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T HE NEW YORK TIMES INTERNATIONAL EDITION MONDAY, AUGUST 5, 2019 | 11Last month, a Nebraska midwife,
Angela Hock, was charged with negli-
gent child abuse when a newborn died
after complications from a breech birth
at home. It’s worth noting that before
this delivery, Ms. Hock, the proprietor
of a business called Nebraska Birth
Keeper, had performed 50 births at
home without incident. Nonetheless,
Ms. Hock was not certified to practice
as a midwife.
It’s unfortunate that these are the
stories about home birth that make
headlines, because they give the prac-
tice a bad name, and contribute to a
sense that home births are irresponsi-
ble, a danger to the mother and baby.
Home births can be safe — as long as
they occur within a system of stand-
ards and regulations of the very sort
that were missing in Nebraska. When
home birth is practiced in the shadows
because of fear of recrimination, pa-
tients are worse off. We can change
this by acknowledging that home birth
is a reasonable medical choice, and by
licensing midwives for home birth in
all 50 states.
I have practiced as an obstetrician in
Washington State since 2006. I attend
births only in the hospital, but I fre-
quently take care of patients who
intended to give birth at home and
ended up transferring to me when
their labor didn’t progress normally.
The American College of Obstetricians
and Gynecologists (ACOG) had long
opposed home birth, but in 2017 issued
a committee opinion acknowledging
that while “hospitals and accredited
birth centers are the safest settings for
birth, each woman has the right to
make a medically informed decision
about delivery.” By contrast, the Royal
College of Obstetricians and Gynaecol-
ogists in the United Kingdom encour-
ages home birth for women with un-
complicated pregnancies.
The source of this discrepancy, as
well as a great deal of controversy, is
that studies on newborn outcomes
have come to conflicting conclusions.
Data collected by researchers in Cali-
fornia and Oregon suggest there may
be an increased risk of death in babies
born at home, while research in the
Netherlands found no significant dif-
ference between the risks associatedwith planned home and planned hospi-
tal births. There is no high-quality data
from randomized controlled trials
because none have been conducted.
This is in part because of ethical chal-
lenges and because very large num-
bers of patients would be needed to
definitively detect differences.
What does seem clear, however, is
that women undergo fewer interven-
tions when delivering at home. A meta-
analysis of more than 24,000 births in
multiple countries found lower rates of
severe laceration, episiotomy and
cesarean section with planned home
births compared to planned hospital
births. Maternal outcomes are likely
better at home because the possibility
of unnecessary interventions is re-
moved, although those interventions
can still be obtained efficiently through
transfer to a hospital. There is also
evidence from Britain that there are
fewer maternal complications, like
postpartum hemor-
rhage, when women
give birth at home.
Cochrane, a trusted
global network of
health researchers,
distilled these fac-
tors to what is most
important: the over-
all safety of home
birth is comparable
to that of hospital
birth for healthy patients assisted by
experienced midwives.
Unfortunately, giving birth at a
hospital isn’t universally safe. NPR
reported that the United States is the
only developed nation with an increas-
ing rate of maternal death, which has
more than doubled from 1987 to 2015.
According to the Institute for Health
Metrics and Evaluation, it is now
nearly twice as dangerous to give birth
here as it is in Britain, France or Ger-
many, despite the fact that the United
States spends more on health care per
capita than these countries. ACOG
notes that the statistics are even more
dire among minorities, with black
women being three to four times more
likely to die than white women.
No one is immune to this risk. In
2017, Serena Williams almost died of a
pulmonary embolism after delivering
her daughter when her complaints of
shortness of breath weren’t taken
seriously at a Florida hospital. Re-
searchers in Alabama and Georgia
found that half of maternal deaths arecaused by medically preventable com-
plications like embolism, while the
other half, including those linked to
rising obesity rates and poor access to
health care, cannot be blamed entirely
on hospitals. Nevertheless, it remains
understandable that pregnant women
have started to lose trust in the medi-
cal establishment.
Marginalizing home birth only en-
dangers patients. There is a better way
to handle this, starting with formal
accreditation. According to ACOG,
approximately 35,000 births occur at
home in the United States each year.
State governments regulate the educa-
tion and experience needed to qualify
as a birth professional through licen-
sure. Certified Professional Midwives
are the only providers required to have
training in home birth, but just 33
states license CPMs to practice.
Nebraska is not one of those states
— only Certified Nurse Midwives who
also hold a nursing degree are li-
censed, and they are prohibited from
attending births at home. This means
that there are no birth professionals in
Nebraska who are “properly certified”
for home birth, making it difficult for
patients who want a home birth to
figure out who is qualified and how to
access services.
A recent study published in PLOS
One showed that in states where mid-
wives are regulated and integrated
into the health care system, rates of
neonatal mortality, cesarean section
and preterm birth are all lower, regard-
less of birth setting.
Washington State has the highest
level of midwife integration in the
country, and our group obstetric prac-
tice at the University of Washington’s
Northwest Hospital routinely works
hand in hand with community mid-
wives to ensure patients are provided
with the information and services they
need.
The women of America deserve
access to the best medical care possi-
ble.
They deserve access to safe home
birth, with a licensed midwife, in all
states.KATE MCLEANis a board-certified obste-
trician-gynecologist working at the
University of Washington in Seattle,
and is the treasurer and vice president-
elect for the Washington State section of
the American College of Obstetricians
and Gynecologists.Giving birth at home is O.K.
To improve
access to safe
birth at home
in America,
nationwide
standards are
necessary.Kate McLean
There’s the Mom Commentary on
behavior. Eyes on the dog, she sees
everything. She’s gotta talk about it.“YOU’VE GOT A LOT TO LEARN! A LOT
TO LEARN!”
— Woman to her dachshund puppy on
the sidewalk“I KNOW YOU GOT EXCITED WHEN
YOU SAW ANOTHER PUPPY... BUT I
NEED MY ARM TO REMAIN IN THE
SOCKET.”
— Woman to happily leash-tugging
retriever“YOU CAN SIT ALL YOU WANT WHEN
WE’RE HOME.”
— Woman to dog not going anywhere“YOU’RE EMBARRASSING YOURSELF!”
— Woman to shy dog avoiding a
friendly dog’s advancesAppropriately (for the category), most
of these speakers are women. In fact,
among my notebook scribblings, the
speakers were women about six times
as often as they were men. Women
speak more often, more quickly and
longer than men — on the sidewalk
and in scientific studies of dog talkers.
They repeat words more and are not
shy about dropping in a term of en-
dearment. This is not to say that men
are immune from the Mom Commen-
tary:“BE NICE! WHEN YOU GET TIRED, YOU
GET NASTY.”
— Man to rambunctiously playing dog“SOMEBODY HAS A BAGEL, AND IT’S
NOT YOU. AND IT’S NOT GONNA BE
YOU WITH THAT KIND OF BEHAVIOR.”
— Man to rapacious houndIn addition to the quotidian “Sit” and
“Stay,” there are also the Perfectly
Implausible Instructions:“YOU GUYS ARE GOING TO HAVE TO
GET COORDINATED.”
— Woman to two dogs pulling in differ-
ent directions“I SEE YOU DOING WEIRD STUFF. CUT
IT OUT.”
— Woman to one of her four small dogs“GIMME PAW! GIMME PAW!”
— Elderly man to three-legged dog“BE PART OF THE SOLUTION, BUDDY.”
— Woman to dog being part of the prob-
lem“YOU HAD BETTER STAY YOUR
BOTTOM RIGHT HERE, SUNSHINE.”
— Woman to sunny pug“IF YOU MAKE IT TO THE END OF THEFENCE, YOU GET A BISCUIT. IF YOU LIE
DOWN, NO BISCUIT.”
— Woman to corgi probably not going to
make it to the end of the fenceIn the spirit of conversation that does-
n’t need an answer, we turn question
marks toward our pups, engaging them
as ifthey might respond — and then
waiting a beat to give them due time to
so reply. This is the Rhetorical Realm:“WOULD YOU GUYS LIKE TO BE IN A
BOOK GROUP?”
— Woman to eager dogs in dog park“HI, HONEY, DID YOU VOTE?”
— Woman to excited dog outside polling
place“WHAT, ARE YOU REINVENTING THE
POO?”
— Woman to long-pooing dogBehind every unanswered question is
the feeling that we might know the
answer, given that we and our dogs live
together, see each other naked, and
obviously know everything about each
other. Hence the reliable appearance of
the We’ve Discussed This utterances
(dog’s full family name implied):“WE’VE TALKED ABOUT THIS: NO
EATING STUFF YOU FIND ON THE
STREET.”
— Man to foraging dog“WE BOTH KNOW WE HAVE TO GO
NOW.”
— Woman to dog gamboling in snow“HEY! STOP IT! (WHISPERS): WE
TALKED ABOUT THIS YESTERDAY.”Most talk I hear is overheard, seem-
ingly not intended for my ears. But
when we talk to dogs around others, it
serves as a social lubricant, a way to
open up the possibility of talking to
each other. “What’s your name?” said
dog-ward is never answered — except,
obligingly, by a dog’s owner. Dogs are
not only reflections of us, they are
social intermediaries for us. Any hesi-
tation I may have about a person ap-
proaching me on the street is deflected
by my dog Finnegan’s smiling, wag-
filled greeting of them; in response,
they talk not to me, but to the dog.
It’s not only strangers who can be
looped in by dog-talk. We talk to our
relatives — our human relatives — via
our dogs as well. The linguist Deborah
Tannen writes of a couple mid-argu-
ment: “The man suddenly turns to
their pet dog and says in a high-pitched
baby-talk register, ‘Mommy’s so mean
tonight. You better sit over here and
protect me.’ ” The dogs enable the
speaking; they are not really the spo-
ken-to.
Of course, through all our talking,dogs are more or less silent. Re-
searchers keep looking for the lan-
guage-using dog, though. Some dogs —
like the Border collies Rico and Chaser,
who died in July — have learned hun-
dreds upon hundreds of words. Dogs in
fMRI studies both distinguish familiar
from nonsense words and process the
emotional content of words. Nonethe-
less, dogs are not talking back. Some
scholars think dog-human communica-
tion represents a “human fantasy” of
how communication might go: all
listening, no responding. “We like our
pets’ silence,” the animal studies re-
searcher Erica Fudge suggests, “be-
cause it allows us to write their words
for them.” I do think this begins to
explain our nonstop chatter with dogs.
When we talk to dogs, it’s as if our
private speech, the conversation we’re
having in our heads, has slipped out.“YOU, YOU, YOU, YOU, YOU.”
— Woman to well-mottled dogThe Russian psychologist Lev Vygot-
sky, formulating his theories of child
development, described a stage of
children internalizing conversations
with those around them — social
speech — into a conversation in their
own heads. He called it “inner speech”
and thought it enabled children to use
language to reflect on and consider
their own behavior. We continue that
monologue with ourselves as we age
into adults. It’s not quite the way we’d
talk to those around us, though, with its
cropped syntax and a “note-form”
shorthand that represents your famil-
iarity with your own thoughts. But it’s
just like what we’re saying to our dogs
— as if they were in our heads.
Dogs are, of course, the preoccupa-
tion of our minds: we hope for them,
care for them, love them. We narrate
our thoughts while we watch them, and
their thoughts while they accompany
us.
One of the things we say to our dogs
daily — two-thirds of us, according to
one survey of North American pet
owners — is I love you.Even the simple
sound of our voice is an expression of
that love, regardless of the content of
the words we say. Through talking to
them, we let them into an intimacy with
us. They hear our secrets, our private
thoughts.
So now you know: Pass me on the
sidewalk, and I may be listening.
Please don’t let it stop you from talking.
It makes me feel optimistic about hu-
mans to hear us talk to other animals.
We are at our best in those moments
when we extend the circle we’ve drawn
around ourselves to include them.ALEXANDRA HOROWITZruns the Horowitz
Dog Cognition Lab at Barnard and is
the author of “Our Dogs, Ourselves:
The Story of a Singular Bond,” from
which this essay is adapted.JOSH COCHRANThings people say to their dogs
HOROWITZ, FROM PAGE 9opinion
view that should have been killed by
evidence decades ago but keeps sham-
bling along, eating G.O.P. brains.
The record is actually awesomely
consistent. Bill Clinton’s tax hike didn’t
cause a depression, George W. Bush’s
tax cuts didn’t deliver a boom, Jerry
Brown’s California tax increase wasn’t
“economic suicide,” Sam Brownback’s
Kansas tax-cut “experiment” (his
term) was a failure.
Nevertheless, Republicans persist.
This time around, the centerpiece of
the tax cut was a huge break for corpo-
rations, which was supposed to induce
companies to bring back the money
they’ve invested overseas and put the
money to work here. Instead, they
basically used the tax savings to buy
back their own stock.
What went wrong? Business invest-
ment depends on many factors, with
tax rates way down the list. While a
casual look at the facts might suggest
that corporations invest a lot in coun-
tries with low taxes, like Ireland, this is
mainly an illusion: Companies use
accounting tricks to report huge profits
and hence big investments in tax ha-
vens, but these don’t correspond to
anything real.There was never any reason to
believe that cutting corporate taxes
here would lead to a surge in capital
spending and jobs, and sure enough, it
didn’t.
What about the trade war? The
evidence is overwhelming: Tariffs
don’t have much effect on the overall
trade balance. At most they just shift
the deficit around: We’re importing
less from China, but we’re importing
more from other places, like Vietnam.
And there’s a
good case to be
made that Trump’s
tariffs have actually
hurt U.S. manufac-
turing. For one
thing, many of them
have hit “intermedi-
ate goods,” that is,
stuff American companies use in their
production processes, so the tariffs
have raised costs.
Beyond that, the uncertainty created
by Trump’s policy by whim — nobody
knows what he’ll hit next — has surely
deterred investment. Why build a
manufacturing plant when, for all you
know, next week a tweet will destroy
your market, your supply chain, or
both?Now, none of this has led to eco-
nomic catastrophe. As Adam Smith
once wrote, “There is a great deal of
ruin in a nation.” Except in times of
crisis, presidents matter much less for
the economy than most people think,
and while Trumponomics has utterly
failed to deliver on its promises, it’s not
bad enough to do enormous damage.
On the other hand, think of the
missed opportunities. Imagine how
much better shape we’d be in if the
hundreds of billions squandered on tax
cuts for corporations had been used to
rebuild our crumbling infrastructure.
Imagine what we could have done with
policies promoting jobs of the future in
things like renewable energy, instead
of trade wars that vainly attempt to
recreate the manufacturing economy
of the past.
And since everything is political
these days, let me say that pundits
who think that Trump will be able to
win by touting a strong economy are
almost surely wrong. He most likely
won’t face a recession (although who
knows?), but he definitely hasn’t made
the economy great again.
So he’s probably going to have to do
what he’s already doing, and clearly
wants to do: run on racism instead.The big flop of Trumpian economics
K RUGMAN, FROM PAGE 1Trumponomics
has utterly
failed to
deliver on its
promises.Order the International Edition today at
nytimes.com/discover
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delivery is subject to confirmation by local distributors. Smartphone and tablet apps are not supported on all devices.РЕ
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