Love and Commerce
September 11, 2009 -- Today NBC's Today Show aired a segment with the title "The Perils of Midwifery," though it later changed the title of the online version to "The Perils of Home Births." The "Today Investigates" segment, introduced by Matt Lauer, was mainly a pre-recorded report by NBC's Peter Alexander. The unbalanced piece used the tragic experience of one couple whose baby died in a home birth setting, including emotional footage from interviews with the grieving parents, to question the safety of home births and midwives generally. Would NBC find one sad obstetrician outcome and run a report titled "The Perils of Obstetricians?" The report also suggested that the apparent trend toward home births is a "hedonistic" one driven by a misplaced desire to emulate celebrities like Ricki Lake, who produced the documentary The Business of Being Born. NBC did include elements that ran counter to its main theme, briefly describing the arguments of home birth advocates and offering a short look at the good home birth experience of another couple. But the report also featured a series of unanswered attacks on home births and midwives, and the ostensible effort at balance just made the attacks all the more persuasive. Perhaps most glaring, the report did not offer a single quote by any midwife expert or midwifery association to defend midwife care, but instead relied heavily on the American College of Obstetricians and Gynecologists, as if physicians were the only real health experts, even about the care of other health professionals with whom they compete. The report ignored the data showing that other developed nations achieve better outcomes at lower costs with less interventionist, midwife-centered birth models. It ignored the research showing that the care of nurse midwives is at least as good as that of physicians. And it ignored the overall safety record of the veteran nurse midwife involved, Cara Muhlhahn. Unsurprisingly, the month after the Today report aired, the couple whose baby died, Catherine and Ricardo McKenzie, filed a malpractice lawsuit against Muhlhahn. The suit itself earned a lot of press coverage, featuring multiple quotes from the couple's malpractice attorney. We urge the Today Show to provide fair and balanced reporting on advanced practice nursing. See the 7-minute video below:
Some of the 7-minute Today report's biased elements are blatant, with the "Perils" titles being the most obvious. But others are so subtle, perhaps a matter of word choice, intonation, or focus, that many viewers may miss them. Lauer introduces the segment as being about "extreme births," suggesting that all home and midwife births are "extreme," and so are risky, if not downright unsafe. But then Lauer 7 the trend toward home births is inspiring a "passionate debate," as if we are just hearing a balanced presentation of two sides. Then he introduces Alexander, who sits facing him throughout the segment.
Alexander tells Lauer that a growing number of U.S. mothers now choose to give birth with "no drugs, no doctor, in the comfort of their own home. "But," Alexander asks, "is avoiding the clinical nature of a hospital birth worth the risk when complications arise?" Note again how the approach projects the appearance of balance--hey, we're just asking questions!--but few viewers could doubt what Today thinks about this "no doctor" thing. The piece fails to explain that midwives do not recommend home births for high-risk patients.
The prepared segment begins, and we hear grieving parents Catherine and Ricardo McKenzie talking about how their hopes and dreams for their baby's birth were dashed, as we get an image of a book whose spine says "Ina May's Guide to Childbirth; From the Nation's Leading Midwife." This image of Ina May Gaskin's famous book encourages viewers to equate the McKenzies' tragedy with midwifery in general.
The report says the McKenzies were inspired by the "extremely popular" documentary The Business of Being Born, which was produced by actress and talk show host Ricki Lake. Yes, the 2008 film had a total domestic gross of $70,000, so it clearly went right down to the wire with The Dark Knight 's $533 million for top-grossing film that year. But of course, it's scarier and more compelling to pretend that midwifery and home births are malevolent forces taking over the nation. We see snippets of a couple clips from the film, and hear that the film challenges how physicians and hospitals approach birth, championing natural births at home with a midwife. The McKenzies liked the film and decided to hire Cara Muhlhahn, an articulate and expert midwife who appeared in the film. Alexander describes Muhlhahn as "one of the country's most prominent midwives." We see a very brief clip from the film in which Muhlhahn describes herself as the "guardian of safety," and Alexander reports that "she's been a certified nurse midwife for the last 18 years." The clip and the seemingly positive background fact, taken together with the tragic outcome on which the report focuses, suggest that Muhlhahn is actually a reckless hypocrite, and that even the most experienced nurse midwives are dangerous.
Alexander reports that after a "healthy pregnancy," last April Catherine's contractions started. We see emotional footage about how excited the couple was, having set up a nursery and picked the name Noah for their baby girl. But Catherine's labor in her living room lasted longer than expected, and Alexander notes that it was "coached not by doctors, but by Muhlhahn and her staff." Note this nicely ominous phrase, which not only sets up the tragedy to come, but also suggests, nonsensically, that physicians would be better at "coaching" the expectant mother than an experienced nurse midwife. This is especially ludicrous given that physicians are almost never present for coaching. They do normally check in on the labor from time to time, but typically do not arrive to stay until a few minutes before delivery. Ricardo says that Muhlhahn and her staff kept reassuring the couple. A tearful Catherine says that they were the "experts" and she "trusted them, that they wouldn't take unnecessary risks."
Alexander reports that "after four days of labor, baby Noah arrived without a heartbeat." Catherine says that the midwife gave the baby to her, but took the baby back right away, and started CPR. Alexander says they called 911, and paramedics rushed to a hospital that was just a block away. Alexander: "But doctors couldn't save Noah. She had suffocated after getting tangled in her own umbilical cord." Here again, the description implies that true health expertise resides solely with physicians; only they were in charge of saving Noah, even though paramedics and hospital nurses would obviously have been involved--not to mention Muhlhahn and her nurse colleagues. We hear nothing about what Muhlhahn might have been doing to monitor the baby during labor. And the report says nothing about how common this kind of injury is. Viewers might suppose that it is a rare thing that physicians can always avoid through their expertise and hospital technology. In fact, however, umbilical cord injuries are unfortunately so common that some malpractice attorneys specialize in bringing "umbilical cord entrapment" cases.
To its credit, Today did offer Muhlhahn a chance to respond. Not surprisingly, given the obvious threat of litigation, she declined to give an interview. But, the report says, she released this short statement:
There is nothing more tragic than losing a child. The entire staff at Cara Muhlhahn Midwifery is grieving the McKenzie family's loss.
Alexander says the McKenzies encountered the "dark side" of the trend among educated urban couples toward home births, once again equating this one tragic outcome with all home births. Next we see New York Magazine contributing editor Andrew Goldman, whose health expertise is not made clear, saying that "one of the doctors" he spoke to said home birth had become a sort of "hedonistic" thing, almost equivalent to a "spa treatment." Then we hear about all the celebrities who have done it, complete with glamorous photos. This suggests that it is just a kooky new celebrity indulgence with a "dark" side, rather than the way women have given birth for thousands of years.
Alexander sets the celebrity bit against an authoritative paraphrase from the American College of Obstetricians and Gynecologists (ACOG), complete with the group's emblem and key text on screen. He intones: "But the mainstream medical community says the safest setting for labor and delivery is in a hospital, or a birthing center within a hospital complex." This effectively presents home births, and by extension midwives, as out of the "mainstream." This would have been one place for an equally authoritative quote from the American College of Nurse Midwives (ACNM), perhaps about all the research demonstrating the safety of nurse midwife care. Such a quote might even have made clear that many nurse midwives deliver babies in hospitals. But there is no midwife response.
Instead, the report piles on the physician criticism. We see "Dr. Erin Tracy, Delegate," ACOG, speaking in front of a Massachusetts General Hospital background:
Unfortunately, when it comes to a delivery setting, some of the emergencies arise [sic] can't be predicted. They happen in low-risk women with no prior medical issues during her pregnancy, and if we can't intervene within minutes, the life of the mother and the life of the baby could be endangered.
Of course, it's true that emergencies may arise in low-risk births. But hospital births also carry risks. Alexander continues:
The American College of Obstetricians and Gynecologists says child birth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause celebre.
This suggests that midwives, who were actually the childbirth experts long before physicians became involved in the process, are just some trendy upstarts that nutty celebrities like Ricki Lake and Demi Moore are foisting on the unsuspected public. Once again, the Today Show allows no response from ACNM or any expert midwife.
Alexander does note, in another of the report's weak stabs at balance, that home birth advocates argue that using a midwife is actually a healthier, safer option. He says these advocates "allege" that hospitals often treat birth like a medical emergency because of fear of malpractice lawsuits, and so perform "unnecessary C-sections," noting that C-sections have risen greatly in the last decade. But this places all the blame on malpractice lawyers, rather than the interventionist, profit-driven physician culture that the Business of Being Born actually presents as the most important factor. Perhaps that idea is too radical for network television. In any case, we then see Marsden Wagner, a home birth advocate from the film whom Today actually identifies as the former director of Women's and Children's Health at the World Health Organization:
If you go to the hospital to have a baby, many unnecessary things will be done to you to stimulate your labor, to hurry up the process, and there is a one in three chance that you will end up with a Cesarean section.
We give NBC credit for at least including this segment. But it's pretty bland; we don't hear who is doing these "things" or why, and we don't hear what the risks of a C-section are. In fact, C-sections are major surgery, and they can lead to serious complications for mother and baby. And though ACOG's Erin Tracy was identified as a physician, Wagner is not identified as one, even though he is; his lengthy former job title is unlikely to impress most viewers as much as the simple "Dr." before Tracy's name.
In another half-way effort at balance, we hear from Cynthia Winnings and David Dillon, a couple who had "a great experience with a midwife." They safely had their first child in their home, and they deliver a few glowing comments about the experience.
Alexander goes on to say that the "CDC" says home birth statistics are limited, but in 2005 home births actually resulted in fewer deaths than hospital births. However, he is quick to add that "doctors" say it's "impossible" to compare the two because hospitals deal with so many more high-risk cases, including twins, diabetic mothers, and breach babies. But although we hear what "doctors" say, we don't hear what "midwives" say. Would midwives agree that it's "impossible" to extract high-risk births, and compare similar patient populations? Might nurse midwives note that it's obviously quite possible, since it's the basis for the studies showing nurse midwife care is at least as good as that of physicians? Today's millions of viewers may never know.
The pre-recorded segment concludes with another emotional visit with the McKenzies, who understandably remain haunted by their experience. Catherine says she would have a hundred C-sections if she could get her lost baby back.
Alexander, back with Lauer, notes that the McKenzies need more "time to heal" but hope to try again to start family. Lauer asks what people should ask of a midwife "before they employ that person." Alexander:
The medical experts that we spoke with said that expectant parents considering a home birth should ask several questions. Specifically, does the midwife have malpractice insurance? Another one would be, does she have a collaboration agreement with a doctor or hospital that would help them care for the baby and the mother in case there is an emergency of this sort?
Who were these "medical experts," we wonder? And while it makes sense to consider such issues in choosing any provider, the implication is clearly that midwives are unreliable practitioners who require special considerations that physicians do not, which has not been established, and cannot be established on the basis of one tragic outcome.
Not surprisingly, the McKenzies filed a malpractice lawsuit against Muhlhahn in October, a little over a month after the Today report aired. The lawsuit itself generated considerable press coverage, and the couple's attorney gave multiple quotes. In one reported comment, he--coincidentally just like the Today Show--selected Muhlhahn's "guardian of safety" quote from the film and turned it against her.
This is not the first time the Today Show has run stories attacking the care of advanced practice nurses. In November 2005, it aired a segment about retail-based "quick clinics" that similarly questioned the safety of those clinics and the nurse practitioners who staff them. That report ignored the research showing the quality of NP care, consulted no nurse experts, and relied solely on uninformed criticism from physicians.
We hope that the Today Show--which is, after all, a product of NBC News--will try in the future to provide a fair and balanced look at issues that involve nurses.
Write to the Today Show at firstname.lastname@example.org or
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