Atlantic Monthly Gets It Wrong on Home-birth/Hospital Birth Thing

I used to love Atlantic Monthly, but in the past several years I noticed that their articles about motherhood issues can be super douchebaggy.  

I remember a crappy piece many years ago by the often great Sandra Tsing-Loh, basically arguing that the ruin of society was caused by parents who try to understand their kids, an article that conflated basic empathy with “zero parental boundaries.”  It had all the nuance of a cow bell.

Later, Hannah Rosin’s "Case Against Breastfeeding" (April, 2009) was similarly monolithic, transforming the author’s personal ambivalence about the act of breastfeeding into a million-watt advertisement for the formula industry and a defense of Neanderthal husbands.  (My response to this piece was published as a guest blog on California NOW's website, and the full text can be found, now, here).

And now it’s a piece about home birth, in their current issue, by a dude OB, who has never, obviously, had to make a decision about where to give birth.  Nor has he ever been to a home birth.  His assessment is based on a time that he accepted a mid-labor transfer from a homebirth midwife.  

I had been planning to ignore the article, since I’ve already cancelled my subscription and told them what I think of their “Cases,” and the way it seems they publish flame-war-generating pieces whenever a dull moment threatens readership.  And I had been planning to ignore it, also, because, as I’ve blogged about before, I’m sick to death of discussions of birth politics that lack nuance and sound like propaganda.

But when I read it, I found it was less of a diatribe and mostly a stupid whinge.  Here’s the gist:

OK, there was this OB, and once he was in the hospital and a woman came in in the middle of her labor, with her midwife.  She had planned a home birth, but after many hours of pushing, the baby hadn’t arrived.  Her midwife had advised her to transfer to the hospital because the birth was now outside the range of normal for homebirth, which is just what home birth midwives ought to do in such a case, just as any kind of care provider ought to refer out when something is beyond their scope.    

So, mom-to-be goes to the hospital and encounters Doctor.  Doctor scowls at her (this is his description, not hers!).

He tells us that he would have recommended a c-section hours earlier.  Not because the baby was in danger —  there is no suggestion that the baby was in danger when they got to the hospital — but just because he would have “worried” (his word, again).

Mom wants to hear whether there are other options.  Doc tells us that there was no medical reason to do a c-section then, but:

It would have been easy to tell Laura that a cesarean was recommended given how long she had pushed, but I knew it was the last thing she wanted, so I explained that we could try some other interventions … 

She agrees to try his suggestion of augmenting the labor with Pitocin to strengthen the contractions. 

After they start the Pitocin, though, the baby’s heart rate decelerates.  Doctor again informs mom of her options.  They can do a c-section.  Or they can use some tools that we’ve developed for this situation, which give us a closer look at the baby and the labor.  They are:  the internal fetal monitor and the intrauterine pressure catheter, and they exist, ideally, to give us a closer look and, hopefully, avoid doing a c-section if there’s no medical need.  

She proceeds with them and, a few steps later, again with his counsel, decides to use the vacuum extractor to assist a vaginal delivery.  

The baby is born safely.  

At no time does the doctor say that he thought that the choices that he gave and that she chose were unsafe or inappropriately risky.  

Afterwards, the mom conveys that she is happy the baby is born, but unhappy that she had to make the transfer, and unhappy with this doctor’s temperament.  To his great surprise, she hopes to try for another home birth next time.

Why is this so astonishing to the doctor, and why does that prove, to him, the “Case” against homebirth?  To me, this story is actually a great example of

  • a patient engaging in responsible adult decision-making, communicating with her caregiver, learning her options, and making appropriate, safe personal choices.
  • how a coordinated system with competent backup for homebirth could work. 

In fact, it seems that the biggest drawback in this case was that the doctor was scowling and the midwife — who actually knew this patient — had no privileges at the hospital and so she couldn’t provide the kind of assistance that helps give better care than you can get from a stranger.  

And why was this doctor scowling at the mom the entire time?  

  • Because she tried for a homebirth originally, and couldn’t forecast this unlikely situation, which, though not dangerous to the baby (he acknowledges that there was no concern about the baby until after the mom received Pitocin) required a big change of plans?
  • Because she wanted him to provide more options than just “we can do a c-section”?
  • Because she expected personalized service, not a generic, “we do a c-section after 2 hours”?  

To me it seems that the mom was pretty much the ideal consumer.  Not because she wanted a homebirth, but because she sought explanations and information, and made good, competent, adult decisions about the care of her own body, with the counsel and guidance of the expert she was paying to help her.


At one point in the essay, the doctor complains that

Short of a cesarean, she had experienced about as invasive a delivery as modern obstetrics has to offer.

I don’t get this complaint.  The mom might feel disappointed, afterwards, that fate handed her this particularly difficult birth, which required medical intervention.  But even really Birthy people, if they are sane and reasonable, don’t reject the idea of medical intervention per se — they reject the idea of using it when it’s not necessary.  In this case, everyone seems to agree that it *was* necessary.

And if this mom preferred Pit and IFM and the vacuum to a c-section, who is this doctor to say that she ought to have preferred the c-section and spared him the extra hours by her side?  She is the customer.  She is the owner of her body.  She is the decider.  He is the servant.

Women seem to like to make decisions about the care of their bodies.  It is not “crunchy” to say that a competent adult woman can be trusted to choose, among safe options that have been explained to her, the course that will be best for her.  


Finally, the doctor whines that he hated this birth because he was forced to clean up “the midwife’s mess.”  

What mess?  

What if the patient had been his hospital birth patient from the start, and had had this exact same labor?  After a couple hours of pushing, he’d have suggested a c-section; she’d still have asked what the other safe options were.  

Would he have forced a c-section on her?  That’s not allowed — as long as we continue to say that laboring women are competent adults, you can’t actually force one to do a c-section, especially when you admit that there’s another safe option.  

They’d have landed in the same exact place.  

There they’d have been — with her preferring to continue to push and use a little Pit and ultimately IFM and the vacuum, and him wishing she’d just do a c-section and get it over with.  It’s clear he doesn’t get why the one is preferable to the other to her, but really?  Who cares why she sees it one way.  She’s the customer.

If she’d been his patient from the outset and had asked for more options instead of doing a medically unnecessary c-section, and they’d proceeded exactly the same, with the Pit and the IFM and the vacuum — would he have then said that he hated that birth because he’d have had to clean up his own mess?  

Or would he have said, perhaps quietly, to a colleague, that he hated the patient because she asked questions, knew her options, and used her doctor as a guide, not a god.  Would he confess that he longed for the days where women were conditioned to behave like docile little lambs, and not ask questions or realize they were competent to make decisions for themselves?  

Or lets say that he wore her down, because she was tired and suggestible.  Let’s say she caved to his pressure and said yes to him.  Let’s say he got to do his c-section and go home.  

And then she developed MRSA and was rehospitalized for days and days after her child’s birth?  

Or had trouble breastfeeding?  

Or was, “just”, deeply unhappy, felt that her integrity was bruised, or that she’d been bullied into beginning her course of motherhood with an unnecessary major abdominal surgery? 

Who would be cleaning up his mess, then?