Saturday, January 26, 2008

Further thoughts on respecting birth

I have been thinking about Kneelingwoman's post, Into the Wild..., and the powerful metaphor that she used. What is so striking to me is that the post could have been written by any obstetrician.

The post itself is basically an ode to experience. Kneelingwoman has found, as Navelgazing Midwife has also found, that one of the most important components to safe care is the experience of the practitioner. More experience is better. A lot more experience is a lot better. Birth has so many and so varied complications and problems, that only a great deal of experience will allow you to see enough to recognize and manage complications. Of course, that raises a question that Kneelingwomen did not address. If her experience has improved her level of awareness and made her a better practitioner, doesn't that mean that obstetricians, who have even more experience and far more varied experience, are even better practitioners?

The analogy with hiking in the wilderness is very apt. A person who has hiked only once or twice (or not at all) is not going to do very well in the face of unanticipated dangers. Reading lots of books about hiking does not prepare you to hike. Someone who has hiked 25 times is going to be more experienced and going to have more skills to call upon in the event of danger. Of course, someone who has hiked thousands of times, in all kinds of weather, and has faced and survived multiple dangers is going to be an even better source of advice and companionship.

Another factor that Kneelingwoman dwells on is the incredible naivite of homebirth advocates. They are like the man who went "into the wild" without a map and trusted "nature". This naivite is embodied in the incredibly inane rallying cry of homebirth advocates: "Birth is not a medical event." As I have written many times in the past, this is a piece of meaningless drivel. When you analyze it, it is supposed to mean that birth is not pathological. Of course, no one ever said birth is pathological. The point of modern obstetrics is that pathology routinely develops during pregnancy and childbirth. Pregnancy and childbirth has always been, in every time, place and culture, a leading killer of young women and of babies.

As Kneelingwomen points out, saying that bears are "natural" does not mean that they are not dangerous, and that they will not hurt or kill you if you make the wrong move. Claiming that birth is "natural" is just like saying that bears are "natural". It tells you absolutely nothing about the dangers that they pose. There is nothing more "natural" than a bear mauling another animal that appears to be a threat. Similarly, there is nothing more "natural" than a baby or a mother dying in childbirth.

I would extend the metaphor even further. When a baby dies at a homebirth, it is the equivalent of being eaten by the bear in the wild. Saying that the baby might have died in the hospital is like saying that the bear might have climbed your fence and eaten your baby playing in the yard. Sure, that can, and rarely does, happen. However, it does not justify in the least taking the baby into the wild where bears are known to roam.

Finally, Kneelingwoman expresses the same annoyance with homebirth advocates that obstetricians express. Her experience and skill was hard won and very valuable. It is frustrating when homebirth advocates refuse to treat that experience with respect. It is frustrating when homebirth advocates dismiss the value of that experience. It is particularly frustrating when homebirth advocates become angry that the experience leaves you unwilling to collude with them in pretending that everything will turn out fine.

The bear is always out there. Childbirth is always shadowed by the possibility of death or serious injury. People who refuse to acknowledge and prepare for it are no different than the people who head into the wild and plan to "trust" the bear.

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