You are responsible for your birth, and for your provider

There's a new article out in New York Magazine about the midwife featured in "The Business of Being Born", Cara Muhlhahn, called Extreme Birth and saying she is "The fearless—some say too fearless—new leader of the home-birth movement."

Right off, this phrasing is weird. Cara may be featured in BoBB and be very popular in New York City right now, but I would say there are much more prominent homebirth leaders (Ina May Gaskin, perhaps?) She's a full-time practicing midwife, which doesn't leave so much time for activism, even if she managed to get a memoir out. But that's just the headline and maybe it was written by a copy editor, not the author. Moving on.

Next comes the statement that "She...doesn’t practice like a typical midwife. Personal experience has led her to dismiss many of what she calls the “myths” that are still taught in school as the bedrock of safe practice." Examples are large babies, VBACs, breeches, and twins. The article continues in this vein. It's like the author, a man whose wife is considering a homebirth with Cara Muhlhahn, thinks she's Rasputin. His wife "laps up" the "home birth pitch" even though her husband is uncomfortable with them choosing a homebirth because of his wife's lupus diagnosis. There's a few things he puts in to balance his mostly negative treatment, but it's mostly bad. He finds a couple that had a negative experience and interviews them. He talks about a lawsuit that resulted from a shoulder dystocia. He points out she doesn't carry malpractice insurance. He gives the impression that this midwife treats too many things as normal and is willing to take too many risks.

I don't know Cara Muhlhahn; I haven't read her memoir yet and all I know about her practice is what I saw in the movie. But I do think that this would be a poorly-written article about any midwife. I have met a lot of midwives happy to deliver VBACs at home. I think it's the atypical midwife (at least among those who practice homebirths) who doesn't at least want the option of delivering VBACs at home. Breeches, twins, and large babies are more debatable (although a lot of midwives would debate a prenatal diagnosis of size). Shoulder dystocia is unpredictable and the outcome she was sued for, Erb's palsy, can happen as easily in a hospital as anywhere else. Many midwives don't carry malpractice insurance, often because they can't afford it.

Asserting that Cara Muhlhahn is different or especially risky is strange to me. And ultimately I think there's something this author doesn't get. I think most homebirth midwives have another important thing in common: they are OK with parents taking more responsibility for their level of risk. If you march in and say you have lupus and want a homebirth, they have to decide if they are willing to take on that level of risk. If they are, that doesn't mean your midwife has just magically made you the exact same risk as everyone else. It means it's back on you to decide if you are willing to assume those risks too, for yourself. There's a difference between trusting your care provider and handing all responsibility over to them.

Put another way: if you want an elective c-section, your doctor might turn you down, citing the risks. You can shop around to every obstetrician in town until you find one who's willing to take you. This person might even read the literature differently and see no excess risk from elective c-section, and tell you so. But this person has not magically changed the evidence out there in the world, or how it applies to you. They just see it differently. It is up to you to do the same research and decide if you see it that way too.

You can go midwife shopping the same way. You can look and look until you find someone willing to take on your homebirth after 3 cesareans. It helps if you feel very comfortable with their training, credentials, and experience, and trust their ability to handle any emergencies appropriately. But ultimately, you will live with the consequences of your decision and have to decide if you feel comfortable with what you're planning.

You have to do your homework for birth, and that's true of the planned hospital birth as much as it is for home births. You should ask about a hospital's c-section rate the way you would ask about a home birth midwife's transfer rate. It's comforting to think about handing over all the responsibility to someone else, but I think ultimately it's unrealistic.