Homebirth midwives “value the art of letting go.” Letting go of what, exactly? The lives of babies born at homebirths.

We know this because it’s written in the MANA Statement of Values and Ethics right on their website,

“F. We value the art of letting go and acknowledge death and loss as possible
outcomes of pregnancy and birth.”

MANA is the professional organization of homebirth midwives. It’s a disturbing statement coming from an organization that claims homebirth is safe, even though it’s 4 times more deadly than hospital birth. It’s troublingly vague, and none of its possible meanings are reassuring:

• Letting go of the grief that accompanies a homebirth death. But I cannot imagine preaching that to a homebirth loss family or to health care providers who’ve lost a patient. People need to grieve.
• Letting go of the desire to seek answers. But the death of every baby, whether at home or at the hospital, should be questioned. We should seek answers about what could have been done differently, what mistakes were made, because that’s the only way to prevent it from happening again.
• Letting go of the life of the baby, by denying life-saving treatment, similar to taking someone off of life-support. But at a homebirth, there is no expert prognosis available on which to base that kind of decision.

The MANA Statement of Values and Ethics was first adopted in 1992 (Rooks, '97). It was authored, in part, by California Licensed Midwife, Judy Luce.

Luce writes on her website:

“In 2001 I completed my Master's degree in Cultural Studies and Midwifery with my thesis: Midwives at the Margins of Life: Home Birth and Home Dying. In this work, I developed the concept of midwives primarily as cultural workers, an idea that is central to my midwifery practice and critique of the medicalization of birth.

"I have served as the Midwives Alliance of North America (MANA) regional representative, helped create MANA’s Ethics and Values Statement, presently serve on the Document Review Committee, and am a member of the California Association of Midwives.” (my emphasis)

A different version of the MANA Statement of Values and Ethics appears in the appendix of the 2010 book, “Professional Ethics in Midwifery Practice,” by Illysa Foster and Jon Lasser. Foster is a homebirth midwife and psychologist in Texas who teaches MEAC continuing education courses and speaks at MANA conferences. An excerpt from the MANA Statement of Values and Ethics reads,

“F. We value skills that support a complicated pregnancy or birth to move toward a state of greater well-being or to be brought to the most healing conclusion possible. We value the art of letting go.6

"G. We value the acceptance of death as a possible outcome of birth. We value our focus as supporting life rather than avoiding death.7"

And in the footnotes of the MANA statement:

"6 This addresses our desire for an uncomplicated birth whenever possible and recognizes that there are times when it is impossible. That is to say, a woman may be least traumatized by having a Cesarean and a live baby, when a spontaneous vaginal birth is not possible. We let go of that goal to achieve the possibility of a healthy baby. Likewise, the situation in which parents may choose to allow a very ill, premature or deformed infant to die in their arms rather than being subjected to multiple surgeries, separations and ICU stays. This too, is a letting-go of the normal for the most healing choice possible, given the circumstances, within the framework of the parent’s ethics. What is most healing will, of course, vary from individual to individual.

"7 We place the emphasis of our care on supporting life (preventive measures, good nutrition, emotional health, etc.) and not pathology, diagnosis, treatment of problems, and heroic solutions in an attempt to preserve life at any cost of quality.” (my emphasis)

The decision to refuse life-saving medical treatment to have a better short-term quality of life is a genuine ethical dilemma, but there is no expert prognosis available at a homebirth on which to base such a decision. And while neonatal surgeries and ICU stays are indeed traumatizing events, I strongly object to an ethical framework that elevates a dead baby with no interventions over a baby with disabilities, or a baby who only requires surgery to live, especially when no expert opinion has been consulted first.

These quotes provide another interpretation of “the art of letting go” that I hadn’t considered: letting go of the ideal birth experience. It’s just benign enough to give midwives some cover when using this horrifying expression.

There is no comparable statement in any of the ACNM literature, such as the Code of Ethics or the ACNM Philosophy of Care. By contrast, the ACNM Philosophy of Care actually promotes a belief in “Appropriate use of interventions and technology for current or potential health problems.” Note that CNMs receive an ACME-accredited midwifery education, the only midwifery education path endorsed by the ACOG. CNMs are the most educated midwives in the world and primarily attend hospital births.

Among other midwives, such as CPMs, LMs, DEMs, who can only attend homebirths, “the art of letting go” has been widely accepted. This disturbing philosophy is promoted through the MANA Statement of Values and Ethics or Foster’s book by the following midwifery organizations, with direct evidence provided in the links:

• Association of Midwifery Educators
• Association of Independent Midwives of Maryland
• New Mexico Midwives
• Tennessee Midwives Association
• Utah Midwives Organization
• Association of Turkish Midwives
• NARM Practice Guidelines

And by MEAC-accredited midwifery schools such as

• National College of Midwifery
• Birthingway College of Midwifery
• Florida School of Traditional Midwifery
• Midwives College of Utah

In an industry plagued with preventable losses, “the art of letting go” is an ominous mantra that is beyond alarming - it's incriminating.

EDIT: Changes have been made to reflect that quotes from Foster and Lasser's book are actual statements made by MANA.