Debunking The Business of Being Born: Part 2

This is part 2 in a series attempting to debunk the claims made in The Business of Being Born. Descriptions of the movie are in bold, my commentary is in normal font.

“most obs have no idea of what a birth can be like.” says Dr. Michael Odent.

“very few doctors have ever observed a normal birth, in medical school or in the hospital. Its almost an oxy-moron.” says the president of citizens for midwifery

cut to ricki lake asking 3 ob residents how often they get to see a fully natural birth. Two of them respond. One says ‘rarely’. One says “almost never”. 

A ‘fully natural birth’ is a matter of opinion. It is a laundry list of requirements that may or may not have anything to do with how humans have given birth in the past (for instance water birth is an entirely new idea, but is considered natural in NCB circles).  If a woman has an IV line, its not a fully natural birth.  If she had a shot of pain medication, that later wore off, it is not a fully natural birth. These distinctions seem pretty trivial to me.

I am sure that I could take all the possible choices in birth, make a list of the ones I thought were the best, and then ask OB residents “how often have you seen this kind of birth?” They would probably say the same thing, because the range of choices available makes for a large number of possible birth scenarios. I also do not think that 3 peoples opinions are the best way to demonstrate this point (if it is even true). They are in the same residency program at the same hospital- it could be evidence of that specific hospitals practices, or of what women in the region want, etc. We are not told how far these women are into their residency or how many births they have seen. Again, these factors are never explored, and hard numbers are never given.

This argument for ‘natural’ birth also invokes the naturalistic fallacy. Ditto for calling spontaneous vaginal delivery ‘normal birth’. I would imagine ‘normal’ birth is whatever kind of birth most people have, and they have already said that NCB is not the norm.

“well I always think that midwives do a better job at the normal deliveries than we do. For a normal, low risk woman, its overkill going to a doctor. The doctors not really excited about things when theyre normal.” says dr jacques moritz. 

“because OBs are socialized to search for pathology, they often see pathology where it does not exist. They find pathology because then they have something to do.”  says a medical anthropologist

“an obstetrician is a trained surgeon, and usually very, very good at what he or she does. And thank goodness we have them! Im so greatful that we have OBGYNS.” says a midwife

“They’re surgeons! They should be doing surgery all day, every day. When its needed. They should not be doing normal births. cause they’re not trained in it. They have no idea how to do it.” says another.

These are opinions, and they are impossible to prove or disprove because they are subjective judgments about the services of OBGYNs. The movie sticks to this kind of rhetoric a lot, mainly because the objective measures of safety for women and infants in out of hospital birth are pretty damning. If OBs are not well suited to spontaneous vaginal births then why are their outcomes so much better than midwives? You have to dress up the argument with a lot of flowery rhetoric, or just plain lie, to get people to ignore the evidence.

Cut to dr marsden wagner repeating the same stuff about how other developed countries use midwives more than the USA. He claims a lower rate of maternal and perinatal death in countries that use more midwives.

Correlation does not equal causation. There are a million reasons that differences could exist in rates of perinatal and maternal deaths. Attempting to attribute it solely to midwives is not warranted by the evidence available, and since the film is making the claim of causation it is up to them to demonstrate it. They fail miserably to provide any evidence outside of “two things happened at the same time, so one must have caused the other”.

I am always reminded of this exchange when someone mistakes correlation for causation:

Lisa: Dad, what if I were to tell you that this rock keeps away tigers.
Homer: Uh-huh, and how does it work?
Lisa: It doesn’t work. It’s just a stupid rock.
Homer: I see.
Lisa: But you don’t see any tigers around, do you?
Homer: Lisa, I’d like to buy your rock.

Text appears on the screen that reads:

The United States has the second worst newborn death rate in the developed world.

No source is cited, so I don’t know what year they are discussing or what countries they count as developed or not. I can’t even investigate the claim because there is not enough information given. Not only that, but they don’t talk about how close we are to the top ranking country. What if all the perinatal death rates in the developed world were excellent, and very close? That is what I found when I took a cursory look into the data for 2004-2008.

A Phd in public health says “the united states is ranked poorly in infant mortality.” 

That is true, but infant mortality is different than perinatal mortality (which is deaths that occur 0-28 days of life). Infant mortality rates aren’t pertinent in a discussion of home birth.

“one of the arguments made is we have different women. We have more high risk women. But this blaming of women is farcical, its not about mothers. Its about the way we treat care in the united states. ” he continues.

If it is true that the US has more high risk women, I am not sure how hospitals are supposed to magically compensate for that. He should have demonstrated that the US has equivalent rates of high risk pregnancies or lower rates of high risk pregnancies in his comparison. I am betting that he avoids talking about the numbers because they aren’t in his favor.

text appears on the screen:

The US has one of the highest maternal mortality rates among all industrialized countries. 

I looked into what counts as a maternal mortality, and it is anything pregnancy related that causes death within 42 days of pregnancy being terminated (either by birth or miscarriage). I am not sure why lack of insurance and socialized medicine is ignored as a factor in the difference in health outcomes. It is a factor that worsens health outcome statistics for the entire country. Why would there be surprise about this?  I am sure that someone with access to data could give the film makers information about the causes of these deaths, and then they could investigate if midwives are a solution to the complications that are resulting in these deaths. If they could demonstrate that, why wouldn’t they?

“This is the outcome when you are a century or so post-midwives. You lose a lot of knowledge. We are the one country where, when birth went into the hospital, the midwives didn’t go there with it. ” says Ina May Gaskin.

The cultural anthropologist talks about smear campaigns against midwives in the early 1900s to explain why they weren’t accepted in hospitals. They discuss the racism of some of the campaigns.

An author talks about the cultural shift in the USA away from midwives. She says that during that time it was more dangerous to give birth in hospitals than with midwives because physicians did not have adequate training in labor and delivery.

creepy footage of old hospitals and pregnant women about to get c-sections are played over an ominous soundtrack while this same narrative gets repeated. 

This has nothing to do with how safe home birth is NOW vs hospital birth, considering that a lot has changed in medicine since the 1900s. The film carefully avoids comparing direct entry midwives outcomes to physicians today. If midwives have such a superior outcome, why won’t their professional organization (MANA) release its death rate statistics?

This part seems to only be there to reinforce the narrative that midwives are good, hospitals are bad. The footage does a good job of instilling a sense of unease in the viewer. Old hospitals are indeed creepy, but do little to prove that anything was lost by moving birth into hospitals.

text appears on screen:

In 1900, 95% of births in the united states took place at home

In 1938, half of all births took place at home

by 1955, less than 1% of births took place at home

It remains at that rate today.

With all the talk about mortality rates before, you would think they would talk about the rate of perinatal and maternal fatalities in the times listed.  If their analysis is correct, then as hospital births increased the rate of maternal and perinatal death would increase as well. Here is what I found when I looked into it:

At the beginning of the 20th century, for every 1000 live births, six to nine women in the United States died of pregnancy-related complications, and approximately 100 infants died before age 1 year (1,2). From 1915 through 1997, the infant mortality rate declined greater than 90% to 7.2 per 1000 live births, and from 1900 through 1997, the maternal mortality rate declined almost 99% to less than 0.1 reported death per 1000 live births

You can see the graph here, that shows an over all decline in maternal mortality that coincides with births being done in the hospital (with an uptick in 1920). Even the increase in 1920 is not as high as the 1900s numbers. The increase in 1920 caused government oversight, which then changed the common practices in hospitals, and resulted in a mortality rate much lower than the pre-hospital era. It is worth noting that this is exactly the kind of government oversight that midwives are currently resisting.

Most of the information on that site is for infant mortality (up to one year), but there is a table demonstrating the reduction of neonatal mortality and the results are the same- a consistent decrease in the death rate over time, which quickly became superior to the pre-hospital era. The article has a lot of information about what technologies and techniques are responsible for the decrease (and the increase of maternal mortality in the 1920s).  There is thoughtful discussion of the history of labor and delivery in the united states. You’ll note that using a midwife is not listed as a strategy associated with decreased mortality, because it simply isn’t supported by the available evidence.

Discussions of the themes so far:

This movie constantly frames the argument as natural birth being in direct opposition to medicalized childbirth,  but I don’t see ‘nature’ and ‘technology’ as opposing forces at all. I would argue that science and technology is absolutely a natural thing for humans to do. Science is a very organized form of what is innate human behavior- to try to understand the world, to experiment, to test our theories about the world. Technology is an application of what is learned through science. It is entirely natural for human beings to work together to invent solutions to problems, like excrutiating labor pain or fetal distress.

These sorts of opinions are aimed at providing empowerment to women who are pregnant or planning on having children. I get that, it certainly appealed to me.  Pregnant women usually experience some fear of childbirth, and these messages from the natural birth community aim to exploit that fear for profit. It is so comforting to hear midwives say that everything is okay, and so frightening to hear doctors talk about what can go wrong. It is a case of your real friends telling you stuff that you don’t want to hear.


2 thoughts on “Debunking The Business of Being Born: Part 2”

  1. Thank you for writing this! I saw right through this movie right from the beginning and I didn’t trust their opinions or stats because it was just hearsay. They could have pulled numbers and stats from their behinds and demonstrated it to sound intelligent. It’s so sad that women don’t look at all sides of the story before joining forces against hospitals & Drs.

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