From Antigonos:
Dr. Amy, I bow to your computer skill. Nice quiz!
From Dianne:
I second, but found the last question a little ambiguous: is the risk of death in question maternal, fetal, or either? ( I answered for fetal and got it right, but that could be dumb luck.)
From Katie:
I would be interested in seeing what some of the "correct" answers are (like to the False questions) and any references you might have.
From homebirther:
You set this up as if home birth supporters actively misrepresent all of these things, or that they are exclusive to home birth.
Maternal cause of death:
My midwife run prenatal care included testing for pre-e. I asked about the hemorrhage risk during prenatal visits; she explained the treatment options, which included drugs, transport and IV. She brings the drugs and IV to every birth. If you based your impression of the care she offers solely on her website, you wouldn't read about these things, any more than you would read about an OB's multitude of treatment options on their or the hospital's website. As an introduction, it isn't relevant. Those kinds of details come out during the prenatal visits (or they should).
"Risk of death list:"
I've yet to see a website that specifically states that breech is safer than c-section. I have seen sites that say it is possible to birth a breech vaginally. Also, the rejection of epidurals has more to do with the way their side effects are not addressed, not that they are lethal.
I was advised to labor at home for as long as possible before coming into the hospital (when I initially signed up to give birth with a CNM at an area hospital). There are complication which can occur in labor that I couldn't know about/wouldn't know about if I didn't have an attendant. Since all labor could be considered a "trial," since you can't see ahead of time what might go wrong, this medically sanctioned advice could've cost me or my baby our life. If the lowest death rate is the only thing worth striving for, by your logic all women should be scheduled for c-section, regardless of actual risk.
"Infant Mortality Rate"
You like to play a game with definitions. Technically, IMR includes all deaths in the first year, so it can be used, even if you don't like how it is used. You define it incorrectly, instead applying the definition for postneonatal mortality rate to IMR.
(Got my definition from http://www.cdc.gov/nchs/datawh/n....htm#perinatal)
Since you can't seem to define it correctly, you can't really argue that other people use it incorrectly.
"Bacteria and viruses"
Again, I've never encountered a website that specifically addresses these issues by downplaying them; like the hemorrhage issue, they would likely come up during prenatal care. But an infection or bacteria doesn't necessarily have any affect on the labor itself, or the delivery, which is the real issue. An untreated infection can be fatal to an infant be it born in a hospital or at home. The issue with this is not mortality associated to the infection, but whether or not prenatal care catches them so they can be treated.
"Lowest perinatal mortality rates"
Well, here's an issue. You are looking at country-wide statistics. However, depending on where you have your child in the US, your local rate could be much different (even within major cities there can be differences). Also, I would think you would have to study the mortality rates within home births that transported to the hospital for complications vs those that didn't have complications to figure out if the time lost to being at home is truly more dangerous.
"Birth is inherently safe"
Opinion, both yours and theirs. Different interpretations of "inherently" and "safe" will lead to different conclusions. Even without modern OB, a baby had a 93% survival rate. That can be viewed as pretty good, and thus 'inherently safe.' You do not, so birth is not 'inherently safe.'
Your last question confuses me. If you make the sentence positive ("If birth were safe, we would survive as a species"), wouldn't the answer then be true? So if birth safe or not?
From Susanne:
"Even without modern OB, a baby had a 93% survival rate. That can be viewed as pretty good, and thus 'inherently safe.' "
You're kidding, right?
From Amy Tuteur, MD:
homebirther:
"You set this up as if home birth supporters actively misrepresent all of these things, or that they are exclusive to home birth."
I do believe that's true, but people can see for themselves by taking the quiz. Homebirth advocacy is based on a series of mistruths, half truths and outright falsehoods. Each question of the quiz is meant to address a specific falsehood or half truth.
Maternal mortality:
It is axiomatic among homebirth advocates that birth is inherently safe, but to the extent that it is dangeous it is BECAUSE OF doctors. The falsehood is that infection is the leading cause of death, that doctors CAUSE infections and that Semmelweis was hounded to an early grave because he dared to show that doctors were wrong. I think it is very important for homebirth advocates, and anyone contemplating a homebirth, to recognize that childbirth has an inherently high rate of maternal mortality (1%) and that the most common causes of death are pre-eclampsia and hemmorhage.
Risk of death list
Another problem with homebirth advocacy is lack of knowledge about the magnitude of the risks. If you listen to homebirth advocates talk, and if you read what they write, you would get the impression that C-section is very dangerous and that vaginal breech delivery is only slightly more dangerous that regular vaginal delivery. That's why it is important to understand how the risks compare. Vaginal breech represents a much more serious risk to the baby than C-section to the baby or mother.
Infant Mortality Rate
Infant mortality rate is the wrong statistic and there is no valid reason to use it when perinatal mortality is available. The DELIBERATE implication is that the quality of OB care in the US is inferior to the quality of OB care in Europe. It is deliberately misleading to use the wrong statistic to make a point that isn't even true.
Bacteria and viruses
Homebirth advocates often claim that the "germs" at home are safer than those in the hospital. The problem is that the organisms which pose the greatest risk to the baby are carried by the mother herself and it is important that people understand that.
Lowest perinatal mortality rates
It's the truth and people need to be aware of it.
Safety of birth
No, it's not a matter of opinion that pregnancy and childbirth are and have always been, in every time, place and culture, one of the leading causes of death of young women and that the day of birth is the single most dangerous day of the 18 years of childhood.
"If you make the sentence positive ("If birth were safe, we would survive as a species"), wouldn't the answer then be true?"
That's not relevant because of a basic principle of logic. The true statement "Even though birth is not inherently safe, we still survive as a species" tells us nothing about the validity of the statement "If birth were inherently safe we would still survive as a species." They can both be true at the same time.
From Erica:
I think the quiz needs to be a lot more specific and thorough in both the questions and the answers. For instance, for the T/F statement, "The most common cause of maternal death is infection," which is false, you need to explain what the right answers are. Also, "Birth is inherently safe" is ambiguous. Some people have very different definitions of safe or a misunderstanding of statistics. (Anything in the 90's sounds safe to them.)
From homebirther:
Susanne,
Personally? No. My point (as Erica said) is that for some anything in the 90s could be construed as safe. It is a matter of opinion for where the 'safe' cut-off is.
Amy,
"Each question of the quiz is meant to address a specific falsehood or half truth."
But half are opinions and the rest are either vague or ambiguous, open to interpretation. You need to be very specific and clear in what you are referring to, otherwise it becomes muddled and points get lost to the ambiguity.
"It is axiomatic among homebirth advocates that birth is inherently safe, but to the extent that it is dangeous it is BECAUSE OF doctors."
Blaming doctors as mother-killers is hardly productive I agree. However, I do not believe that death is the main point of concern for home birth advocates in terms of the doctor-patient relationship. I think instead it is the mistreatment of the mothers. I spoke with many people during my pregnancy about their pregnancies, and not one liked the way they were treated, the way doctors threatened them with interventions ('If you don't get this baby out with the next push, I'm going in with foreceps! or My shift ends at 12, so if you don't deliver bt 11:20 we're doing a c-section.' Both of these were used on coworkers.) Since most people (hospital or home birth) assume the baby and mom will survive, the treatment of the mom during the labor and birth, and the judicious use of medical options, does become a concern.
"I think it is very important for homebirth advocates, and anyone contemplating a homebirth, to recognize that childbirth has an inherently high rate of maternal mortality (1%) and that the most common causes of death are pre-eclampsia and hemmorhage."
Pre-eclampsia can be predicted and treated (many midwives will risk out a mother from home birth if she develops pre-e). Considering the number of postpartum visits which happen, if it develops afterwards (a very unlikely scenaria), they can spot it and send the mom to the hospital. Hemorrhage yes is a great risk which should not be downplayed. But again, most midwives do carry tools (IV and drugs) to counter this, and if it is truly serious can call an ambulance. Do you have stats to show the occurrences of maternal death by pre-e or hemorrhage as they relate to home birth?
"It is deliberately misleading to use the wrong statistic to make a point that isn't even true."
No more so than to use the wrong definition and wrong terminology to argue your point. Since you are arguing they are wrong, you need to be very accurate in your words, and here you are not. Also, I believe that no matter how you crunch the numbers, other countries achieve as good (and frequently better) rates than the US with significantly less usage of medical interventions like c-section. Also, can you please post a link to the study which supports your claim? My google searches have me going in circles.
"Homebirth advocates often claim that the "germs" at home are safer than those in the hospital. The problem is that the organisms which pose the greatest risk to the baby are carried by the mother herself and it is important that people understand that."
Hmm, I think you are mixing ideas. It is one thing to discuss the germs of the place of birth, another to discuss the germs of the mother. By giving birth at home, you avoid any possible exposure to germs present in a hospital, which the negates that risk factor as pertaining to hospital-born infection in giving birth at a hospital (it's a bit of a duh statement I realize). No matter where you give birth, you will expose your baby to your germs. Some of these can be treated/anticipated with adequate prenatal care, which will affect the likelihood of death.
"No, it's not a matter of opinion that pregnancy and childbirth are and have always been, in every time, place and culture, one of the leading causes of death of young women and that the day of birth is the single most dangerous day of the 18 years of childhood."
Not arguing leading cause of death, just that whether or not it is safe is a matter of opinion.
From Amy Tuteur, MD:
homebirther,
Your observations would be relevant if you were trying to make the argument that homebirth advocates understand that childbirth has inherently high rates of neonatal and maternal mortality, and that homebirth increases the risk of preventable neonatal death, but that increase is acceptable to them. That's not the position of homebirth advocates. The typical homebirth position is succinctly expressed in the statement "Homebirth, as safe as birth gets." As safe as birth gets is hospital birth, a C-section rate of 15-20%, universal prenatal care and comprehensive prenatal monitoring and testing.
Homebirth is based on factually incorrect empirical premises. Homebirth advocates' erroneous claims about birth are not a matter of opinion, the reflect a fundamental lack of knowledge. That's why it is so ironic that homebirth advocates claim to be so "educated". Much of what they think they know is actually false.
From Susanne:
"Pre-eclampsia can be predicted and treated (many midwives will risk out a mother from home birth if she develops pre-e)."
Pre-eclampsia can be predicted? How precisely does that occur? What predictive signs are there? Before we get to the high blood pressure and protein in the urine phase, of course. Please do tell, because I sense a medical breakthrough.
From Liz:
The trouble with pre-eclampsia, of course, is its insidiousness and unpredictability. I have a very personal interest in this subject, and wish Dr. Amy would comment on it at some date. I suspect it is both under-reported and sometimes undetected - all those "unexplained" stillbirths. I had high BP, proteinurea, swelling - but was told "not PE". Same with my daughter. The Homebirth question is simple for me - it would have meant dead mother/dead baby
From homebirther:
Susanne,
"Pre-eclampsia can be predicted? How precisely does that occur? What predictive signs are there? Before we get to the high blood pressure and protein in the urine phase, of course. Please do tell, because I sense a medical breakthrough."
I think I used the wrong word. It can be diagnosed, and can thus be treated (including risked out of home birth). It would be nice for a simple blood test to predict what you would get sick with down the road. Maybe one day.
Liz,
"The trouble with pre-eclampsia, of course, is its insidiousness and unpredictability. I have a very personal interest in this subject, and wish Dr. Amy would comment on it at some date."
Amy, I pass the ball to you. Can you explain about pre-e a bit, perhaps risk factors, stats on occurrence, diagnosis, and treatment? Just so we are all on the same page.
"I suspect it is both under-reported and sometimes undetected - all those "unexplained" stillbirths."
Under-reported? Maybe (although why wouldn't it be reported)? Undetected? Probably. Illnesses of all sorts can show up and not get noticed or overlooked because it doesn't fit the classical set of symptoms. The cause of 'unexplained' stillbirths? Don't know about that. I look at those much like I do the 1 in 5 chance a perfectly healthy woman has of miscarrying in the early weeks; it just happens, and there may not be a specific reason for it.
"I had high BP, proteinurea, swelling - but was told "not PE". Same with my daughter."
Knowing nothing about your medical history, or how aggressive your OB was for handling (potential) complications during pregnancy, I can only say that maybe you didn't present enough of the symptoms? The list I read included some 15 or more things which indicate PE. I had swelling, lots of weight gain, and high BP, but it was decided I didn't have PE (I suspect if even once I'd had proteinurea she would've risked me out).
"The Homebirth question is simple for me - it would have meant dead mother/dead baby"
I'm curious, why is it so simple? The worst rate I've heard quoted for home birth has an infant survival rate of 99.7%, so the odds are good for survival. Is your statement one of hindsight (something happened during labor/delivery which could've been fatal if you hadn't been in the hospital)?
Oh Amy,
Can you please check out this article?
http://www.cnn.com/2007/HEALTH/
0...eref=rss_latest
In particular, point 2 which mentions anxiety during labor relating to the hospital, premature interventions, and laboring at home.
From Amy Tuteur, MD:
homebirther:
"The worst rate I've heard quoted for home birth has an infant survival rate of 99.7%, so the odds are good for survival."
This is precisely what I mean about homebirth and misleading statements. 99.7% sounds pretty good until you know that 99.9% is the expected rate. Morever, you need to consider the relative risk. For example, the leading cause of death of small children is accidents, yet 99.99% of children do not die from accidents.
That's why it makes much more sense to express the risk in comparison to hospital birth. There is an increased risk of 1-2/1000 over hospital birth for low risk women. That means that the chance of neonatal death at homebirth is more than 3 times higher than hospital birth.
From Amy Tuteur, MD:
homebirther:
"In particular, point 2 which mentions anxiety during labor relating to the hospital, premature interventions, and laboring at home."
The statistics do not tell us whether staying at home until 3 cm lowers the C-section rate. That's because many women having medically necessary C-sections and inductions never get to 3 cm, severely skewing the numbers.
There is precisly zero evidence that women are more anxious in 2007 or coming to the hospital earlier or asking for epidurals earlier than 10, 20 or 30 years ago, so it is highly unlikely that these issues account for the increase in the C-section rate. I suspect that it relates more to the expectation of a perfectly healthy baby every time. Doctors are loathe to take any risks.
From homebirther:
Amy,
"The statistics do not tell us whether staying at home until 3 cm lowers the C-section rate. That's because many women having medically necessary C-sections and inductions never get to 3 cm, severely skewing the numbers."
I didn't read this article as it speaking to medically necessary c-sections or inductions. I think the 3 cm guideline is assuming spontaneous start of labor. From my early prenatal care, I was told by the CNM that lots of women have false labor pains during their first pregnancy, or react too early to their labor pains, and come in too (and if I did show up too early, they would send me home!). I think the implication is that entering the hospital before labor is truly under way increases the likelihood that drugs may be used to 'kick start' the process, and that this does have a link to c-sections. It would require some in-depth analysis of labor and delivery numbers to extrapolate the various rates for the past few years. Intuitively though, the 'cascade effect' of one intervention leading to another does suggest that arriving early and being given drugs which in other circumstances does lead to frequent c-sections will increase your chances of have a c-section.
"There is precisly zero evidence that women are more anxious in 2007 or coming to the hospital earlier or asking for epidurals earlier than 10, 20 or 30 years ago, so it is highly unlikely that these issues account for the increase in the C-section rate."
I don't think the article (or the doctor) really meant that women are more anxious, but that they now recognize that anxiety can have an effect on some laboring women, such as stalling or slowing down the labor, which can start the cascade effect, and that by reducing anxiety you can reduce the need for interventions such as drugs and surgery. I think the rise in c-section rates has to do with insurance companies and lawsuits (merited and otherwise), impatient doctors, and c-sections on request by the mother (for convenience/looks/whatever).
"I suspect that it relates more to the expectation of a perfectly healthy baby every time."
I've read this from you before. With few exceptions, almost every person going in for medical treatment assumes a perfect outcome, so why should childbirth be any different? And if it is different, how much does this have to do with the patient vs the doctor/hospital creating the impression that they can fix everything/anything? It is not like OBs (or any medical person) advertise their personal mortality rates, or rate of NICU admission.
"Doctors are loathe to take any risks."
Doctors take risks all the time. And in the case of labor and delivery, since there can be a huge variation in how it progresses, hard guidelines (if a woman does not dilate 1 cm every hour, do abc -just an theoretical example) can create risks where there may be none (if the baby's HR is fine, and mom is fine with the rate of advancement, and nothing is 'wrong,' then abc treatment is probably unnecessary, but if it is done, creates the need def intervention). L&D is a place where I think a more reserved approach is warranted specifically because of the wide range of 'normal', and one that midwives (in and out of hospitals) provide with a much great frequently than OBs and L&D nurses.
From Amy Tuteur, MD:
homebirther:
"they now recognize that anxiety can have an effect on some laboring women, such as stalling or slowing down the labor"
But it doesn't. There have been quite a few studies on women who have problems with anxiety in labor or even pathologic fear of labor and the incidence of interventions is exactly the same.
"With few exceptions, almost every person going in for medical treatment assumes a perfect outcome, so why should childbirth be any different?"
It is very different. When a person is having a heart attack everyone knows that he or she may die and if they don't, they credit the doctor. In contrast, since most women do not understand the inherent risks of childbirth they EXPECT that the baby will be perfectly healthy and if that doesn't happen, they assume that the doctor was at fault.
"Doctors take risks all the time."
Doctors take risks with the lives of babies all the time? Such as?
"one that midwives (in and out of hospitals) provide with a much great frequently"
However, homebirth midwives preside over preventable neonatal deaths. That's the tradeoff we were discussing in the previous thread. They trade the lower risk of intervention for the higher risk of death. Frankly, I think it is a very poor trade, and what's even worse, most of them don't even realize that's what they are doing.
From homebirther:
Amy,
"But it doesn't. There have been quite a few studies on women who have problems with anxiety in labor or even pathologic fear of labor and the incidence of interventions is exactly the same."
Please provide links/references to these studies. I'd like to take a look.
Do these studies control for the doctor's inclination to use interventions? Or for the woman's? Were they for a woman's first birth, or just in general? Were the reasons for the anxiety considered (it is one thing to be afraid of the pain, and another thing to have a profound fear of needles)? How did they control for the women who were not anxious/afraid to figure out if the rate of interventions was the same or not? Basically, where can I read these studies? And if these studies have conclusively found that anxiety has no affect on labor, why then are hospitals taking the mother's state of mind into consideration, by doing things like making home-like delivery rooms, providing tools like birthing tubs, or allowing a woman to labor in any way she pleases? The one study I found summarized online did not look at anxiety during labor, but at anxiety during pregnancy, and said it had no effect on the baby. These are very different times, and the baby is not the only person to be considered.
I found this study (but can only view the abstract)
http://www.blackwell-
synergy.com...journalCode=aog
In the conclusion it states "The clinical implications of the study are that the delivery staff should consider women’s fear during labor and pay attention especially to primiparous women’s increased risk of higher levels of fear during an early stage of active labor, as compared with multiparous women’s. The challenge for staff of a delivery ward is to support the woman in labor in a way that decreases fear, which in turn might reduce the woman’s need of pain relief." Obviously, they found that there is a link between fear and the need for interventions.
"It is very different. When a person is having a heart attack everyone knows that he or she may die and if they don't, they credit the doctor. In contrast, since most women do not understand the inherent risks of childbirth they EXPECT that the baby will be perfectly healthy and if that doesn't happen, they assume that the doctor was at fault."
Let's consider a different scenario (one where life or death is not usually on the line). Breast implants. These are usually done for cosmetic reasons, but also to rebuild a woman's chest after a mastectomy. I bet those women expect 'perfect breasts' afterwards, and are understandably upset when they are misshapen, lopsided, leaky, whatever. I bet most of those women also did not fully understand the risks or built-in error rates for breast augmentation. They too blame the doctor (and probably sue). Generally speaking, when things go right people thank god, and when they go wrong, they blame the doctor. To use your example, if a person went in with a heart attack and died, the doctor may also be blamed and sued just because the surviving family members are unhappy with the outcome.
"Doctors take risks with the lives of babies all the time? Such as?"
Personally, I think any doctor who entertains a woman's request for a non-medically necessary c-section done for convenience or looks as a doctor who is taking unnecessary risks with the baby and mother. How? By exposing both to the risk factors inherent to major surgery without medical cause.
If your ultimate goal with this blog is to end home birth, then you need to get hospitals to address the concerns of those women who chose home birth. Regardless of what you think of them and their desires, they are what cause them to not go to the hospital. Show them they can get what they want at the hospital (and many of those desires can be accomplished if the hospital were to listen), and I bet fewer would have the birth at home.
From Amy Tuteur, MD:
homebirther,
The study that you cite showed NO difference in length of labor or interventions.
"I think any doctor who entertains a woman's request for a non-medically necessary c-section done for convenience or looks as a doctor who is taking unnecessary risks with the baby and mother"
That's extremely uncommon. If you think that doctors take risks with babies' lives "all the time", surely you can think of some better, more common examples. Or, perhaps, doctors don't take those kinds of risks at all.
"If your ultimate goal with this blog is to end home birth"
That's not my goal. My goal is to counter the mistruths, half truths and outright falsehoods of homebirth advocacy by telling women the truth. What they decide is up to them.
From Faedrake:
Off Topic: Rise in Maternal Death article
Articles on the rise in maternal death due to childbirth are making the rounds. But, their information is confusing and incomplete. They blame C-sections without citing data, while mentioning changing policy in the way maternal deaths are reported in two states in a very offhand manner, without details.
I was wondering if Dr Amy has some light to shed on this subject?
From homebirther:
Faedrake,
You beat me to it!
Ironically, this shows how statistics and the studies which contain them are difficult to explain to the layperson and prone to manipulation. Depending on how information is reported, on what the focus is, on the controls used to pull out the numbers, you can create very different results.
I wonder if the source of the rise of maternal death rate is more a combination of maternal condition before and during pregnancy and differences in reporting. If being obese leads to more complications for labor, and for c-section, this is what needs to be addressed. Same for women getting pregnant at an older age. Is the solution reducing obesity and convincing women to have kids earlier rather than later?
For the reporting issue, I wonder, if they are reporting deaths after c-section as relating to childbirth, thus increasing the maternal death rate, what were they reporting them as before? Surgical deaths (as opposed to childbirth deaths)? Why did they change their method of reporting (did those states want to improve their rates in some other section?)?
Amy,
"The study that you cite showed NO difference in length of labor or interventions."
Isn't pain relief an intervention? Because I don't have the money to buy the article, I must extrapolate that more fear=more pain relief. Why else would they suggest reducing fear in the mother to reduce the need for pain relief?
"That's extremely uncommon. "
I think it is much more common than you care to admit, particularly in the realm of higher-class families and women whose appearance is very important. What about the OBs who 'routinely' schedule inductions at 38 wks without medical need (since inductions done to a woman whose body is unprepared for labor/birth frequently lead to many more interventions, each of which exposes mother and baby to additional risks)? Considering due dates can be off by several weeks, they may well be delivering a baby that would otherwise have counted as premature. Or doing a 'routine' amniocentesis (which can increase the risk of miscarriage)? These things increase the risk of complications (including death), and some docs do them as part of their normal care even when there is no specific medical need for them.
From Amy Tuteur, MD:
Faedrake:
"Articles on the rise in maternal death due to childbirth are making the rounds. But, their information is confusing and incomplete. They blame C-sections without citing data, while mentioning changing policy in the way maternal deaths are reported in two states in a very offhand manner, without details."
I agree it is confusing and I don't know where their conclusions are coming from. I've been reviewing the maternal mortality statistics from 2004 and 2003 and it seems that the increase is much smaller than stated, and that the increasing age of mothers accounts for a significant portion of the increase. Once I have all the data assembled, I'll be writing more.
From Cindy Cummings:
I have attended at least 77 births since 1990 and alot of them hospital, I can only say Dr's were uncaring and I recommend home birth to those who are committed and healthy! The unnessary stuff done at hospitals prolongs birth and at times causes many unnessary C-sections! I live in a small town in ID and find the Dr's around here are quick to "get it over with" So pictocin is given or C-sections rule!
From Susanne:
Prolongs birth, or gets it over with? Which one is it?
From Arno:
I stumbled on your quiz today and I find it very bizzare. (the best term I can think of without being offensive) I am a science teacher and have research experience both in science and education. It seems like this quiz is designed to get people to give you the answers you want, or the answers that will make them look ignorant, and you therefore more knowledgeable. Where are most diseases found, as if a midwife would let them die from these diseases; ... Highest infant mortality, which has no bearing on obstetrical care etc. etc. If you were interested in helping people learn the truth why don't you compare countries that use midwifery care and have homebirths as commonplace with care in the US. It seems that your entire webpage is dedicated toward playing into our culture of fear. Almost as if you are using this page to justify your existence as a doctor. It is this attitude that has led to spiraling healthcare costs in this country, and prevented people and politicians from seeing the whole picture. Perhaps the real issue is that if people are taught to think for themselves based on the evidence they won't choose you anymore.
From Antigonos:
[homebirther]If your ultimate goal with this blog is to end home birth, then you need to get hospitals to address the concerns of those women who chose home birth. Regardless of what you think of them and their desires, they are what cause them to not go to the hospital. Show them they can get what they want at the hospital (and many of those desires can be accomplished if the hospital were to listen), and I bet fewer would have the birth at home.
~~~I'm not sure the point of the debate is to END homebirth, but to make women aware of its risks. And while I support measures that make hospitals nicer places to be, the fact is that no responsible hospital will EVER be able to give some women what they want, which is almost directly opposed to what they NEED. No one in a hospital is going to sit idly by while a woman insists on treatment--or lack of it--which is dangerous for her baby or for herself.
Cindy makes the point, for me, that midwives delivering at home, or primarily at home, simply lack the experience to be objective about risk. 77 since 1990? An infinitesimal sample! You cannot derive ANY conclusions from so few births, except highly subjective, anecdotal ones.
The situation isn't "either-or". In the US, you cannot simply deliver "either" in hospital, "or" at home without incurring greater risk to oneself and one's baby. We've pointed out the reasons before: lack of uniform standards for birth attendants, so a woman knows her midwife is qualified to give her good care; lack of standards of practice, so high risk women aren't accepted for home birth; lack of adequate emergency backup. I don't care how many beautiful, spiritual, etc. births one has witnessed in the home; that's just luck. And the proof of the pudding is in the eating: less than 1% of women choose to risk themselves and their babies in home deliveries.
From Amy Tuteur, MD:
Arno,
You seem to have missed the main point of the quiz. The quiz is designed to show that most of what homebirth advocates think they "know" is actually false. Now it's up to you. Do you wish to simply dismiss accurate information because it doesn't agree with your philosophical outlook, or do you want to find out the truth?
From Kirsten:
I have to ask... who cuts your paychecks? Is it Big Pharma? Insurance companies? Who? You can always weed out those fear-mongers by knowing who's the puppet-master. Nobody directly benefits from home-birth like physicians, insurance companies, hospitals and pharmaceutical companies benefit from "medical births". I know you're afraid. You should be. These attacks are really unnecessary though. You won't change a woman's mind just by twisting facts, numbers, statistics and percentages. A woman who is actively seeking out an alternative to the corrupt western medical system will not listen to the nay-sayers. The advances in medical care in this country have come about, in large part, to improved hygiene of the hospital staff. In generations past, the safest births have been those not occurring in hospitals but in homes attended by midwives. They are trained to care for the whole person and to know the woman's body and track closely any changes that may signal a problem. Physicians now depend on nurses (though now that role has gone to EFM machines) to closely watch the laboring moms, they're not by the woman's side. They wait till the machine beeps then do something. Often by that time it's too late and she's whisked off for sectioning. I believe and have always believed the first step to a section is the I.V. You immediately give bodily control over to a machine and remove yourself from the process. You are then a mere vessel to be emptied of the child. Terrible. I endured 2 hospital births then found home birth as an option and had two more children at home, 1 being a water birth. I could write a book on the differences I experienced, but you'd not likely listen. It was like night and day for me. My pregnancy was a complete joy, I gained half the amount of weight, my diet was carefully monitored for balance (didn't get that from any doc), my babies were larger, labor was amazing, they nursed perfectly and weren't drowsy and drugged, no postpartum depression at all, my other children were there, had an intact perineum, my husband delivered both of them as the midwife looked on, didn't have to worry about infection from the sick people in the hospital as my body and my baby's body were already used to "our" germs... I could do this all night.
My point? Don't ever underestimate the power, skill, concern, and resolve of a mom intending and experiencing a home-birth. And... don't knock it till you try it.
From kristin:
what an inflammatory, scare mongering quiz this is. i can't believe you think this helps anyone.
From A Sarah:
Kristin, do you not believe the information in the quiz to be correct?
From carrie:
Dr. Amy,
"I agree it is confusing and I don't know where their conclusions are coming from. I've been reviewing the maternal mortality statistics from 2004 and 2003 and it seems that the increase is much smaller than stated, and that the increasing age of mothers accounts for a significant portion of the increase. Once I have all the data assembled, I'll be writing more."
This is because the U.S. doesn't keep accurate records of maternal mortality. On death certificates there is not even an option to check whether death occurred within a period of time after giving birth.
At least with midwifery care and homebirth you get 3 at-home postnatal visits to check the mothers well-being and the health of the baby.
As far as the question about bacteria and viruses...my son was in the NICU at San Francisco's Children Hospital. A mother there had a newborn with RSV and didn't want to take him home when the doctors said he was fine. She was scared to. The doctors honest statement to the woman was that her son was safer at home because he would probably only catch something else here at the hospital with the number of patients that each doctor sees and the people who touch the baby. My son also contracted a bacterial infection in the hospital during his 11 day stay (contracted it within 2 days).
So, although a mothers body is the place where a newborn may be apt to get a bacterial/virus infection, the mothers body is with the baby at home or the hospital and a hospital certainly doesn't have less bacteria/viruses than the average home. If it does, the baby has been exposed to them in utero through the mothers blood.
In short, I think this "quiz" is just as misleading as you claim HBA information and case studies. Your questions have been "prepared."
From Amy Tuteur, MD:
carrie:
"This is because the U.S. doesn't keep accurate records of maternal mortality. On death certificates there is not even an option to check whether death occurred within a period of time after giving birth."
No, that's completely false.
"So, although a mothers body is the place where a newborn may be apt to get a bacterial/virus infection, the mothers body is with the baby at home or the hospital and a hospital certainly doesn't have less bacteria/viruses than the average home."
You clearly don't understand. The biggest threat to babies is GBS and herpes.
From Carrie Russo:
Amy,
If my statement about the U.S. not keeping accurate data on maternal mortality is wrong then give me proof. They don't even keep names of women who have died from maternal mortality, let alone track all deaths caused by MM.
I do understand that your answer said the biggest threat to babies is GBS and herpes. But what I'm saying is that in order for those to not be a threat than you have to take away the mothers body, not homebirth...so what doesn this statement have anything to do with homebirth. Secondly, if you asked, which place has more bacteria and/or viruses...home or hospital? The answer is hospitals.
From FLmom:
The second to last question is worded poorly, risk of death for whom? Mother or child?
Also, giving more information for all answers (even with "That is correct") and siting your sources would make this quiz much more informational and believable. The way it is written now, for all we know you made it all up.
From Amanda:
It would be in hospital's best interest to make low intervention deliveries the norm, instead of the exception.
But they won't, they would rather piss and moan about it like spoiled children because that is the EASY way out, pushing for positive change is difficult.
Do groups like the AMA or ACOG even take a moment and wonder WHY women are looking for other birthing options? If they think its just to be "trendy" or "fashionable" they have revealed their own ignorance and refusal to listen to their patients.
Is is any wonder that women are seeking Midwives . . . or even going it alone?
Just some humble food for thought.
From Alexis:
It isn't in their interest, though, and this is the problem. The incentives for doctors and hospitals are all to lower their individual level of risk. From this POV, VBAC bans and the like are rational choices (remember, a doctor is much more likely to be sued for the CS they didn't do). A hospital suffers no negative consequences if a patient elects to home birth or even UC because of a VBAC ban or other bad policy. If you want to change the behavior of hospitals and doctors, you need to change their incentives.
One position paper I read (I can't remember if it was AMA or ACOG; ironically the MDCers were all pointing to it as proof of medical perfidy) acknowledged the effect of restricting VBAC on women's decisions. So they aren't entirely unaware of the issues; they just don't know how, or don't want to, solve the problems.
From Amanda:
Okay, how about promoting "Evidence based practice" instead of routine interventions, just for the sake of routine and having "something" to chart.
My point earlier was that if Dr's and hospitals want women to deliver at a hospital they need to give women some good incentives as well.(like doing away with politics and the red tape BS, respect womens desires for a low intervention birth etc)
I also recognize that "fear of litigation" pushes dr's to practice defensive medicine, putting the "CYA mentality" above the wishs (and sometimes well being) of the patients.
We need tort reform, NOW!
From Amy Tuteur, MD:
Amanda:
"how about promoting "Evidence based practice" instead of routine interventions"
Routine interventions ARE evidence based medicine. The only people who appear to be unaware of that are homebirth advocates.
From Alexis:
Dr. Amy, you can't argue that with a straight face. There are simply too many examples of OBs rejecting evidence based practice. Induction prior to 41 weeks without medical indication, continuous EFM, overuse of pitocin, strict time limits on labor. All used by many OBs, and no evidence that they're beneficial.
One of the reasons women are so susceptible to the misinformation spread by some natural-birth advocates is the attitudes and actions of OBs.
From Amanda:
Amy,
Let's take vaginal exams as an example.
Dialation and effacment tells us nothing about mom/baby's heath, and as long as baby is tolorating labor, mom's "progress" is a non issue. VE's are invasive and uncomfortable (no matter how skilled or gentle the nurse/OB is)
Also, no matter how "Sterile" the exam is thought to be, there is always the risk of increased infection. Is there any "Evidence" that VE's improve outcomes?
Dialation and effacement are a rather poor indicator of labor progress anyway, if Mom is stressed (worried that she is not progressing "fast enough") or feeling the "fight or flight" reflex, her labor will slow or stop altogether.
Putting time limits on labor is setting women up for a c-section: as long as mom and baby are fine, the stopwatch should be out of the picture.
From Susanne:
Amanda: "Dialation and effacement are a rather poor indicator of labor progress anyway, if Mom is stressed (worried that she is not progressing "fast enough") or feeling the "fight or flight" reflex, her labor will slow or stop altogether."
Bullshit, Amanda. There are tons of women in preterm labor who are FAR more scared -- of REAL things, like premature babies! -- and their labor doesn't stop. Please stop repeating the falsehood that "scared mommy" = slow or stalled labor. How do women deliver in taxis and in cars, then, if they're so scared?
Stop pretending that labor is under the mother's control. It's random. This woman will have a quick, uncomplicated, baby-slides-out labor. This woman will have a long, drawn-out, tiring, need-some-help at the end labor. It is not "due" to anything other than luck of the draw. It is not due to mom's mental state.
From Susanne:
Amanda: "Do groups like the AMA or ACOG even take a moment and wonder WHY women are looking for other birthing options?"
Really, Amanda? The % of women choosing homebirth -- or even CNM -- is minute. There's an OB *shortage* in this country, not an overabundance.
From Amanda:
Please provide a qoute of when I actually stated that "labor was under mom's control"
I'm not stupid, I know labor cannot be controled, and I wasn't refering to "preterm" labor, how about actually reading before responding, lol.
If Mom is stressed (worried that she is not progressing "fast enough") > I wrtoe this in referance to the time limits that are put on labor: if a woman is told she only has X amount of time to deliver and she is "progressing slowly", you really think she wouldn't worry about it? (with a c-section being held over her held, be real)
And as far as your other comment, if the number is so low, then why are the AMA and ACOG even wasting their time making statments about hombirth?
What, did "The Business of Being Born" piss them off THAT much that they were thrown in paranoia about women giving birth at home? . . . right!
The bottom line is politics and profit.
From Alexis:
Susanne, the fact that a relatively small number of births are handled by non-OBs isn't proof that women are happy with the experience. (by the way, CNMs handle about 10% of births, more in some states). It's also because most of them either don't know about, or don't have, an alternative to an OB-led hospital birth. I'm not portraying the majority of American women as sheep, either. It's normal and rational to trust the system, and when some of the alternative proponents are so unappealing it's no wonder women don't take them seriously.
I wonder if the relative numbers of births handled by OBs and CNMs will change as fewer people want to go into OB/GYN. HBAs often argue that ACOG has a vested interest in keeping CNMs "down" because of financial issues (and they have the means to do that because of written practice agreements), but if there are more patients than OBs can handle anyway they don't have that incentive.
I actually agree with Amanda that ACOG/AMA's approach to homebirth is contradictory. They simultaneously argue that it's a miniscule trend, and yet it's important and dangerous enough to denounce and require "model legislation" of unspecified content. I also think that ACOG is in some ways the worst group to argue against home birth, because they'll be viewed as having economic and professional motives against it.
NICE is attempting to bring evidence based medicine into use and has issued several guidelines on obstetric care; they make interesting reading.
From Caryn:
if Mom is stressed (worried that she is not progressing "fast enough") or feeling the "fight or flight" reflex, her labor will slow or stop altogether.
No, there's no known correlation between stress and the rate at which labor progresses.
That's not to say that knowing you were laboring slowly wouldn't worry you, just that there's no evidence that the worry would slow your labor further.
The Caesarean isn't being "held over her head", because that implies that if the laboring woman just gets her act together and quits being so stressed, she'll go vaginally, but if she can't perform, it's time for the section. That's not it; it's nothing to do with the mother's effort or desire or worth. Some women don't progress, are dystocic, and fall into a population for whom a Caesarean is less risky than continued unproductive labor.
From Susanne:
"And as far as your other comment, if the number is so low, then why are the AMA and ACOG even wasting their time making statments about hombirth?
What, did "The Business of Being Born" piss them off THAT much that they were thrown in paranoia about women giving birth at home? . . . right!"
For the same reason that the pediatrics association makes statements about vaccines, even though the % of people who reject modern-day vaccines is quite small in the absolute.
From Amy Tuteur, MD:
Amanda:
"Dialation and effacment tells us nothing about mom/baby's heath, and as long as baby is tolorating labor, mom's "progress" is a non issue."
That's simply not true. It is important to know if labor is progressing for a variety of reasons. The underlying assumption of your claim, moreover, is profoundly wrong. All labors are not normal, nor should they be expected to be normal. Dysfunctional labors have consequences ranging from mild to severe. Bandl's ring, and other serious complications are almost non-existent in first world countries precisely because we monitor progress and treat dysfunctional labor earlier, not later.
A cornerstone of the World Health Organization recommendations for intrapartum care is the partogram which is simply a graph of labor progress. The WHO strongly recommends the partogram and strongly recommends specific interventions when women fall off the normal curve.
From Amanda:
Amy,
I have said that "all labors are normal" (I'm asumming this entire discussion revolves around healthy low risk deliveries)
You are completely missing (or ignoring)my point. Let me clarify, as long as mom and baby are stable, whether mom is "2,5 or 7" cm shouldn't really matter . . let me repeat . . as long as they are stable.
VE's are invasive and uncomfortable, no matter how skilled or "gentle" the nurse /ob is.
I'll ask again, is there any reliable evidence that frequant interal exams improve outcomes?
And how many things are happening in L&D "just for the sake of routine"? (and not because it is PROVEN to improve outcomes?)
From Amanda:
Caryn:
I get what you are saying about C-Sections, sometimes they just need to happen.
My comment was based on the fact that ALOT of OB's put time limits on labor and that for women who are trying to avoid a section in the first place, being "put on the clock" can add unjust stress to the situation. Some women deliver in 6 hrs, some need 26 hrs and I think that as long as mom and baby are stable and there are no issues, mom should be able to labor as long as she feels appropriate.
From Amy Tuteur, MD:
Amanda:
"Let me clarify, as long as mom and baby are stable, whether mom is "2,5 or 7" cm shouldn't really matter . . let me repeat . . as long as they are stable."
But it DOES matter. That's my point. The progress of labor makes a difference in the outcome of labor and the incidence of complications, particularly maternal complications.
From Amanda:
Susanne:
With all due respect, I'm not buying it. The statments made by ACOG and the AMA were politically motivated.
From Amy Tuteur, MD:
Amanda:
"The statments made by ACOG and the AMA were politically motivated."
No more or less than the statements made by MANA or other homebirth advocacy organizations. After all, MANA has a lot more to lose, economically and otherwise, than either ACOG or the AMA.
From Susanne:
Amanda: "My comment was based on the fact that ALOT of OB's put time limits on labor and that for women who are trying to avoid a section in the first place, being "put on the clock" can add unjust stress to the situation. Some women deliver in 6 hrs, some need 26 hrs and I think that as long as mom and baby are stable and there are no issues, mom should be able to labor as long as she feels appropriate."
But it doesn't matter "what you think." It matters what the science says. It's an empirical question. It has been studied over and over again, and there is risk / danger / no benefit to letting mom fall off the curve. You want to *believe it doesn't matter, you want to *believe that "women's bodies know what they're doing" but that doesn't mean that your belief equals empirical truth.
From Amanda:
Oh, I forgot science has never been proved wrong.
And we have to put ALL our faith in science don't we?
Look, I'm not saying that monitering labor doesn't have any benefits. But the cooki-cutter approach to birth is outdated, not every woman "needs" AROM, pit, (constant) EFM, etc. Sure, there are times when these interventions are really needed and I'm glad women have access to those things. But assuming that every delivery is a disaster waiting to happen is extreme, just like saying every delivery "will turn out perfect"
From Susanne:
"Oh, I forgot science has never been proved wrong.
And we have to put ALL our faith in science don't we?"
It seems the smart thing to do, since it's the aggregation of hundreds of thousands of data points, doesn't it? I mean, you could take one or two data points and extrapolate from that, but that wouldn't be as smart as extrapolating from hundreds of thousands.
"Look, I'm not saying that monitering labor doesn't have any benefits. But the cooki-cutter approach to birth is outdated, not every woman "needs" AROM, pit, (constant) EFM, etc. Sure, there are times when these interventions are really needed and I'm glad women have access to those things. But assuming that every delivery is a disaster waiting to happen is extreme, just like saying every delivery "will turn out perfect"."
Can you provide any guidance for an everyday OB to tell him or her exactly when a patient needs pit and when she doesn't, when she needs AROM and when she doesn't, when she needs cEFM and when she doesn't? Surely you must have a better sense and some helpful guidelines that everyday OB's would appreciate. If you don't, well, then, your "advice" to "do it less" isn't terribly useful. Offer specific suggestions to sort out the pit-AROM-cEFM-needing women from those who don't -- ahead of the game.
From Amanda:
Use your head, its not that complicated.
If OB's weren't so hounded by litigation fears and "rules" from their malpractice insurance carriers,(not to mention CYA hosiptal "policey") perhaps they could step back and take things on a more case by case basis. I'm not going to presume that "I" can tell dr's how to do their jobs: but too much intervention can and does lead to problems.
If you are not able to recognize sarcasm when you see it, I don't know what to say.
From Susanne:
"If OB's weren't so hounded by litigation fears and "rules" from their malpractice insurance carriers,(not to mention CYA hosiptal "policey") perhaps they could step back and take things on a more case by case basis. "
OB"s are hounded by the specter of BAD OUTCOMES. That can't be predicted in advance. Because as much as you want to believe it, the bad outcomes can come straight from Ms. Full-Term Low-Risk.
"I'm not going to presume that "I" can tell dr's how to do their jobs: but too much intervention can and does lead to problems."
But your advice is meaningless unless you have specifics. Here's a typical hospital with 10 low-risk full-term laboring women. Let's pretend you're the OB covering them all, for the sake of argument. How can you better determine who needs cEFM and who doesn't? Do you have a window into the future to say "that baby's going to wind up in trouble, so cEFM that mother, but these other 9 babies aren't"?
From Amanda:
Susanne:
Oh come on! you cannot deny that litigation, hospital red tape, and insurance limits don't play a role in
"defensive ob." Drs don't want to get sued!
Have you actually read anything I have posted? . . . .I wonder.
In truth Dr's have no way of knowing.
You mentioned CEFM, okay lets go with that . . . . . what is wrong with using a doppler, thus allowing Mom to move and get off the bed during labor? Play it by ear and if anything looks questionable, by all means, get mom back on the moniter.
If I were in that position, I would play it by ear, intervene WHEN NEEDED and be proactive, but I wouldn't expect things to go to hell in a handbasket because I "fear" a bad outcome.
Dr's have NO way of knowing which deliveries are going to "sour" and which will be easy, thats just commen sense Susanne.
However, like I said, treating EVERY pregnant woman as a lawsuit waititng to happen is foolish and unfounded (but a sad reality, considering how sue happy people are)
Changes need to be made on both sides of this issue . . . that isn't "what I think", its fact.
From Amanda:
Susanne:
I suppose you would defend the routine use of the lithotomy position as well?
Try having a BM while lying that way, not fun or very effective.
From Caryn:
If I were in that position, I would play it by ear, intervene WHEN NEEDED and be proactive
But how could you tell when it was needed and intervene before it was needed and only when it was needed?
Because that's the problem.
What OBs do is treat everyone who falls into a population for whom there is a known risk factor bigger than the risk from the intervention. Risk of fetal death from breech birth is 6/1000. Risk of death from Caesarean of all breech babies before labor starts is rather lower than 6/1000.
You don't know which babies will get stuck ahead of time; the only choices are to try vaginal delivery for everyone and then have 6/1000 die because their heads get stuck, or to section everyone.
Which do you pick?
From Amy Tuteur, MD:
Amanda:
"I forgot science has never been proved wrong."
The beauty of science, and its strength, it that it CAN be proven wrong. It depends on evidence and understanding and both of those things can change. In contrast, homebirth advocacy CANNOT be proven wrong because it has never been proven to be right. It is a belief system that is impervious to scientific facts. Homebirth advocates fabricate claims, provide no evidence for their claims and insult anyone who does not believe their claims simply on their say so.
Doctors are quite honest about the fact that they are not always right, and that current treatments will almost certainly be replaced by better treatments when we learn more. Only people who do not understand science and medicine would ever claim that doctors believe that science cannot be wrong.
From Antigonos:
I suppose you would defend the routine use of the lithotomy position as well?
~~~~No, I don't, I prefer the left lateral position myself. But in certain situations, lithotomy is unavoidable.
From Amanda:
Amy, Please quote where I have said that Dr's believe science cannot be proven wrong.
Caryn,
Intervention just for the sake of "prevention" doesn't keep bad things from happening either.
Of course there will be a population of pg women who are higher risk and therefore would need closer monitering and intervention, that is a given.
Antigonos:
I understnad that, sometimes with epidural's (for example) lithotomy is really the only way to go.
Squatting is a good one too, along with hands and knees.
From Jen:
"Intervention just for the sake of "prevention" doesn't keep bad things from happening either."
Huh? That's kind of the point. There will always be bad things that happen, yes, but the point of doing something like CS for breech is that it will PREVENT the KNOWN complications of vaginal delivery with a breech. I really don't know if I've misunderstood you somehow...but this really doesn't make sense to me....
"Of course there will be a population of pg women who are higher risk and therefore would need closer monitering and intervention, that is a given"
Women who are in the "low risk" group can turn "high risk" in a moment's notice, that's the point! A woman can have had a completely uncomplicated, unremarkable pregnancy and early labor and than BAM! out of nowhere baby is now in major distress and needs out NOW! There would be absolutely NO WAY to know that beforehand, only after the baby is showing signs of distress (and hopefully it is caught very early, with, you know, all that darn monitoring, otherwise baby may become damaged with no one being the wiser until it's too late)
From Amanda:
Jen:
This discussion is about homebirth, is it not? I assume that homenirth is suitable for women with healthy low risk pregnancies, okay. When I make referance to interventions in the hospital setting, I'm refering to those done during a low risk delivery.
The example you used was absolutely correct, CS on a breech presentation is justified.
Jen, you aare correct "low risk" can turn spetic in a flash, I have never said otherwise.
I never said intervention was a bad thing, but its the misuse of these (sometimes life saving) proceddures that are driving women away from hospitals. Legal fears, rising costs and staffing shortages (among many other things) all are factors in why OB care in this country is broken.
For example:
Can anyone here justify the 30% CS rate we have right now?
From Alexis:
Suzanne, the trouble is that "not knowing" and using interventions anyway goes against evidence based medicine, which says active management of labor and continuous EFM don't improve outcomes in the absence of known risk factors. In other words, covering your ass doesn't actually help. It just makes you think it has. Instead, you've subjected a large number of women to an intervention they didn't need, just because one of them may have had an issue. Obviously, you're never going to have perfect judgment and you're always best erring on the side of caution; however, at present US OBs are exceeding that margin.
From Amy Tuteur, MD:
Amanda:
"but its the misuse of these (sometimes life saving) proceddures that are driving women away from hospitals."
They are being "misused" only in your mind. They save literally hundreds of thousands of lives each year.
From Amanda:
Amy,
Why are women seeking other options?
Can you justify the 30% C/S rate?
So you maintain that interventions are NEVER used inappropriatly?
From Amy Tuteur, MD:
Amanda:
"Why are women seeking other options?"
They're not. Less than one quarter of one percent of women have a homebirth with a direct entry midwife.
From Amanda:
Nice dodge of my other questions, very telling.
If women are not seeking other options in birth, why are the AMA/ACOG making public statments condeming out of hospital deliveries?
Here is a novel idea, how about using your blog for a positive purpose. Perhaps brain-storming on how hospitals, Dr's and CNM's can work together or how hospitals can become more birth friendly.
Or (god forbid) share some ways CNM's can make homebirth safer.
Look, I know you are trying to "expose" HBA's, everyone sees that. You can make your point and at the same time advocate for change on BOTH sides of this debate.
The midwifery model is far from perfect, but the medical model has its own shortfalls as well, and as long as BOTH sides are not willing to acknowledge their own flaws, nothing will change.
Unless that is what you want?
From Antigonos:
[Amanda] Here is a novel idea, how about using your blog for a positive purpose. Perhaps brain-storming on how hospitals, Dr's and CNM's can work together or how hospitals can become more birth friendly.
~~~Doctors and CNMs DO work together, but they don't decide hospital policy unless they own the hospital. And hospitals have very little incentive to make "friendly" changes, especially if they can compromise care. A really homey "home-style delivery room", for example is extremely difficult to clean between patients, and no one wants to give birth where they might become infected. It's tough enough to clean an OR-type room properly.
Or (god forbid) share some ways CNM's can make homebirth safer.
~~~As long as the laboring woman is not in the same place as all emergency facilities for all unanticipated complications are located, homebirth will continue to be unsafe. I agree that forcing all midwives to be CNMs would help in that the better-educated women would be more aware and see complications arising earlier, but that is at best only a partial improvement.
From Amy Tuteur, MD:
Amanda:
"why are the AMA/ACOG making public statments condeming out of hospital deliveries?"
Because it leads to preventable deaths of babies. Isn't that a good enough reason for you.
"Here is a novel idea, how about using your blog for a positive purpose"
I already do. Transmitting accurate information is a positive purpose.
From Amanda:
Amy:
Why won't you answer my question regarding our 30% C/S rate?
From Caryn:
Amanda, try here: http://homebirthdebate.blogspot....label/C-
section
From Susanne:
Amanda, do you not get that some of those CS are better-safe-than-sorry, and the only way to bring those down is to create crystal balls?
That when a fetus is in distress, for example ... you *can wait, and maybe baby will be fine, but you can cut and ensure that baby will be fine, and "reducing the CS rate" means that you hold your breath and wait out more of these? And that the tradeoff is fewer CS but more damaged babies?
From Liz 1:
But Susanne, the damaged babies won't be theirs! Only those obviously defective high risk women have damaged babies! And if they would just not get pregnant, or stop suing, everything would be so much better for all the "healthy, low risk" mothers who are so much better educated and organised.
From Alexis:
Susanne, some of them are, but even Dr. Amy said a 30% CS rate is not medically justifiable. The high rate is not solely due to judgment calls at critical points.
From Susanne:
Of course not. But there's no way around it. It's like saying that 3% of all car rides (number made up) will end in car accidents, so how can we get ourselves down to a 3% seatbelt-wearing rate. It's not going to happen without crystal balls. Either it's 90% and we accept "unnecessary" seatbelt-wearing as a necessary evil, or it's 1% and people die.
From Amanda:
Susanne:
Have I ever denied that some C/S are appropriate, no. Its only a given that some C/S will be needed.
30% is just too high, but I also know that there are no easy answers to this problem.
From Susanne:
Well, in all seriousness, saying that "the CS rate is too high" is just meaningless words on a computer screen unless or until you can provide SPECIFIC solutions or guidelines that OB's in practice can use to bring it down.
Many HBA/NBA think that they are adding value, however, by pointing out that the CS rate is high. Well, duh. OB's know that as well. It's high because they are making a deliberate tradeoff. They'd rather "disappoint" 99 mommies with CS than devastate 1 mommy with a dead baby. And until they can accurately predict AHEAD OF TIME which mommy is going to have the dead baby, that's how it has to be.
From Amanda:
Susanne:
Perhaps organizing some (independant) studies to map out why the C/S rate is climbing, as you cannot make changes until you know what you are dealing with.
And for the record, I'm not really a "HBA" I just think women deserve choice in their births, whatever path they take is theirs and I can only speak for myself.
Do YOU have any guidence to help lower the C/S rate,Susanne?
From Susanne:
Oh, that's right, Amanda -- the OB community hasn't even thought once about what to do about the rising CS rate. @@
From Amy Tuteur, MD:
Saying that the C-section rate is too high is like saying everyone should live in peace. Okay, we all agree. So, that accomplishes precisely nothing.
From Susanne:
Amanda, the CS rate is climbing because the risk tolerance for bad outcomes gets lower and lower. There you have it. The end.
From Kris Wells:
I had problems with this quiz. I was unable to read some of the questions fully. I played guess the answer based on the ant HB slant and was lucky. Not the most useful quiz then
From Amanda:
Susanne:
"Oh, that's right, Amanda -- the OB community hasn't even thought once about what to do about the rising CS rate. "
Please provide a qoute . . oh wait you cannot, because I never said that.
LMAO!
From Caryn:
Perhaps organizing some (independant) studies to map out why the C/S rate is climbing, as you cannot make changes until you know what you are dealing with.
This is the subject of *constant* study. I am assuming that's why you've thrown the word "independent" in there; you're suggesting that maybe someone who isn't an obstetric professional would be able to figure out why the Caesarean rate is climbing, because obviously they haven't been able to stop it from doing so.
I would suggest that they know perfectly well why it is climbing, and the fact that they have nonetheless been unable to stop it might provoke a bit of caution.
From Amanda:
Caryn:
I never assumed it wasn't being studied.
From Caryn:
I didn't say that you did. In fact I pointed out that I was deducing from your choice of words that you already knew that. Please do, though, elaborate on why it is that you're speculating that an independent study would produce new information?
From sue:
Infant mortality is a good measurement of the quality of obstetric care: Answer false
So Dr. Amy is saying that higher infant mortality rates equal improved quality of obstetric care.......hmmm
From Antigonos:
Sue:
INFANT mortality is deaths up to one year of age. Lots of babies die from illness that has nothing to do with birth during their first year. Infection, such as gastroenteritis, and respiratory problems, is the leading cause of death in this group. With 47 million Americans without health insurance it's hardly surprising that kids don't get to the doctor in time.
The correct statistic is PERINATAL mortality, as has been explained repeatedly on this site. And the US's standing in perinatal mortality is ahead of "home birth friendly countries" like the Netherlands.
From Antigonos:
Amanda: what is wrong with using a doppler, thus allowing Mom to move and get off the bed during labor?
~~~Except that a doppler just gives you the heart rate for a few seconds, or even a minute. You cannot hear the constant changes in rate which indicate that the baby is OK [reactivity]. Further, the time when the baby is most stressed, during contractions, it is almost impossible to keep a doppler on the abdomen of a moving mother who is massaging herself, etc. And this is the MOST critical time, because if there is a deceleration during a contraction, and the FH does not immediately return to normal, THAT BABY IS IN DISTRESS. And a doppler does not give a paper record which can be perused [or used as evidence]
No one would be happier if we had better tools to work with. Wireless monitors with sticky electrodes like EKG machines, for example [athough babies move in utero and they'd have to be frequently reapplied]. But we don't. So we have to go with what we've got, which is an imperfect technology. But it is a great improvement on the alternative, which is nothing.
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