Sunday, July 27, 2008

Medicine values judgment; homebirth advocacy insists on certainty

Homebirth advocates include a spectrum of opinion, but on one point everyone seems to agree: complications are rare. There's just one problem. Complications are not rare, they're common.

Why the disconnect? Partly it is because of the underlying, and erroneous, belief that if it is "natural", it must be good. Therefore, the way childbirth occurs in nature can't have many complications if it is to be "good". Yet there is another, more profound reason that speaks to the deepest longings of homebirth advocates, the desire for certainty. Homebirth advocacy is made up of a few simple rules: "nature" is always right, everything must be allowed to happen naturally, interfering is what causes complications, etc. All of them can be summed up conveniently in the aphorism: Trust Birth.

Homebirth midwifery requires very little in the way of training (compared to other forms of midwifery) because very little knowledge is supposedly needed. Keep your hands off and call 911 in the rare case that a disaster occurs. In the meantime, you are free to let labor to drag out endlessly, and, to encourage the mother not to give in to the basic human desire for pain relief.

Obstetrics, on the other hand, presupposes that childbirth is complicated, complications are fairly common and judgment is key to ensuring good outcomes. In other words, you can't simply sit back and assume that everything is going to turn out fine. Since the chances are relatively high that complications will develop, observation is critical; detecting early signs of complications is desirable; and judgment is needed to interpret the early signs and determine a course of action.

Why do obstetricians spend four years beyond medical school delivering hundreds or thousands of babies before they're allowed to practice on their own? If you believe that judgment is a critical element in providing safe care, you are committed to a long period of training. The only way to acquire good judgment is by experience with a large and varied array of situations.

Homebirth midwifery assumes that one size fits all. Just stand back and everything will be fine. Obstetrics, in contrast, assumes that reasoning and judgment will often be required, and makes every effort to hone those skills. Homebirth midwifery laughs when a woman has an "unnecessary" Cesarean for a baby who turns out to be healthy; if only the doctor had "trusted" birth, everything would have been fine. Homebirth midwifery is shocked when a baby who is assumed to be fine emerges dead. Yet that kind of outcome can only occur when the practitioner is not paying attention, is not reasoning, is not using judgment to distinguish between the theory of "trusting" childbirth and the reality of the woman in front of her.

"Trust birth" is a one size fits all strategy. It provides comforting certainty. Obstetrics is individualized and uncertain. That makes it far more difficult, but it also makes it safer.


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