which had the surprising finding of a higher fetal death rate in low-risk women cared for by midwives than for high-risk women cared for by obstetricians. But that study does not clearly define location of labor as a factor, only the care provider. And the authors of this study do not conclude by condemning the midwifery model but instead recommend a reevaluation of the Netherlands care system. As tragic as fetal loss is, again, it cannot be used in isolation as the only endpoint when determining models of care.

Stuart J. Fischbein M.D., FACOG, LOS ANGELES