There's nothing more natural than being born. There's also nothing quite as fraught. A whole lot can go wrong during that long and tortuous journey from the womb to the world. Modern medicine can eliminate a lot of the risk, but in doing so, it can also turn what could be a joyous experience for the mother into the equivalent of an all-day appendectomy.
It's this fact that has always been responsible for the fault line between obstetricians who are trained to view birth as a medical procedure and midwives, who see it as that but as something less clinical too. And if a new study conducted by two researchers at Oregon State University (OSU) is any indication, peace is not likely to be brokered between the two camps any time soon. (See TIME's photos: ER's Long Goodbye)
For a society as technologically far along as the U.S., we do a surprisingly poor job of looking after our tiniest members. About 99% of all births in the U.S. take place in hospitals, yet we rank 29th in the world in infant mortality below Hungary and tied with Slovakia and Poland with 6.71 deaths per 1,000 live births. That compares to a rate of about 3.5 deaths per 1,000 live births in Far Eastern and Scandinavian countries such as Singapore, Japan, Norway and Sweden. (See TIME's photos of spiritual healing around the world)
Part of the solution is improving hospital care, particularly for fragile preemies and making sure all moms get equal access. Certainly, the American Medical Association sees things that way. The doctors who write AMA policy are also very clear that hospital care is the only prudent care. In 2008, the AMA passed its much-argued-over Resolution 205, which states flatly that, "the safest setting for labor, delivery and the immediate post-partum period is in a hospital or a birthing center within a hospital." To ensure your newborn's health, in other words, make sure the highest-tech medicine is close at hand.
But midwives disagree. Home births attended by trained nurse-midwives are no less safe than hospital births, they argue, providing the midwives are affiliated with a nearby hospital to which the mothers can be brought in case of complications. "The most comprehensive study of this was published in the British Medical Journal in 2005," says Melissa Cheyney, an assistant professor of anthropology at OSU and a practicing midwife herself. "It showed that for low-risk [home] births in the U.S. and Canada, the infant mortality rate was roughly 1.7 per 1,000, or about the same as it is in hospitals." The key, of course, is the "low-risk" part which means young, healthy mothers with routine pregnancies and no complicating variables like multiple fetuses or a history of delivery problems. These are the only kinds of cases midwives are supposed to handle.
Cheyney decided to test the British journal's findings in her home state, where the rate of planned home births is at least twice the national average, due both to Oregon's culturally liberal leanings as well as its wide rural stretches, which can make hospitals hard to reach. (From 1998 to 2003, parts of the state also had higher than average rates of premature and low-birthweight babies, leading some critics to conclude that midwifery was partly to blame.) Cheyney and doctoral student Courtney Everson examined one county's birth records from the entirety of that period and found that in that area at least, there was not any increased mortality risk associated with low-risk home births. In interviewing doctors for her study, however, she also learned a few very important things about why they remain so fixedly opposed to the midwifery option.
For one thing, even Cheyney admits that while the odds of mortality in the case of routine births may be no higher at home than they are in the hospital, they're no lower either. And even the lowest-risk birth can turn high-risk fast with maternal hemorrhaging and fetal distress just two of the dangers making immediate access to high-tech care imperative.
Cheyney's conversations with physicians turned up other, more complicated issues. When hospital-based obstetricians see midwives and their clients it's usually because something has gone wrong and the laboring mother is rushed in for care. OBs don't see the uneventful births that proceed successfully at home. What's more, doctors in this position find themselves not just being forced to take on someone else's case, but someone else's problem. That's enough to sour them on the entire profession.
"We've been getting a lot of insight into their world view," Cheyney says, "and it's been illuminating."
One thing that might help soften that world view, she believes, is if the obstetricians try to see things from the midwives' perspective. "The U.S. has a limited idea of what it means to have a positive outcome at the end of a delivery," she says. "Basically it just means that everyone's alive. But when you don't have a lot of medical intervention, you also tend to have more breast-feeding and reduced rates of postpartum depression." Cheyney acknowledges that the kinds of mothers who choose midwifery might be the very kinds who would be less inclined to suffer postpartum depression or nursing problems in the first place, and her study addressed such so-called sampling bias.
"We do think [sampling bias] is true for about half of them," she says. "We see women who are very well-educated and healthier to begin with and that helps them have better outcomes having home delivery. But the other big group is the uninsured or underinsured. They tend to have poor outcomes in the medical establishment but do better with home care or birthing center care." Again, though, those better results do not mean that the risk of infant mortality is lowered with home birth, but that the postpartum health of the mother and baby may be improved.
Some of the debate may be resolved this summer, after Cheyney and a colleague draft new guidelines to help midwives and doctors work together more cooperatively. It will, she says, be "a model for collaborative care that will be the first of its kind in the United States." Even Cheyney's critics would have to agree that, if nothing else, she does walk the walk. She spoke with Time, but only briefly, grabbing a brief break while her infant daughter was taking a nap. Her one-week-old baby was born at home.