From Cristen:

As an advocate, it is easy to feel protective of the fragile movement for respectful, rights-based maternity care. There is a lot of criticism of that movement, and the majority of it is rooted in sexist, racist, and historically skewed treatment of midwives and women.

But as a communications professional who very closely follows media around maternity care, I’ve realized something over time that conflicts with my own protective instincts around a movement I deeply support. That is: when it comes to the things that must change, the ways in which advocates and professionals fall short and can even perpetuate harm, these harms are only rooted out when they are aired out. It forces a reckoning. This kind of a reckoning–public and uninvited–is a difficult one, of course, because it does not come from a place of love and collaboration.

Along those lines, this past weekend, an extraordinarily lengthy, in-depth investigative journalism piece examining the out-of-hospital (OOH) birth industry was published. The piece included numerous accounts that have surfaced over the years, as well as some previously unheard stories, of families whose babies died at or following an OOH birth. Many appear to have received poor care from their midwives and/or affiliated obstetrician.

I was pleased that my dear friend and colleague Diana Snyder gave me permission to post her thoughts on that investigation here as the following article. After reading what she so brilliantly wrote, I knew I would not have written anything different and it’s past time we dive into these tough conversations. Diana and I have worked together closely over the years on many difficult issues in the world of birth advocacy and I value her perspective very much. I second her invitation to discuss how we, as advocates, can do our best to support all families and value accountability in every setting.

A word about Diana: When Diana and I met at one of my workshops about legal rights in maternity care about six years ago, she was an associate at a top national law firm and interested in birth issues.  In addition to her day job, she immediately joined our small, determined group of advocates to play a leading role helping young mother Kimberly Turbin bring a lawsuit for medical battery after a forced episiotomy.  Among her other critical work on Kimberly’s case, Diana was the lawyer who contacted 80-some individuals and organizations to try to convince one of them to represent this woman–ultimately, successfully.  Since then, she has moved to Boston to work at another top law firm and then left corporate practice altogether to establish Matrescence, a private doula service supporting women and families through birth and postpartum, and a parallel legal and patient advocacy practice dedicated to women’s rights in childbirth and the practice of midwifery. Diana serves as outside counsel to the Bay State Birth Coalition, a consumer organization advocating for legal recognition of certified professional midwives in Massachusetts. Today, she is a valued source of support to both her doula and legal clients, who range from women and families to midwives and other birth professionals. She now resides in Southeastern Massachusetts with her husband Mike, son Bennett and beloved vizsla, Rocky.

From Diana:

As all my friends know, I am a strong OOH birth and midwifery supporter. As such I always approach negative media coverage with a very skeptical eye. Given the historical oppression/misunderstanding/oversimplification of OOH birth and midwifery by medical interests and society generally, such pieces are typically riddled with bias, lack necessary context & nuance, reference debunked studies and more. Its very frustrating.

I am not going to go into detail about the ways in which this piece exhibits the usual deficiencies. That’s not the point of my post here.

I read the piece in its entirety, with an open heart, and struggled with it all day yesterday. As an OOH birth/midwifery supporter, I feel a moral and ethical obligation not to dismiss every piece of negative coverage out-of-hand. I feel an obligation to sit with the hard issues, and acknowledge them in my community. What I wish to share is this.

The problems with this piece do not discredit the fundamental issues raised: (1) while rare, loss absolutely happens in out-of-hospital birth. (2) sometimes, losses are the result of poor quality care and lack of true informed consent. (3) in such cases, accountability is elusive. These are facts, and I do not think we should hide from them or deflect attention from them by pointing back to how much negligence exists in hospitals, how these pieces are driven by anti-CPM propaganda, or how families traumatized in the hospital don’t get accountability, either. These things may be true, but families who have been traumatized by or suffered loss from their home birth experiences also deserve to be heard, if they want. In particular, they should be heard and validated and supported WITHIN the home birth community — not just by outside, anti-home birth interests because they have nowhere else to turn.

In that vein, I find it especially concerning that some of the loss families featured in this article report being shunned and even blamed for their babies’ deaths by the birth community. One mother reported being “booed” by other home birth moms when she showed up to testify in court about the death of her baby. The article also quotes a midwife blaming a loss mom by alleging the raging infection that killed her baby was the result of the mother’s choice to labor in water — a near universal, safe practice/request at home births that midwives would vehemently deny is dangerous in other contexts. Even if blame is unjust, who boos a loss mom? Who suggests that the death of a baby is the mother’s own fault? These accounts are astonishing to me, and while they may not be representative, I think we should discuss them.

At this juncture, I feel the need to point out that making loss families feel alone, blamed and unheard — even unintentionally — is exactly how pieces of this nature get traction, and how the “Skeptical OBs” of the world exploit the grief and isolation of these families to further an anti-home birth, anti-choice-for-women agenda. I do not want to minimize how terribly difficult it must be to have a conversation with a loss family about the cause of their baby’s death, and how sometimes, blame may occur even if unwarranted. It is natural for care providers to feel scared and defensive. Nonetheless, we must acknowledge that questions about care are legitimate and to be expected in the wake of loss. Suppressing them is extraordinarily unfair and damaging to the family, and increases legal and PR risk to the midwife. We cannot decry the anti-home birth movement and dismiss pieces fueled by it without examining the ways in which our own self-protective conduct may contribute to that sentiment. We must offer loss families a safe space within our community, first and foremost because it is the right thing to do, but also, because an ounce of prevention is worth a pound of cure when it comes to extreme narratives in the media, anti-choice and anti-midwife legislation, and anti-home birth sentiment.

I will also comment on the notion of personal responsibility in home birth. I have written before about how taking responsibility, and accepting the outcomes for our decisions, are extremely important when planning a home birth. And I stand by that. But just because families take a higher level of responsibility when planning an OOH birth, certainly does not mean midwives are automatically absolved of responsibility. Midwives are trained professionals, with competencies, standards of care and ethical obligations. Every midwife I know takes their responsibility for practicing those things seriously.

In order for a family to truly take “responsibility” for a poor outcome, there must have been informed consent not just about the original choice to plan a home birth, but at every decision point during the whole course of care, including labor. Home birth is not merely a one-time rejection of hospital care; it is ongoing collection of many complex decisions — an evolving assessment of whether home is still the safest, preferred place. Whenever changing circumstances, including during labor, warrant reexamining the decision to stay home, issues of informed consent, standard of care, gray area in recommendations/risk, and others are implicated. Midwives bear a heavy burden in terms of initiating these conversations for the client’s decision when appropriate, while not needlessly bringing distraction and fear to the laboring person. I don’t envy that.

Because OOH birth is widely seen as a panacea to poor hospital care, it is understandable that sometimes, both consumers and midwives may be lulled into a low-key approach to these things. But clients cannot be expected to take responsibility for a poor outcome if they were not adequately informed of risks/benefits and given clear choices — including the option to transfer or stay the course — at key junctures on the path to loss of life. These are complex discussions beyond my experience — reasonable minds can disagree about what constitutes adequate information for informed consent on a particular issue and when exactly something reaches the point where it needs to be raised with the client prenatally or during labor. And there’s also always the issue that sometimes client and midwife accounts differ. But I have faith that the home birth community can reflect on whether current approaches to informed consent in the OOH setting actually allow parents to take responsibility for outcomes.

I cannot imagine how difficult it must be to approach a conversation with a family when there is a dispute as to whether a bad outcome was avoidable and what the appropriate allocation of client vs. midwife “responsibility” is. And I don’t deny that sometimes, blame may be placed without cause. But loss families are entitled to explore these things with their midwife, with whom they have developed a close and trusting relationship, and who is often the only other person with firsthand knowledge about the death of their baby — something grieving families will naturally be desperate to dissect. They are also entitled to talk about their experience in the birth community that they have become a part of without being attacked and guilted into silence. I know that these conversations can be had, without ghosting or getting defensive, and certainly without resorting to blaming or smearing a loss family. I would welcome the chance to discuss how to do so with my friends who have a view on it.

Many will be saying “NOT ALL MIDWIVES” — and I agree. I cannot see a single home birth midwife that I know acting the way described in that article, and yet, I still believe that it happens. I consider myself a believer of women’s lived experiences, and if I am that, then I will also make room for women who say that their home birth team caused harm, just the way I believe women who experience harm in the hospital. Just because it is rare, and because home birth is a vulnerable underdog that needs protecting in many ways, doesn’t mean we should sacrifice these families to protect a narrative of home birth as unassailable. They are not disposable. They are us.

We need to have the hard conversations. All industries suffer from similar problems, and there is no shame in admitting it — especially because many of these issues are the predictable legacy of how oppressed and marginalized OOH birth/midwifery have been and a direct result of industry and consumer retaliation against hospital care. Admitting it is part of accountability and this can only make home birth stronger, in my opinion. Taking ownership of problems can distinguish the home birth community from hospital systems in a positive and meaningful way.

So, I would like to call in my many friends who have had OOH births, support OOH births, and attend OOH births, to continue the conversation with me about how we can better support loss families, and support midwives in feeling secure enough to have hard conversations with loss families, so that they aren’t made to feel at fault, isolated and ostracized in their grief. The OOH community is built on the notion of supporting all women, holding space for birth trauma, and so forth. This must ESPECIALLY be the case for those whose birth stories are really hard to hear — the stories that are tempting to sweep under the rug and dismiss as the inevitable cost of all the other lovely home births and happy clients that are easier to lift up. Let’s also support midwives in talking with loss families, and in reflecting honestly on whether something could have been done differently. Throwing up walls, dismissing the family’s recollection of events, protecting the cause at all costs — this is conduct that I expect from hospitals, not from the OOH community. There will also be clients who decide to cut off communication with a willing midwife of their own volition, and who may turn anti-OOH birth no matter how thoughtfully the midwife approaches discourse. This cutting off of contact is tragic and painful for the midwife, who is also suffering. All of this suggests a lack of sufficient resources for navigating these heartbreaking situations. So let’s open it up and talk about it. How do we help these situations go better, while also acknowledging that it won’t always be as simple as kumbaya? Midwives are not equipped to shoulder the entire weight of their client’s grief, and also shouldn’t wear a target on their backs. But there must be a way to ease these conversations.

What I absolutely love about OOH midwifery and supporters is that we are trying to be the change. I challenge us to also be the change on the issue of holding space for loss families or families who have questions about the care they received. It feels very vulnerable, yes — but Brene Brown style, we must be courageous enough to face and embrace these families, because they sure don’t get a choice about facing what happened to them every day. I don’t want to oversimplify, because these issues are not easy, but loss families are not always looking to demonize home birth or sue. Just like families traumatized in the hospital, they want to be seen. They have questions. They need to process their grief. They want someone to validate what they went through without gaslighting them or diminishing their pain. They need to explore whether mistakes were made — this is a natural part of grieving that will not always evolve into blame. Midwives and the birth community can take these questions on with grace and humility. I know it.

For those in the birth community in contact with other parents facing OOH loss, it is not a betrayal to a deeply held commitment to OOH birth or midwifery to show loss families that you are not afraid of their story and want to hear what they have to say. Yes, it can be very uncomfortable, but what would it look like if home birth loss families could expect the OOH community to band together to support them? I think so much positive could come from that. To those who fear that making themselves available to loss families is like taking sides, which we are naturally afraid to do when we don’t have all the facts, I say that this is not a zero sum game. We can support OOH midwives and acknowledge that sometimes, loss happens, while also holding space for loss families and also acknowledging that poor practices exist, too. Just like we say about safety and the birthing person’s autonomy: these things are not mutually exclusive. We don’t have to choose one or the other. How would you wish to be treated if God forbid, the worst happened to you, and not only that, but everyone turned on you and blamed you?

I believe if we support OOH birth, we should welcome these opportunities for growth. Because these issues are complex and nuanced, I certainly don’t know all the answers, but I look forward to continuing this conversation with you all. Please share your thoughts with me. Especially my midwife friends: What has your training been in talking with loss families? What resources do you wish you had? How can we support you in feeling supported too, in the event of a loss? What do you think the midwifery community needs around this issue?


We welcome your constructive thoughts in the comment section below.