From Susanne:
What's especially funny (well, it would be funny, if it weren't serious) is that the whole premise of preecl is both that the mother's body starts to decline AND that the failing placenta affects the health of the fetus. Eating all the protein in the world isn't going to make a failing placenta un-fail, or get to baby somehow. There's zero biological basis.
The Brewer diet websites never seem to have any biochemical pathway discussion. why is that? Because they appeal to people who simply don't even realize that theories of diseases need to be rooted in biochemical pathways, not in "well, I saw this happen, so it must work."
KW's comment in the other thread is particularly disquieting - that she's "seen Brewer work." Uh, you could have fed bread to those people and some would have turned out fine and then you would have concluded that feeding bread works, too. It's insane, how no one seems to want to map reality with science and replicable observations.
From Yehudit:
If you need a mechanism for telling whether or not a homebirth midwife is a quack, that must mean that there are, in your view, homebirth midwives who are not quacks. Just checking.
From Liz:
I don't think homebirth midwives are quacks. I think they are optimists. This may range from believing that haemmorhage can be dealt with by eating the placenta to believing that sudden and unpredictable disaster is unlikely. I'm a bit of an optimist myself - but I wouldn't risk a homebirth. I don't doubt there is a huge difference between a well-trained midwive operating in a system with full backup and a "birth junkie", but are the arguments in favour of homebirth that different? A truly low risk woman would probably do just as well with either. A properly trained midwife is more likely to "risk out", but that doesn't seem to be what homebirthing mothers want.
From Liz:
Caryn, no specialist yet, but a much more reassuring hospital visit yesterday.
I do realise that the odds are in my daughter's favour - she got to 35 weeks last time. It isn't so much the risk of pre-e that troubles her, as the fear of it - which is, unfortunately, inevitable. I got fantastic care the second time. It didn't stop me being scared, but it did help a lot. Unfortunately, it kind of underlined how hit and miss the care can be for "low risk" women.
From Amy Tuteur, MD:
Yehudit:
"that must mean that there are, in your view, homebirth midwives who are not quacks. Just checking."
Sure, but that doesn't change the fact that homebirth increases the risk of neonatal death.
From Yehudit:
We don't have the evidence to show that either way (the differences aren't statistically significant and/or the studies have flaws).
From Caryn:
The Brewer diet websites never seem to have any biochemical pathway discussion. why is that? Because they appeal to people who simply don't even realize that theories of diseases need to be rooted in biochemical pathways, not in "well, I saw this happen, so it must work."
Actually, they *do* have a biological pathway. It's just desperately wrong; it's the whole serum albumin thing.
From Caryn:
Unfortunately, it kind of underlined how hit and miss the care can be for "low risk" women.
Oh, exactly.
From Amy Tuteur, MD:
Yehudit:
"We don't have the evidence to show that either way (the differences aren't statistically significant and/or the studies have flaws)."
The Johnson and Daviss study shows it very clearly, and the fact that MANA is withholding their own statistics confirms it.
All existing state and national statistics also confirm that homebirth has an increased risk of neonatal death. The only people who are unaware of this are homebirth midwives.
From JJ:
There's no denying that nutrition is important to a healthy pregnancy, though. Not that the Brewer diet is a perfect pregnancy diet, but it has been helpful in steering some women towards better eating habits.
While a woman certainly can have a great, healthy pregnancy despite eating junk the whole time (just in the same way that the Brewer diet can apparently "work" for some women - i.e. luck or coincidence), that doesn't mean that nutrition is an unimportant part of a healthy pregnancy.
I'm not promoting the Brewer diet. I just sometimes get the impression that criticism of the Brewer diet and emphasis on stereotypes like "Midwives depend on herbs and nutrition to fix everything" can sometimes result in an impression that mainstream medicine considers nutrition during pregnancy to be unimportant.
I don't know what standard practice is, but my OB did not discuss nutrition at all, and it seems to be a common occurrence among my friends and acquaintances (not just locally, either).
From JJ:
I know we've talked about this before, but I just looked at the CDC data and ran a query for place of birth and birth attendant. I'm interested in mortality rates for CNMs. I looked at 2004.
What I see is that in-hospital, it's 2.96, and out-of-hospital, it's 2.53. I'm interested in CNMs particularly because I feel that the training they receive makes them qualified homebirth attendants (unlike many DEMs or CPMs who may have insufficient experience, training and/or equipment).
It also seems odd to me that MD homebirths apparently have a death rate of 26.86. That seems exceptionally high. Why is it so high? I can understand why MD hospital births have a higher rate of death (7.0
- this includes high-risk births so naturally it follows that the death rate would be higher.
Anyone who could help me understand how to use the CDC data, it would be greatly appreciated. I assume I am doing something wrong.
From JJ:
That was "(7.08 )" - I forgot the 8 next to ) makes a smilie.
From JJ:
I changed the parameters to include only term births (37 weeks or more) and that helped tremendously. 1.79 for in-hospital CNM births and 2.18 for OOH.
What exactly are you searching by to supposedly make this data significant? It seems you can really fiddle with it a lot of different ways.
From Ericacrochets:
The Brewer diet is pretty high in calories, and involves drinking a quart of cow's milk a day. He also says it's not a problem if a woman gains 60 pounds in her pregnancy. Aspects of it are healthy, like whole grains as opposed to not, and not eating a whole bunch of Oreos or cheetoes all day. But it's nothing special.
And the quart of cow's milk is an odd recommendation biased towards Northern Europeans, considering that most people in the world have some degree of lactose intolerance.
If the placenta is functioning correctly, and the mother is eating a sufficient amount of calories, the baby will be well nourished. The body does it on its own from whatever it gets. Folic acid supplements important before pregnancy and in the first couple of months as well as iron if there in a deficiency.
From Emma B:
JJ, one reason for the high death rate of MD out-of-hospital births is that many of those are not planned homebirths. Rather, they're scenarios where the mother goes into precipitous labor somewhere (often prematurely) and a doctor who happens to be present stops to help out. Just about every doctor of every specialty has a good-samaritan story like that -- it's one reason why obstetrics is a required rotation for all medical students.
Also, the birth certificate data isn't perfect, so that a baby born in the ambulance on the way to the hospital might have its birthplace correctly listed as out-of-hospital, but the doctor who treats the patient when she gets to the ER might get listed as the birth attendant.
From Jolene:
"The Brewer diet is pretty high in calories,"
I think people forget that the population he was working with was (generally speaking) undernourished in general, living in poverty with little access to whole foods. There is no question that when you start from such a place, a diet with more calories and whole foods (IE, containing all the vitamins etc) will benifit the woman and her pregnancy. And it is no wonder a premium was placed on whole protein either.
When we try to move from the undernourished women living in poverty, to a healthy American population today, the diet has much less significance.
From Caryn:
Preeclampsia rates do not vary geographically, as I understand it. They're the same in India and the USA. If diet were a factor, we'd see a difference in rates.
From Jolene:
Caryn, Do you doubt that a whole foods diet with plenty of calories will improve pregnancy outcomes in malnourished women?
(Notice, I said nothing at all about pre-e in either email when talking about the Brewer diet)
From Caryn:
And I said something specifically about preeclampsia, because Brewer explicitly claimed for his diet 100% prevention of MTLP, not that generally eating better quality food would lead to generally better outcomes for pregnant women when it came to conditions other than preeclampsia.
I don't think anyone disputes the idea that diet and exercise might be relevant to pregnancy outcome. But it is moving the bar to say, oh Brewer works for pregnancy conditions generally then, even if it doesn't work for preeclampsia.
Here's what Cochrane says you can expect from nutritional recommendations to tweak energy or protein intake: ...Dietary advice appears effective in increasing pregnant women's energy and protein intakes but is unlikely to confer major benefits on infant or maternal health. Balanced energy/protein supplementation improves fetal growth and may reduce the risk of fetal and neonatal death. High-protein or balanced protein supplementation alone is not beneficial and may be harmful to the infant.Protein/energy restriction of pregnant women who are overweight or exhibit high weight gain is unlikely to be beneficial and may be harmful to the infant...
So that's not exactly a ringing endorsement; nutritional changes in calorie intake or protein intake seem to have minimal effect in multiple studies.
From Catherine:
I don't understand why your approach is so negative and attacking. How is this negativity helpful to women and people working together for woman's and babies health?
I am teaching my 4 and 8 year old not to name call and to treat all people with respect even and especially if you disagree with them. The way people behave on these blogs is very disappointing.
From flim flam:
its called HOMEBIRTH DEBATE. people with fixed beliefs not based on scientifc evidence always perceive any challenging of these beliefs as an attack. debates involve a robust, frank exchange of views, it's not like MDC and their " no criticism allowed " policy. big girl panties required!. not sure about the treat everyone with respect thing. what if someone is a racist? a paedophile? do i still have to "respect" their warped beliefs?. how about westboro baptist church with their "god hates fags/bushfires in australia are the result of sinning and we got what we deserved" nonsense. should i teach my kids to respect their beliefs? might be a bit hard given how much they love their gay uncles...
From Caryn:
Jolene, think of it this way: care providers are supposed to provide evidence-based care.
It isn't evidence-based to say that good nutrition is broadly beneficial to pregnancy outcome unless we have some evidence for it, and that evidence can't be confirmation bias in the populations we're familiar with.
However, it *is* evidence-based to say that folic acid supplementation pre-pregnancy and during early pregnancy lowers the incidence of a particular type of birth defect.
We have to be specific about what we're claiming and we have to check it against reality once we've done that. Everyone's got intuitions about this stuff, but that doesn't necessarily mean anything when push comes to shove.
From Catherine:
We have different ways of seeing the world and that is fine. I do not believe that hate dispels hate. Or whomever yells louder wins. If you really believe in change then approaching debate with respect or empathy and avoid childish calling is wise. If you just want to spout off your opinions and offend that is your choice but unfortunately those that you would like to listen are turned off by your approach.
Specifically to reply to flim flams question - yes I teach my children to look at those with such hatred with empathy even though we feel they are wrong in their beliefs.
So on the topic of beliefs and practices not based in Scientific evidence. Explain to me the non-evidence based routine use of episiotomies in childbirth? The non-evidence CONTRAINDICATED TO LABEL USE OF Cytotec also known as Misoprostol for labor augmentation or intuction? What about the increase of inductions for non-medical purposes not at patient request?
I believe it is important for women to be able to make informed decisions about their place of birth and to be accountable for it and for that decision to be respected.
From Alexis:
Episiotomies have been on the decline for years and in many of the most medical hospitals only 10% of women get one (not what you'd expect if you think the science of obstetrics is a problem) New doctors are not trained to cut routine episiotomies. As older doctors retire we'll see the rate decline further, I think.
Misoprostol is a pet cause of Marsden Wagner. The manufacturer doesn't want to submit it for testing so it will always be off label which is perfectly legal. They're disclaiming responsibility so they can be off the hook for the whole thing, not necessarily because it's dangerous.
There are non-evidence-based practices in obstetrics and you did mention one, inducing for no reason. But you need to be careful to sort fact from NCB rhetoric.
From Susanne:
"The non-evidence CONTRAINDICATED TO LABEL USE OF Cytotec also known as Misoprostol for labor augmentation or intuction?"
This is a classic case of stuff that's meant to incite people who don't know any better. The theory is that if you say "OMG it's off label" it conjures up "evil, deceitful OB's who don't even have the ethics to refrain from using drugs in ways that are off label."
Indeed, off-label use of drugs is no big deal, it happens all the time in every field of medicine, and it doesn't mean the OMG-they're-evil subtext that the poster above thinks that it means.
As Caryn has pointed out, magnesium sulfate is "off label" for preeclampsia treatment too. Funny how no one says OMG-mag-sulfate-is-off-label.
Now, if you want to talk about Cytotec from a medical standpoint, feel free. But to say that it's bad because it's off-label is misleading and ignorant. I can hardly blame you, Catherine, though. The NCB deliberately fed you that line, so that you'd conclude that OB's were doing something dastardly and shady and therefore their motives needed to be questioned. They were counting on you not knowing that off-label use of meds is commonplace and accepted practice in many specialties, not nefarious.
From Alexis:
She's used the slightly more sophisticated version of that gambit, though--the contraindication. The manufacturer did issue a warning not to use it for that purpose. I was told, though I couldn't verify it, that this was for legal reasons rather than medical. They have no interest in doing more testing or submitting it for licensing and don't want to be held liable.
As you said, "off label" is meaningless. Many safe and popular drugs are off label, because it's the manufacturer's job to submit it for licensing. If the drug is out of patent it's not worth their time or money to do that. No one will ever submit magnesium sulfate for FDA approval. No one will bother with metformin for PCOS (approved on the NHS as effective but not formally licensed, AIUI). Out of patent, no money to be made from the approval. It doesn't mean trials aren't done and efficacy established or disproven.
From Susanne:
Caryn, what does the evidence say about the incidence in preeclampsia either in cultures where there is not the access to good nutrition that there is in the US, and / or times when there hasn't been access to good nutrition? (London during the Blitz type of thing)
From Melissa:
"So on the topic of beliefs and practices not based in Scientific evidence. Explain to me the non-evidence based routine use of episiotomies in childbirth?"
This argument has always seemed a silly one for people to make against the medical profession, because if you read both of Ina May Gaskin's books, she and the other Farm midwives also cut episiotomies. No one wants one, and maybe many people who had them ages ago when they were routine were better off not having them, but they're certainly not solely the province of doctors and obviously even the most revered midwife has found use for them. Just saying.
My mother had one when I was born because I was breech, so it was kind of necessary. I always wondered why though, if it was as evil and traumatic as people claimed, why she can't remember for the life of her whether she had one with my sister?
From Caryn:
Susanne, IIRC, preeclampsia rates, including historical ones, don't change with economic circumstances. Only the possibilities for treatment of the condition when symptoms appear change.
As for nutrition in general, this is an interesting discussion.
From Emma B:
As Caryn has pointed out, magnesium sulfate is "off label" for preeclampsia treatment too. Funny how no one says OMG-mag-sulfate-is-off-label.
Actually, I have seen this in Midwifery Today, both in the context of preeclampsia and of preterm labor. Terbutaline also gets painted with the off-label brush. In fact, know how many tocolytic drugs are on-label? None, that's how many. Yet they save the lives of babies every day.
I have also seen Midwifery Today recommend Brewer for prevention of preterm labor. The proposed mechanism there is even less logical than preeclampsia.
From Yehudit:
On misoprostol, there is probably more evidence *now* on the efficacy and safety of misoprostol for labour induction than there was about PGE2 when that was brought into common use.
However, it was originally a drug used in large quantities 200mg tabs, and obstetric use involved all sorts of DIY pharmacy - to cut quarters and such like to get the right dose. There has also been a lot of use outside of clinical trials when still untested (unethical, in my opinion, for a new induction agent), with high doses. Some of the high profile VBAC/uterine rupture cases involved use of misoprostol in this sort of way (high doses, outside of clinical trials), which has harmed the reputation of both VBAC and misoprostol.
Which is a tragedy - because, though not necessarily more effective as an induction agent, misoprostol has some definite advantages over PGE2. Firstly, it is much cheaper (though of course the pharmaceutical company might charge more for a "obstetric use" misoprostol). Secondly, it does not require refrigeration (unlike PGE2). Thirdly, it can be used for postpartum haemorrhage. These things make it particularly useful in the developing world, and it is increasingly used there - notwithstanding the cloud that hangs over it. Use outside of clinical trials have delayed its acceptance, which I think is a great shame.
From Yehudit:
Sorry, that could have been 200mcg in my previous comment. The standard dose for vaginal tables is now 25mcg.
There is a very good website with lots of evidence on misoprostol at http://www.misoprostol.org/
From Courtney:
The problem with the 25 mcg of miso is that there is no guarantee when we cut the tablet that we aren't getting 200 mcg in one piece and 0 and some fillers in the other. So one woman has a section for hyperstimulation and fetal distress and the other has a section for failure to progress.... Maybe lower mcg tabs are available in other places but in my hospital it involves me and a pill cutter in the med room. For that reason miso makes me nervous.
From Yehudit:
Yes, that is exactly the problem with DIY back room pharmacy pill cutting. But misoprostol is now manufactured in 25mcg vaginal tablets under the brand names Prostokos and Vagiprost - so what is the excuse for not using these?
From Courtney:
$$$$$ maybe? We were always told it wasn't an option.
From Alexis:
Can you get those tablets in the US, though? If they're not approved or marketed in the US, you can't use them.
I don't know what the situation is but there are cases where available formulations vary. For example, you can't get the oral Daktarin gel in the US, even though you can get the active ingredient (miconazole) in other forms.
From Yehudit:
Misoprostol is not approved in the US for obstetric use. It is only approved by the FDA for the prevention and treatment of gastric ulcers resulting from chronic administration of NSAIDs.
So, if lack of approval will inhibit you from using Prostokos/Vagiprost (marketed in Brazil and Egypt respectively, which both do approve misoprostol for term induction) then it surely will inhibit you from using Cytotec cut up into pieces?
In any case, is there any justification in a wealthy country with refrigeration for using misoprostol in preference to PGE2? (Especially given local unavailability of manufactured tabled in the correct dose for term induction?)
As long as obstetricians are prepared to use Cytotec cut into pieces in the back room, there is no incentive for the pharmaceutical company to manufacture an appropriate dose tablet for term induction.
In the UK use of misoprostol outside clinical trials has basically been put off the agenda by NICE/RCOG because there is no appropriate licensed product available - and lo and behold, Alliance is bringing out Isprelor 25mcg, with all the clinical trials to back it up.
From Alexis:
I don't mean approved as in on- vs off-label--I've taken off-label drugs myself. I'm referring to it only in the context of availability. If the vaginal tablets require specific approval to be sold at all, and they don't have it, it's not an option. It's not about the ethics of using an "unapproved" drug (the Marsden Wagner argument).
From Yehudit:
If US obstetricians wanted to ship 25mcg tablets into the US for off-label, I see no reason why they couldn't.
Indeed, if US obstetricians wanted a locally-produced 25mcg tablet, the ACOG need only strongly advise against pill cutting and you would be sure that Searle/Pfizer would bring out a 25mcg product - given the size of the labour induction market.
From Yehudit:
Anyone interested in this issue might want to read this paper from the BJOG http://www.misoprostol.org/File/
...flabedebate.pdf
From Liz:
Oh dear. Are we finally defunct? Should we hold a wake?
I expect the MDC brigade will be delighted to see the end of this. Pity.
From Jen:
"Oh dear. Are we finally defunct? Should we hold a wake?
I expect the MDC brigade will be delighted to see the end of this. Pity."
It seems to be, I'm afraid. And I wouldn't be surprised at all to find some people rejoicing. And probably some rumors about the "cause" of it all, for good measure, lol.
From Jolene:
Anyone up for discussion of the Baxter "slip up" of live avian flu in their flu vaccine?
From Kneelingwoman:
KW here: The women I saw "respond" to a modified Brewer Diet under the supervision and with the complete approval of my OB backup who is considered top notch in our area ( Detroit ) and who has been in practice for more than 35 years were diagnosed, by him, with Preeclampsia. I have never kept a woman in my practice out of OB care when questionable situations arose. Any woman with 2 or more symptoms had to see him--period. He had also seen dietary improvement "work" and is quick to say that he doesn't know "why" it sometimes works but it seems that it does, for some women. In my case, early intervention with increased protein and other "additions" including increased fluids, exercise, stress reduction etc. eliminated ALL symptoms and the women went on to have healthy normal pregnancies and births. I did have 4 women over 15 year s( out of the 12 who became symptomatic during that time frame ) who did not respond and were transferred out of my care to his. Many CNM's work with diet to deal with Preeclampsia; it's not just homebirth midwives and I know several Ob's who will try diet first. Given that no one is yet sure what causes it, it makes sense that we do not yet know, with certainty, the best way to treat it. There are far more relevant issues regarding "quackery" in midwifery than whether someone gives women dietary advice. Now, if a midwife insists on "treating" preeclampsia with diet only, and without contacting an OB for backup; then she's messing around. You guys take this stuff way, way too seriously!
From Alexis:
KW, those of us who have had severe preeclampsia--and in some cases nearly lost babies or our lives from it--damn well DO take PE seriously. And I don't blame Caryn, or Susanne, or anyone else for feeling that way.
We DO know that the pathways proposed for the Brewer Diet are false and that his data hasn't been replicated, and that's enough for me.
From Jolene:
Honestly, it does seem fairly straightforward to attempt to replicate Brewer's study if midwives were so inclined.
From Bridgette:
There's an interesting discussion going on in an online forum for doulas where a woman is asserting that the Brewer diet, done right, prevents Pre-e. When asked point blank about the women the diet didn't work for and if they were to blame that poster danced around the issue by saying thosewomen were misinformed and didn't practice the diet correctly because they were given misinformation.
Her "proof" that the brewer diet works is her own website which has a timeline and quotes from a 1977 book.
http://home.mindspring.com/~djsn...jones/
id95.html
Another doula pointed out that there is no current or best evidence to support the assertion that the Brewer diet is effective and the poster linked above is doing all kinds of nifty deflection.
From Alexis:
Yeah, the author of that page was all over the last Brewer thread on here. She's also been on the preeclampsia forums.
From Caryn:
Given that no one is yet sure what causes it, it makes sense that we do not yet know, with certainty, the best way to treat it.
We know that no treatment has been shown to be effective. As I've said before, I've spoken to multiple NICHD researchers about this, and if you would be willing to coordinate a study population or know someone who would, contacting me at caryn at preeclampsia dot org would be an *excellent* way to get moving on this topic.
So far, the response I hear from homebirth midwives is that they couldn't possibly test Brewer's diet, because it would be unethical to feed an inadequate diet to pregnant women since it would cause preeclampsia, and after all we would need to do this to do a proper study, so they're just unable to do it ethically. But, of course, this assumes the premise that diet is causal. I've also checked with an ethicist on an IRB, and been told that IRBs would have no problem approving a study using the ACOG's recommended diet as the control group, so long as all women who became symptomatic were moved to standard treatment.
Any takers out there?
From Alexis:
The bigger problem is the assumption that the Brewer diet is the only healthy diet out there and that there aren't other healthy diets which don't meet Brewer's specific requirements.
From Ericacrochets:
"I did have 4 women over 15 year s( out of the 12 who became symptomatic during that time frame ) who did not respond and were transferred out of my care to his."
Honestly, I don't understand why you or your OB thinks that the diet and stress reduction fixed these 8 women and that the symptoms wouldn't have gone away by themselves.
The relationship between diet, exercise, stress, and preeclampsia have actually been pretty well studied. Any OB who tries "diet first" for preeclampsia is most certainly not following evidence based medicine. Any doctor who "believes" in the Brewer diet is a quack or just recommends treatments because he/she thinks they work but can't explain why is a quack. Brewer himself was a quack, although probably a well meaning one. The whole point of doing scientific studies is that a single health care provider can't tell if a treatment works based on a small number of patients--it's impossible.
Oh, but no, let's just ignore this large body of evidence and go with what feels good and sounds nice and makes everyone feel warm and fuzzy, even though it makes no sense and we can't explain it.
Why won't I let this drop? Because women come home from the hospital after having this terrible disease and and inevitably get told by an ignorant friend or family member that they need to eat better so it won't happen next time, based on a completely made up, unsubstantiated theory. This is wrong and cruel, and it must be stopped.
From Caryn:
The bigger problem is the assumption that the Brewer diet is the only healthy diet out there and that there aren't other healthy diets which don't meet Brewer's specific requirements.
Well, yeah. 
It certainly doesn't go any way at all towards explaining why the rate is constant across geographic boundaries, in countries where adults are generally lactose- intolerant, in countries where adults are generally malnourished by our standards, etc.
From Liz:
Kneelingwoman's story sounds good, doesn't it? Eight out of twelve had their symptoms reverse! And if I were a woman who knew little about pre-e, I would be encouraged by it. Unfortunately I know more about pre-e than I want to, and it isn't called after "lightening" for nothing. And unfortunately, this comforting story leaves rather a lot out. What was the time-frame? What were the symptoms? Unfortunately, they are seldom clear-cut and adhering to the textbook. I don't find it particularly reassuring that an OB was convinced, either. Part of the threat of this disease is that there are doctors who don't take it seriously enough, either. That is why women and babies still die from it. Rapidly, sometimes, with no time to test theories of diet. Unnecessarily, sometimes, because of complacency. I showed the first signs at 29 weeks, daughter was born at 35. Some days in that time, my blood pressure returned to normal. Some days, no protein. Was I "cured"?
From Caryn:
I see Joy's listing a letter Brewer wrote to the editors of ACOG as a publication in the ACOG journal.
Yeah.
From Holly:
Nutrition can't cure anything other than nutritional deficiencies (Rickets, Scurvy, etc.). Good nutrition can be preventative, but certainly Brewer doesn't have a monopoly on diets that promote "good nutrition".
Speaking of "good nutrition", I'm wanting to limit the amount of weight I gain with my next pregnancy to 20 pounds. Both times I gained about 40 and I can't stand being that overweight after the babies are born. The first 20 weeks of my second pregnancy I tried to limit what I ate (even went low carb) but I would wake up in the middle of the night STARVING so that I couldn't go back to sleep until I ate something. What's the minimum amount of calories you need when you're pregnant? 1800? 2000? Doing weight watchers that would be 36-40 points a day. I can't just say to myself, "cut out sugar", I need an actual plan. Anyone seen any concrete evidence on sugar substitutes in pregnancy?
From Bridgette:
It's really disturbing to me how many so called "professionals" who boast evidence based information and care are signed up for Joy's website. It's rather scary.
It's also rather scary that on a doula site with thousands of members there's only 1 doula speaking out about the total lack of evidence for the Brewer diet.
Evidence based information must only apply when it suits their needs.
From sarahz:
Re: Cytotec: It is DEFINITELY approved by the FDA for induction of labor in elective terminations. It is 1/2 of RU-486 and that is definitely a FDA approved use.
I understand the problems with Cytotec, but personally consider it a GODSEND for miscarrying women who wish to avoid a D&C for GREAT reason (Asherman's Syndrome?)
Right now, IMO, it is the best solution for a missed miscarriage and I did EXTENSIVE research on the issue. I don't like people saying it isn't approved for induction, because in cases where the baby has passed, it totally is.
Another FYI, the research I did recently suggests that sublingual Cytotec admin is the wave of the future. Apparently, according to a UMich study, Cytotec compromises the immunity of the vaginal tract when administered vaginally, and is equally effective when administered sublingually. Oral admin is not as effective. Some women who have had Cytotec administered vaginally have had a rare Clorstridum bacterial infection and died.
FTR, I did 'reverse' what looked to be emerging Pre-E. (Rising BP, mildly pitting Edema). My midwife (CNM) used a combination of: reducing my salt intake, cal-mag supplements, herbs (hawthorn, passionflower), frequent swimming, 3/4 bedrest, daily BP monitoring, moxibustion, and accupuncture. Basically throwing every single thing at the problem that we could think of. And resolve it did.
While the Brewer diet may not work, and does seem a little cheezy (although WIC makes you drink about that much milk too) I don't agree with a defeatest additude toward emerging symptoms of any medical condition/disease. I do believe early detection and action can have some affect, as with all disease states.
From sarahz:
Holly: I am sort of shocked. You would rather engage in experimentation with barely approved sugar substitutes than deal with a few extra pounds post pregnancy? :shock:
If you are interested, check out the story of how the FDA approved NutraSweet/Aspartame (owned by Monsanto???). It is a fascinating tale, but if you read the actual story of the actual science and history, IMO, no sane person would consume it.
Also, it is my opinion that simple sugar in sane amounts contributes not one iota to weight gain. High Fructose Corn Syrup on the other hand, as well as sugar beverages (good luck finding those, it is mostly HFCS beverages) instead of water.
If you are interested in limiting weight gain, I would cut out CRISCO completely as well as HFCS. If you have done this and still can't lose, you could limit refined grains and only go for whole grains.
Artifical sweeteners are a trap, they are dangerous, IMO (precautionary principle, prove they are SAFE), and when people use them they think they are doing all that to lose weight when really they aren't doing too much to really make healthy dietary changes. They also have been shown to increase appetite. Really their contribution to weight control has been wholly and roundly disputed.
From sarahz:
ETA: I forgot massage to move the fluid from swelling, we did that too as part of the avoid Pre-E regimen . . .
Also, ETA2: Crisco is otherwise known as Partially Hydrogenated or Hydrogenated Soybean Oil.
From Liz:
I would say again that I think it is highly unlikely that it is possible to reverse or treat pre-e. However, there may be a problem with anyone, including a fair number of doctors, being all that clear on what pre-e is, never mind what pre-e does. There are clear and severe cases, and, maybe, a lot of murkier areas, and maybe that is where both the dangers and the confusions lie. A comparitively rare lethal disease where you don't feel ill? Plenty of room for a false sense of security there. And plenty of room for terror and false theories too.
From Caryn:
However, there may be a problem with anyone, including a fair number of doctors, being all that clear on what pre-e is, never mind what pre-e does.
Exactly. The way researchers run these studies is to move women with two bp readings of either of 140/90 and a 24-hour catch of +300 mg/dL to the category "preeclamptic." They don't say, oh, your blood pressure's up a bit and you've got a +1 dipstick, so let's send you swimming, tell you to drink a lot more to water down the urine, and only count the low bp readings, oh look you don't have it any more. (This, of course, since bp is labile in the early stages of PE, a +1 will often correlate to a +300 on a 24-hour, and swimming lowers your swelling.)
A real trial would include moving women with standard symptoms to the standard of care.
From Ericacrochets:
"I can't just say to myself, "cut out sugar", I need an actual plan. Anyone seen any concrete evidence on sugar substitutes in pregnancy?"
The month before I went on the gestational diabetes diet in my 2nd pregnancy, I gained 10 lbs, and I after that I would gain 0-2 pounds. I didn't need to gain much weight since I started a bit overweight. Eating low carb snacks instead of bready ones (cheese instead of toast, for instance) makes a huge difference for me, but I have an insulin resistance problem, as evidenced by the GD, making me the kind of person low carb works best for.
The ACOG is pretty comfortable with sugar substitutes...
From Elizabeth:
Reducing diets during pregnancy are a big no-no. Surprised they don't teach that in your fancy accelerated program. And yes it is a reducing diet even if you are just retarding a healthy process of gain. By definition, healthy pregnancy gain is not "overweight" just because it doesn't instantly drop off post-partum. 1800-2000 is at the very low end of what a woman needs when not pregnant, regardless of what WW says; that you can instantly cite to their protocols disturbs me. Caloric restriction will only make you fatter in the long run by murdering your metabolism. If vanity outranks outcomes in your book, maybe you should reconsider getting pregnant at all. A permanently girlish figure is a near-impossible goal in any case... but trying to combine it with the earth-mother thing is just mad.
From Emma B:
The problem with nutritional bp-lowering tactics is that if the emerging consensus about shallow placentation is correct, you're treating a symptom rather than the underlying problem -- and not necessarily the symptom that causes trouble. If I understand the mechanism correctly, the high blood pressure is actually beneficial to the fetus, since it forces more blood across the placenta. No dietary strategy is going to change the placental structure, so if you eat Brewer and see a decrease in bp and swelling, you haven't fixed anything -- you've just masked the symptom. Won't stop you from getting into trouble later on, if it's slated to happen.
From Liz:
If I understand the mechanism correctly, the high blood pressure is actually beneficial to the fetus, since it forces more blood across the placenta.
Anecdotal, but that would be borne out by me and my daughter. We both have text book normal blood pressure when not pregnant. Mine hovered around 130/90, 140/100, no great cause for alarm perhaps. My daughter's was astronomical. Her premature baby was fine, normal growth. Mine - wasn't. (protein was a much bigger problem for me, swelling for her) Neither of us got particularly good treatment.
From Caryn:
Yes, it's likely an adaptive strategy on the part of the father to improve blood flow temporarily, thus increasing fetal weight.
The problems come when the mother's body doesn't approve of this, because it's also vested in having the baby fit out. Whereas the parental genes in charge of placental growth can always try knocking someone else up, and so they're vested almost solely in postpartum survival via fetal size.
When OBs do use bp meds, they are concerned with bloodflow across the placenta, and monitor the baby closely. (They use primarily alpha and beta-blockers, which aren't diuretics.) Aside from that, I'm unaware of any evidence-based nutritional bp lowering tactics. Anecdotes galore, but...
From Emma B:
So if you're really starting to develop preeclampsia, eating a bp-lowering diet is actually the *worst* thing you can do for the baby, right?
I mean, no, you don't want to get seizures or stroke out, but for women who are in the early stages, I'd think you'd want to prioritize fetal development. If Brewer does lower the blood pressure, then it's actually harmful to the baby and potentially increases cases of IUGR and stillbirth.
From Caryn:
First, it's not at all clear that it's a bp lowering diet.
Second, it *is* routine to treat pressures that are high enough to compromise maternal health. It is also routine to treat chronic hypertensives. That doesn't mean that they are treated casually, though, and they're in for additional close checks, NSTs, etc. and their dosages frequently require tweaking.
Dropping maternal pressures too low may compromise placental perfusion, because when the placenta implants, it implants *in a particular environment*, and it compensates for that environment. So if it implants in a chronic hypertensive whose baseline pressures run 130/85, it sets up to "anticipate" the sorts of changes it's evolved to expect to see in a chronic hypertensive as pregnancy progresses.
The genes in humans with the most variation are the genes governing placentation. This is our bottleneck -- this is the thing that historically has killed the most people -- or else it wouldn't be the part of the genome with the most variation. Placentas are under massive selection pressure. This is one reason why miscarriages are so frequent; it's not difficult to hit on a combination of genes that aren't conducive to term pregnancy.
This is very interesting reading for anyone interested in this sort of thing.
From Caryn:
(Also, chronic hypertensives have a 25% chance of developing superimposed preeclampsia, so even if their blood pressures are 90/60 in the second trimester without drugs they merit additional surveillance. It's thought that they're possibly carrying genes that predispose them to become more annoyed by foreign placentas.)
From A Sarah:
Popping in briefly because I couldn't risk sharing this with y'all:
http://xkcd.com/55/
From A Sarah:
Whoops, sorry! Actually it's here:
http://xkcd.com/552/
From Susanne:
Sarahz: "ETA: I forgot massage to move the fluid from swelling, we did that too as part of the avoid Pre-E regimen . . ."
Move it where? And what good does that do?
I can blow my nose and move mucus elsewhere, but that doesn't mean I've stopped my cold. I've just treated a symptom. All the stuff you're talking about is treating symptoms, not reversing the underlying process.
From Caryn:
All the stuff you're talking about is treating symptoms, not reversing the underlying process.
Yes. Brewer is like this too -- it's the classic flagpole-shadow example. Using trig and a measurement of a shadow you can deduce the height of a flagpole, but you can't *explain* the flagpole's height by saying, well, trig and the length of this shadow here...
Similarly, PE symptoms. Sure, plasma volume expansion is inadequate in preeclamptics, but that's because the placentation is somewhere around a couple sigma off of normal. Anything regulated by the placenta is going to be *dysregulated* because placentation is dysregular, including plasma volume expansion, maternal metabolism, fetal growth, labor and labor onset, postpartum milk production, etc. But you can't *explain* PE by pointing at those symptoms, any more than you can explain a flagpole by pointing at the shadow.
From Ericacrochets:
One day during my 2nd pregnancy, I had a little bit of protein at one visit. My doctor had me come back the next day to be checked again. That must have cured me because it went away!
What if he had told me to eat 10 eggs that night before my followup? The eggs cured me! Or 2 packs of M&M's? The M&M's cured me! M&M's are the cure to preeclampsia!
From Esther:
I could really get behind an M&M cure for pre-E. Hell, I'd fake pre-E for M&Ms ...
From Adrianna Joanna:
Is anyone else disturbed by the ableist nature of this debate, not just about complications like pre-eclampsia but natural childbirth in general?
Obviously, if you developed pre-eclampsia, you didn't follow the diet. If you developed any other complications, you just didn't follow the rules and are, to be blunt, uncaring and incompetent. There is NO MEDICAL EXCUSE for pregnancy complications because birth is NATURAL AND SAFE! The idea that if you try hard enough and care enough, your birth will be perfect and that sick or disabled women aren't worthy of babies, apparently.
Moreover, if you do have complications, you are worthy of pity. You needed a C-section? You needed an induction? You needed whatever? Poor you. Your pregnancy and delivery were just all for nothing, weren't they? You and your children must be suffering. Well, I'm glad I got what I wanted. I did this and this and this and it worked great for me.
What these people refuse to acknowledge is that not only are they not so special that none of these negative outcomes can happen to them, but frankly, natural childbirth has no intrinsic value whatsoever. To me, surviving pregnancy complications and interventions is a bonding opportunity, our first major trial together, and interventions do not traumatize us. They give us life and health. If your interventions were planned ahead of time, it is simply another way for a mother and baby to live and grow, to give birth and be born.
The Brewer diet in itself is rife with ableist connoations. Women with certain allergies and medical conditions cannot survive on that. Therefore, if they develop pre-eclampsia, it is their fault. What were those cripples doing having babies if they couldn't "do it right?"
This whole NCB/HB issue just makes me mad. Pregnancy and childbirth aint safe, guys, and they aint achievements either.
From Caryn:
What these people refuse to acknowledge is that not only are they not so special that none of these negative outcomes can happen to them, but frankly, natural childbirth has no intrinsic value whatsoever.
Word.
Pregnancy complications are intrinsic to being human. Deal with. Though I wonder if our historical cultural coping technique hasn't been precisely to blame the victim, given the lack of alternatives until recently.
From Ericacrochets:
Another problem with Brewer is that diabetes and gestational diabetes are strongly correlated with preeclampsia, but his diet is too high in carbohydrates to be used by someone with those conditions.
From Elizabeth:
Is anyone else disturbed by the ableist nature of this debate, not just about complications like pre-eclampsia but natural childbirth in general?
Yes.
I just made the mistake of checking out MDC, which I hadn't done in a long time. I thought it would have entertainment value or something. Boy, did I miscalculate that one. Among other things I found a thread where a woman had gone to donate blood, and came to MDC seething with resentment that the Red Cross literature mentioned that blood products are used to save women when birth goes awry. WTF?
Caryn, from my experience in a religious tradition that really makes a fetish of female fertility in many ways, I haven't seen much victim-blaming with respect to bad outcomes. Haven't seen any, really (aside from the Eve myth WRT pain, but that's a different issue). Not that contemporary religious conservatives are a reliable guide to the historical cultures they grew out of, but it's an interesting reference point. A group that seriously regards babymaking as mandatory (as virtually all Western religion did until the past century or so) is going to have too much unmistakable data on its hands to tolerate illusions about ensuring good results through proper technique. That sort of healthism is largely a replacement for traditional religious and cultural mores. My conservative religious friends who've had bad outcomes have told me, credibly, that they are at peace because they know it's out of their hands, and noone in those circles would dream of suggesting otherwise. I may be biased, and Heaven knows traditional cultures are no cakewalk for the weak and vulnerable, but I see ableism as an overwhelmingly modern and secular phenomenon.
From Liz:
This debate cannot die, because it is just too interesting! The posts above by Adrianna and Elizabeth are fascinating to me, and to some extent touch on the issues that brought me here. People like me are, as Adrianna points out, supposed to be the grateful recipients of other people's rather complacent pity. It is complicated - but I did find it somewhat hilarious when my children were younger that the school-gate mothers who resented the rather easy accomplishments of my younger daughter were greatly comforted by the presence of my other daughter in her wheelchair. Am I disturbed by ableist assumptions? No. They can be irritating, but given that they rest on a kind of smug naivety are more often slightly comic. You may want to believe that the right diet and exercise is a magic spell that guarantees immortality and perfect children, but, sadly, sooner or later reality may intrude, in one form or another.
As for the attitude of those of a religious bent - well, it is kinder, much less arrogant. But being told, or having it implied, that it is all part of God's plan can occasionally get a bit tiresome. I am not all that keen on the idea that I am being "tested".
I do think Adrianna has a point. Bad and stressful events can have positive as well as negative outcomes. You learn some things. One of them is that what other people think is not terribly important. Another is that the reality of a situation is often different, in surprising and interesting ways, from how you imagined. A sense of proportion, if you are lucky, and possibly not to be too judgemental of the misapprehensions of the well-meaning. Attributing agency to a good outcome is understandable enough, and in itself does no harm. It is the tottering edifice of false beliefs that can be extrapolated from that which damages those who are bullied into believing that they "failed" at something they actually have little control over that is pernicious.
From Myriam:
Do any of you ever challenge the views put forward on MDC and the like? I was riled enough to do so the other day on another VBAC site.
Someone posted that they were happy and excited because their consultant had given them the green light for a trial of labour. They had been wondering about the possibility of a waterbirth but the consultant had said "let's keep it safe shall we". Then the responses came. Lots of: "I had to go and calm down before replying", "Grrrs" and *sighs* etc. In other words, look how angry and righteously indignant I am therefore I must be right. They would say that the anger is directed at the health professionals but the hapless original poster can't help but feel that the agression is directed at them. It's another way of stifling discussion.
Then come the collective attempts at attitude adjustment: you must never say "the consultant let me". Everyone repeat after me: My birth, my baby, my body. I did point out that it is somewhat ironic that the board moderators are trying to impose a blanket ban on the phrase "they let me". Who's being authoritarian now? My question is am I completely wasting my time?
Next comes all the "but Mary Cronk, Sarah Buckley, Ima May Gaskin say..." So what! And references to the article "VBAC: on whose terms" That's the founding document of the whole VBAC movement. Can someone do a critique of it please?
I don't really care if people with a natural birth perspective want to reinforce each other's views, it's the proselytising and assumption that everyone shares similar priorities that rouses me to action!
From Adrianna Joanna:
"Another problem with Brewer is that diabetes and gestational diabetes are strongly correlated with preeclampsia, but his diet is too high in carbohydrates to be used by someone with those conditions."
Unless, of course, you believe that diabetes is curable by diet and exercise, and that GD doesn't exist. On a serious note, though, you're right.
"I may be biased, and Heaven knows traditional cultures are no cakewalk for the weak and vulnerable, but I see ableism as an overwhelmingly modern and secular phenomenon."
If we are talking just about childbirth, I agree with you. I don't recall there ever in history being a recollection that childbirth was about one's performance. They knew better, and that is what Amy is always talking about. The perspective of natural childbirth advocates is ahistorical and they are unaware of their class privilege. As for in general, I would say that ableism has existed since the beginning of time.
"I do think Adrianna has a point. Bad and stressful events can have positive as well as negative outcomes. You learn some things. One of them is that what other people think is not terribly important. Another is that the reality of a situation is often different, in surprising and interesting ways, from how you imagined."
I don't think anyone thinks this, but I just want to make sure that people don't think I see strife as inherently valuable. I just believe that you can plan, and you can follow those plans, but life is unpredictable and you live with it. I believe that most times, if you are open to not having everything go your way all the time, everything will be alright. One of my favorite quotes is "Eveyrthing will work out in the end. If it didn't work out, it's not the end."
I grew up in a white, upper-middle class background, and I was never socialized to believe that natural childbirth was best, or that I should "have it all," or anything else. My mother herself would have had an epidural if she had the chance, but I arrived in less than an hour, and for most of her labor, she felt no pain at all until transition. It's actually a really amusing story, but this isn't the place for it. Maybe some other time.
Anyway, I also am well acquainted with disability and illness, and I have had surgery. I did have the option of going with a less invasive method, but surgery was more effective, and I was tired of being in pain, so I chose it. So this idea that you can ensure your good health if you "behave," or that medical intervention is inherently bad, are ludicrous to me. My backgroud tells a completely different story, and that's part of why I don't like being preached at by natural childbirth advocates about anything, must less how sorry they feel for me.
Not all doctors are equally caring or competent, but that's separate from the issue of intervention itself.
"It is complicated - but I did find it somewhat hilarious when my children were younger that the school-gate mothers who resented the rather easy accomplishments of my younger daughter were greatly comforted by the presence of my other daughter in her wheelchair. Am I disturbed by ableist assumptions? No. They can be irritating, but given that they rest on a kind of smug naivety are more often slightly comic. You may want to believe that the right diet and exercise is a magic spell that guarantees immortality and perfect children, but, sadly, sooner or later reality may intrude, in one form or another."
See, my problem is that I am disabled myself, so these assumptions bother me a lot because people treat me differently and like a second-class citizen. Never mind that I rather resent that because of my disability, people think that I am completely incompetent, that my life is tragic, and that my aspirations go no farther than being able to get up out of bed. That I need a cheering section for my smallest achievement.
When you are a disabled person with children, it gets even worse. People might see your children as being diseased or treat them as though they are fragile because of the "tragedy" going on at home. If a disabled person is pregnant, we already know they are on those evil medical interventions, poor things.
I got exposed to the idea of natural childbirth fairly recently, because itt just wasn't part of my life, like I described. I was instantly turned off, and I never turned back.
From Susanne:
FWIW, Elizabeth has a great post in response to Adrianna Joanna's points that seems to have gotten posted far upthread and out of chronological order (at least in my haloscan) ... people might want to check it out. It shows up in recent comments, but is posted along with comments that were posted days ago.
From Liz:
"I am disabled myself, so these assumptions bother me a lot because people treat me differently and like a second-class citizen. Never mind that I rather resent that because of my disability, people think that I am completely incompetent, that my life is tragic, and that my aspirations go no farther than being able to get up out of bed. That I need a cheering section for my smallest achievement."
Adrianna, I am not for a moment suggesting that it SHOULDN'T bother you. There is a big difference in our positions, but not a huge difference, perhaps, in some people's attitudes. My life is supposed to be tragic, too, and I am familiar with the others you mention because that is what people assume about my daughter. Other people's attitudes and assumptions are more of a problem and a barrier than the disabling conditions themselves, because it is constant and relentless. One of the things I dislike is that your life becomes public property, and individuality gets lost.
From Holly:
From Elizabeth:
Reducing diets during pregnancy are a big no-no. Surprised they don't teach that in your fancy accelerated program. And yes it is a reducing diet even if you are just retarding a healthy process of gain.
Well, sure they SAY they are a no-no, but 20 pounds is in the correct range to gain if you have a BMI of between 25-30. If a reducing diet makes me in between that range of 15-25 pounds of weight gain for someone with an "overweight" BMI, then is it really a no-no?
From Alexis:
Myriam, I actually do really hate it when HCPs use the word "let". It is seriously condescending, and I find it infuriating outside of the childbirth context. You're my doctor, not my parent, and you don't "let" me do anything.
From Myriam:
Alexis, yes I hate it too. On the other hand, if someone said to me: "I'm really happy because the doctors are going to let me have a trial of labour but they said I have to have continuous monitoring" I wouldn't fly into a rage, assume that they were unaware that they were entitled to refuse treatment and take it upon myself to subject them to lengthy conscious-raising.
And of course, when it comes to something like a waterbirth in hospital, it really is a case of what the doctors will allow.
From Myriam:
consciousness-raising even.
From Holly:
Or what the hospital will allow. Most places just aren't equipped. Heck, one clinical site I was at didn't even have private bathrooms in their L&D rooms. Imagine that.
From JZ:
~From Alexis:
"JZ, the smile may be wiped off your face. With licensing comes scrutiny and responsibility. CPMs are going to face stricter regulation as time goes on. All it takes is one reckless CPM who didn't transfer, and then the legislature will start talking about mandatory requirements for transfer. Etc."~
(From previous post) with licensing comes scrutiny and responsibility...seems to me everyone on this blog has accomplished scrutiny of midwives, legal or not. Most midwives ARE responsible caregivers and I'm certain there are a few bad apples who are not, just like there are good docs and bad docs. But that's no reason to devalue midwifery and homebirth as a whole.
But most of what I see here is midwife bashing and how they are not competent and dont have the skills and education to be doing what they do. So here we are now, at a point where they may become legal across the board, (states are recognizing that CPM's are adequately trained or they wouldn't be legalizing them) and the scrutiny continues. Hopefully with legalization will come more respect for midwifery and maybe stricter regulations will be a part of that but as far as this blog is concerned it doesn't matter either way because midwives will still exist!!
For instance "From Liz: It is really unlikely to kill "us guys", JZ. The odd baby, perhaps."
I mean seriously, now midwives are baby killers!!!!!!! Are you kidding me? People that make comments like that really devalue this blog to nothing more than catty women sitting around the card table gossiping about their neighbor's affair. It's the same stuff, same people, round and round.
BOTTOM LINE, it's the woman's choice, not yours, not mine, not the midwife or the doctors & nurses. If women are able to choose abortion they should be able to choose where they give birth. And if that choice is in their home then BRAVO to the states who are incorporating CPM's into their health care systems and giving those women the choice they deserve.
From Caryn:
JZ, this blog is for *debating* homebirth, and I don't think anyone posting here wants midwives to stop existing. Dr. Tuteur's said on multiple occasions that she's worked frequently with midwives.
it's the woman's choice, not yours, not mine, not the midwife or the doctors & nurses. If women are able to choose abortion they should be able to choose where they give birth.
It's clear that women have the right to be provided with medical care. It's not clear that they have the right to be provided with medical care *in a particular venue*.
From JZ:
"It's clear that women have the right to be provided with medical care. It's not clear that they have the right to be provided with medical care *in a particular venue*."
So if I'm driving my car in bad weather and get into an accident, just leave me there on the side of the road, don't call an ambulance because I don't have the right to medical care because I'm in my car.
From JZ:
Maybe they dont want midwives to stop existing but they sure do want homebirth to stop existing. As hard of a blow as this may be, homebirth isn't going anywhere, it has been around for as long as women have been having babies, and there will ALWAYS be women who will still choose to have their babies at home regardless of "regulations" and "legal issues".
From Alexis:
No, bad analogy. You have the right to medical care; you don't have the right to demand that a full surgical team be assembled and do their work at your car. You can be transported to a hospital and receive appropriate care.
(states are recognizing that CPM's are adequately trained or they wouldn't be legalizing them)
I wouldn't be convinced of that. Legislators are not, by and large, medical professionals. They accept what others tell them. NARM have a certifying exam and a report saying that the exam assesses the material it's meant to, and the legislature reckons it's better than lay midwifery and embarrassing prosecutions. Meanwhile, the AMA's intransigence over home birth acts as an own goal, so they're not even very effective opposition.
From JZ:
I didn't know that hospitals always have full surgical teams assembled and on standby every time a woman gives birth? Wow, learn something new every day.
From JZ:
"You can be transported to a hospital and receive appropriate care."
THANKYOU!!!!! Exactly my point.
From JZ:
"I wouldn't be convinced of that. Legislators are not, by and large, medical professionals. They accept what others tell them"
So you're saying legislation gets passed because "someone told me so". NO. I'm sorry that's not how it works. Roe v. Wade didn't get passed because someone said "do this".
From Caryn:
"You can be transported to a hospital and receive appropriate care."
THANKYOU!!!!! Exactly my point.
Right. So you can't require the state to provide you with homebirth care, because you can be transported to a hospital and provided with care there. So why should the state be licensing care providers for homebirths then?
From Caryn:
"Legislators are not, by and large, medical professionals. They accept what others tell them"
So you're saying legislation gets passed because "someone told me so". NO. I'm sorry that's not how it works.
Yes, it is, for precisely the reason Alexis gave; legislators are not medical professionals, and they generally accept the authority *of* medical professionals when it comes to questions about medical care.
From Alexis:
Roe v. Wade was not a law (it was a Supreme Court decision) and was not made on any medical grounds--it relied on the "right to privacy". Legislation can be and IS passed because people lobby for it, not because legislators have the time or imagination to think everything up.
Larger hospitals have OBs and anesthesia available 24/7, so yes, surgery can be performed at any time. At smaller hospitals they would be paged in.
From Liz:
As hard of a blow as this may be, homebirth isn't going anywhere
JZ, that is a very strange way of putting it. It implies some kind of competition, with winners and losers. Let us look at that. Let us say that Team Homebirth "wins" the right to go on believing in a fantasy of safety, and have their babies in the comfort of their own home attended by poorly trained midwives. Ever heard of a Pyrric victory? Those of us who oppose homebirth are not a homogenous group. I am not against homebirth per se, I am against an ideology that insists that homebirth is safe, and I am against women being persuaded that wishful thinking is all you need to keep you safe, and I am against a group of people calling themselves midwives who promote that idea. There have always been midwives and their have always been home births, you say. Sure. What is new - ish is the rationale behind these things. I don't think anyone has a problem with the idea of competent, well-trained midwives operating from within a system whose first priority is safety.
If my daughter were to decide that she wanted a homebirth, I would, with very sinking heart, support her right to make her own decisions. Nothing would persuade me it was a sensible decision.
From JZ:
"Right. So you can't require the state to provide you with homebirth care, because you can be transported to a hospital and provided with care there. So why should the state be licensing care providers for homebirths then?"
No one is "requiring" the states to provide homebirth care. The states are, on their own, passing laws that say, yes it is ok to have a homebirth. Laws that say, "yes this woman is a midwife and she is a trained professional and she can take care of you." Laws that protect the woman and her midwife.
So in response to... "Yes, it is, for precisely the reason Alexis gave; legislators are not medical professionals, and they generally accept the authority *of* medical professionals when it comes to questions about medical care".
It is VERY obvious that the "medical professionals" are saying homebirth is ok and safe or the legislators wouldn't pass laws legalizing CPM's and homebirths in their state.
"Roe v. Wade was not a law (it was a Supreme Court decision) and was not made on any medical grounds--it relied on the "right to privacy"".
Pennsylvania is currently seeking legalization of CPM's for the same reasons. The Supreme Court ruled on May 23, 2008 that midwifery IS NOT medicine and midwives should not be subject to prosecution for "practicing medicine without a license" because like I said before midwifery is not medicine.
From JZ:
"I am against an ideology that insists that homebirth is safe, and I am against women being persuaded that wishful thinking is all you need to keep you safe, and I am against a group of people calling themselves midwives who promote that idea"..."I don't think anyone has a problem with the idea of competent, well-trained midwives operating from within a system whose first priority is safety".
Well, I'm against an ideology that insists that women should do what their told. I'm against those who pursuade women into believing that they are not adequate and their bodies are illequipped to have children even though their bodies have been doing it since the beginning of time. I'm against doctors who say "well you're too short to have a baby, lets do a c-section instead...it'll be better that way". I am against those who convince women that they *have* to have their babies where everyone else wants them to and not where they want to have them.
If noone here has a problem with midwives who are well-trained then why is it still a sad day on this blog when more states are coming forward and integrating them into their health care systems? Don't you see that the "untrained midwives" that everyone so badly hates here will have to be trained in order to practice under the legislation? Therefore, protecting the women who so choose to have a homebirth. Therefore, making the midwives "competent, well-trained midwives, operating from within a system whose first priority is safety"...
From Liz:
their bodies have been doing it since the beginning of time.
And fairly substantial numbers have died or been destroyed by it since the beginning of time as well. Until the 1940s, and proper medical care.
As far as am concerned, any woman who wants to take her chances is welcome to get on with it. Just let go of the idea it is safe, and we have no quarrel.
From Caryn:
It is VERY obvious that the "medical professionals" are saying homebirth is ok and safe or the legislators wouldn't pass laws legalizing CPM's and homebirths in their state.
No. Because, as you point out, midwives say that they are not providing medical care and that no one needs to ask medical professionals about whether or not they're safe, because they get to set their own standards for their practice.
I'm against those who pursuade women into believing that they are not adequate and their bodies are illequipped to have children even though their bodies have been doing it since the beginning of time.
There's nothing incompatible about both having a lot of humans around *and* having a high rate of maternal mortality. The lifetime maternal mortality rate in Afghanistan, in the absence of modern medical care, is one in six. That means one in six women dies during pregnancy or labor *at some point in her life*, perhaps after she's had a few children and then develops a severe PPH with her fourth. Or perhaps during her first, of eclampsia, but her sister makes it through five successful deliveries (and blammo, there are more people in the next generation if the numbers work like that even *if* both women die in childbirth.)
And frankly, if you want to characterize the fact that I would have died at around 34 weeks gestation of stroke or kidney failure as my "inadequacy", or the fact that my mother would have died of complications from an ectopic between her third and fourth living children as her "inadequacy", or the fact that all of those women in Africa are walking around with fistulas as their "inadequacy", then that's *your* problem, not mine.
From Susanne:
"I'm against those who pursuade women into believing that they are not adequate and their bodies are illequipped to have children even though their bodies have been doing it since the beginning of time."
But many bodies are ill-equipped to have children. That's not an attack on WOMEN, that's just a fact of life.
Many eyes are ill=equipped to see perfectly, but no one feels attacked when it's pointed out that x% of the population needs glasses. Why are you so personally insulted by the fact that many women's bodies aren't well-equipped to have children, AND that said issue isn't "known" til in-the-moment?
From Susanne:
"I'm against those who pursuade women into believing that they are not adequate and their bodies are illequipped to have children even though their bodies have been doing it since the beginning of time."
Just to follow-up ... if MY BODY doesn't "perform" perfectly at childbirth, that doesn't make ME inadequate. What would make you feel inadequate about needing, for example, a CS to deliver safely? You may not like a CS, you may be bummed you had one, may not like the recovery time, etc., but why would that make you inadequate?
From Holly:
I agree with you JK. In the bill before the NC legislator, there is an additional educational requirement in that bill that would require CPMs to receive additional training beyond what is dictated by NARM. Of course some people are upset about this, but I don't see how more education is a bad thing. The problem presented is: How do we get licensed, trained professionals out there to women who will birth at home regardless? The answer is not to force them to birth in the hospital. The answer is not to force them to use untrained, unlicensed, criminal midwives. That is not sufficient. The state needs to find a better way. And they are.
From Holly:
read: legislature. I'm multi-tasking with the babes.
From Holly:
And I would argue that it is the state's business to license midwives. It's the states business the same as the right to assisted suicide and just like the legalization of marijuana is the state's business. It's the state's job to listen to the voices of their people and to act accordingly. That's why we elect them. That's why they are here. So if enough people complain about the lack of trained professionals available to homebirthing women, it's the state's JOB to respond to those complaints. Of course you can voice your opinion about how you would LIKE them to respond, but that doesn't take away their DUTY to respond and to meet that need if the STATE deems that a need exists. I think you are all upset that it's out of your hands. It is, I'm sorry. Your little bitch sessions on the internet are going completely unnoticed by anyone but yourselves. We have homebirthing women up the ass lobbying here in NC. Where is the opposition? The squeaky wheel gets the oil, folks. It's not going to change anything unless you're bitching to the right people in the right numbers, and obviously y'all aren't.
From JZ:
I'm not arguing the fact that women have died in childbirth, nor am I arguing the fact that modern medicine has done good for women. But the more "modern" the medicine becomes the more control others feel they need...resulting in all the classic interventions of a hospital birth which have proven to increase the risks of child birth.
"Just let go of the idea it is safe, and we have no quarrel"...that's about as likely as you letting go of the idea that homebirth is unsafe!!!
Or perhaps Caryn, you're grapsping at straws...population and maternal mortality rates, you make no sense. We don't live in Afghanistan and we have modern medical care. Whats your excuse for the neonatal mortality rate for the US? One of the worst in industrilized nations...homebirths account for 1% of births nationwide so you can't tell me that homebirths and midwives have driven that number through the roof. There's obviously a major flaw in the current maternity care system that is responsible for babies dying, not midwives.
I've never argued the fact that women don't have complications in pregnancy so I'd rather appreciate you not putting "words in my mouth" by saying that I'm insinuating that inadequacies are an equivilant to stroke, kidney failure, ectopic pregnancies, and fistulas. You're arguement reeks of desperation.
Most midwives work in conjuction with an obstetrician and have the ability to refer and consult if a woman develops a problem. Besides, anyone with any of the above problems you mentioned would not give birth at home so what is your arguement really?
From Holly:
I have to tell you I was at three out of the four legislative study committee meetings on licensing midwives in NC and I was a little disappointed. I expected the OB groups in NC to really bring it, and instead the response was just impotent.
From JZ:
Holly, I definitely agree with you as well. I'm studying for my CPM right now, but I'm also an RN in maternity with my BSN and I wouldn't have done it any other way. I don't feel I would have sufficient education or experience if I went straight into the CPM process without the other education first. I think the states will come up with a good plan to get the midwives good training and the women who want homebirths the access to a competent midwife.
From JZ:
Is NC close to passing the legislation? I get emails from The Push Campaign and I recently got a couple regarding the NC midwives.
From Holly:
We're closer than we have ever been before. We couldn't even get anyone to sponsor the bill in years past. But, we got a sponsor, then the study committee meetings went very well, the committee recommended that CPMs in NC be licensed, and now we have a bill in the house. We'll see how it goes. The study committee meetings were packed. Breastfeeding women all over the place, lol. Anyway, even if the bill doesn't pass this year, there will be next year. I know these women and they are going to keep at it. You can join NCFOM for updates. They have a facebook group that's really active.
From Caryn:
the state's business to license midwives.
Of course it is.
Where is the opposition?
On alt-med generally, well behind the curve. But we know that.
From JZ:
Well, good luck and I'll add them to my facebook. PA has a lot in the works but as far as I know nothing in the house, hopefully soon.
From Caryn:
Or perhaps Caryn, you're grapsping at straws...population and maternal mortality rates, you make no sense.
I'm sorry, but that sentence makes no sense. Could you restate your argument?
Whats your excuse for the neonatal mortality rate for the US? One of the worst in industrilized nations
Have you seen this?
I've never argued the fact that women don't have complications in pregnancy so I'd rather appreciate you not putting "words in my mouth" by saying that I'm insinuating that inadequacies are an equivilant to stroke, kidney failure, ectopic pregnancies, and fistulas.
If women have strokes and ectopic pregnancies and develop kidney failure and fistulas *just because they're pregnant*, how do you square that with your complaint that I'm against those who pursuade women into believing that they are not adequate and their bodies are illequipped to have children even though their bodies have been doing it since the beginning of time.
Haven't women been dying because of pregnancy from the beginning of time too?
Most midwives work in conjuction with an obstetrician and have the ability to refer and consult if a woman develops a problem. Besides, anyone with any of the above problems you mentioned would not give birth at home so what is your arguement really?
I developed severe preeclampsia at home and my CPM failed to risk me out because her training was inadequate.
From JZ:
Well, I'm sorry to hear that that happened to you. But that doesn't mean that all midwive's training is inadequate or that they're incompetent which is what everyone here seems to think. And that was my main arguement to begin with. That along with it's a woman's (or couples) choice to birth where they want and you're busy going off on a tangent about "having a lot of humans around *and* having a high rate of maternal mortality" and the maternal mortality rate in Afghanistan. I really don't see how this is relavent to the arguement.
Also, anything that Dr Amy posts is unreliable, especially her charts that she makes up. Please show me where in the CDC report it breaks infant mortality rates down by care provider because I'm not seeing it anywhere.
From JZ:
If this chart that she made came from the CDC Wonder site then you can make those numbers say whatever you want. It just depends on the options you choose for it to calculate.
From Liz:
that doesn't mean that all midwive's training is inadequate or that they're incompetent which is what everyone here seems to think.
As far as I am aware, after careful reading, no-one here thinks all midwives are incompetent. Far from it. Quite a number of us think that competence may not be enough if you need resources that are not available, The problem to some extent may centre on who is entitled to call themselves midwive, and the very inaccurate statements made by those who really do seem to believe that safety is a matter of willpower, or eating the placenta, or following the Brewer Diet. When "midwife" website after website tells women that PPH is no big deal and that doctors are just conspiring to humiliate women or make more money, then some of us see that as a problem. The "transfer at a hint of a problem" brigade may be safER, but it is hardly foolproof, unless you are convinced that all problems allow for that as a solution, and they don't.
And Holly, I personally find your ya booh, cock a hoop assumption of victory a bit sickening, and your assumption that lawmakers always act for the Good of the Many a bit naive. The British Government is favouring homebirth. It isn't because they have suddenly been converted to the cause of women's choices. Historically, women dying in childbirth was not a popular cause. Women had babies, women suffered, women died. It was ever thus. Sanctioned by Genesis. If anyone was really that interested in what women want, there would be better statistics, better hospitals, and -horrors - more money spent. Don't hold your breath.
From flim flam:
great arguemnt JZ!. anything that disagrees with you is made up?. if you would actually read the papers amy has up (check the side bar) you might learn something.
see, thats the problem a lot of us have here with homebirth advocates, you all just dont listen to anything that doesnt fit in with your "yay! homebirth rocks, all obs are women hating meanies, women have been giving birth forever so anyone can pop one at at home no worries!" crap.
Why should the state license unqualified people to attend births? do i have the right to demand that a surgeon comes to my house and perfoms an operation in my lounge while i sit in a little swimming pool because i think it's "more natural"?. if misguided women choose to risk their own, and their babies lives by giving birth at home that's their problem, it's not empowering, it's purely a gamble.
what is boils down to is that most of the time, you can give birth at home, in the back of a car, or a field, or up a tree and everything will be ok, but when things do go wrong, it happens quickly and often leads to death or damge to both mother and baby
i've written before about a work mates daughter, who last year, having swallowed the homebirth koolaid decided on a home waterbirth, first baby. all going well, lovely music, candles etc. baby took his time but delivered, comes out blue, not breathing. while the midwife and her assistant are working on him, mums on the bed unoticed,having a massive PPH, dad rings the ambulance, baby is dead, she ends up nearly bleeding out, had to have a hysterectomy. THIS WOULD NOT HAVE HAPPENED IN A HOSPTIAL! is the perfect fantasy empowering birth worth this?. nobody told her this could happen. she did all the right crunchy things, organic food, yoga, lamaze etc. she lost the gamble. and this is in australia with "proper" well qualified midwives.
it is simply the fact that at home, if anything goes wrong the risks to the mother and baby are enormous, as are the consequences.
i know exactly what you're going to say JZ.."but babies die in hospital!". they would be the babies that would definitely die at home too, and hospitals manage the highest risk women of all catagories. for example, my hospital is the state centre for: refugee mothers, young mothers (we're talking 14 years old and up) drug addicted mothers, multiple births, obese women, women with PE,GDM and pretty much anything else you can think of. they have a fantastic PICU and have babies survive from as early as 24 weeks.
can your average homebirth madwife do neonatal resus? do they carry the oxygen? can they intubate a baby ( it's a highly skilled procedure and you can do a lot of damage if you mess it up)do they have an incubator? a neonatal resus team to work on the baby while the obs and nurses help the mother? no?. so how exactly is it safe and why are you promoting it?
From Holly:
Liz, I didn't say they were acting for the good of the people, only that the system is designed to work for the *will* of the people. You know, a government "of the people, by the people and for the people"... So, enough people care about an issue, it's the governments job to pay attention to that issue. Of course, in this day and age, at least in federal governments, you have hired lobbyists and it's mostly whoever has the most money, but on the state level, I think grassroots protests and demonstrations do make a difference.
From Alexis:
So, Holly, if people want something, the state is obligated to provide it regardless of the safety issues? I don't think that argument works.
And I do have to agree with Liz--your attitude is pretty sickening here.
From Liz:
"nobody told her this could happen."
And that is what I oppose, and will oppose, for ever and ever. I can see that there is a problem - pregnant women do not want to hear horror stories, and, maybe, should not. But selling them the idea that it is all a stroll in the park, homebirth is safe, UC is safe, is, in my opinion, just plain wicked. Sure, most can bask in the fantasy that a good outcome is due to their good management, but I have yet to see any convincing evidence that the Ostrich position is an asset to anyone. Give women real facts, and if they choose to risk it when in full possession of ALL the facts, then fine, I have no problem with that. But if one misguided optimist buys what NCB advocates sell, and finds out the hard way that it is false, then I believe they have a lot to answer for. And they don't - they shrug it off. And I believe it is a form of mass delusion let loose on the unsuspecting - Koolaid indeed.
From JZ:
All of you can cry about homebirth ALL YOU WANT...it's here to stay AND I will say again for the hundreth time that it's the woman's choice. Nothing you women say on this blog is going to change that. You can question the safety of HB til you're blue in the face and come up will all your little scenerios and what ifs but if someone truly believes in homebirth and it's safety you're not going to change their minds. And states are going to continue to pass legislation and legalize them.
flim flam, all HB midwives know neonat resus and carry oxygen if they don't they have no business doing births. Your idea of a midwife and their skills is pretty misconstrued and I'm sure your fearless leader had something to do with that.
NCB advocates don't "sell" their ideas, women do have a mind of their own. You guys probably have dreams at night of hippie midwives with a gun to a pregnant woman's head forcing her into the water birth tub.
We all have a mind of our own and we will do what we believe is right for ourselves. The anti HB/midwife junkies on here have absolutely NO RIGHT to judge others decisions. I mean this isn't even a debate because you all get down right nasty to anyone who has a different opinion.
From Alexis:
JZ, you might want to look more closely at some of your colleagues-to-be. Not all are certified for resus, and many have done it so infrequently that I wouldn't let them near any baby of mine.
I agree that home birth is here to stay, if only as a niche. I don't agree that the best way to deal with the issue is to create a 2nd class of midwives with insufficient training requirements.
If someone "truly believes" in the safety of home birth to the point that nothing can change their mind, then they're deluded and I can do nothing. Personally? I believe that there is a risk. I believe that risk can be minimized, and that steps to do so are not always taken. But it is always there and I have seen home birth advocates lie about it and claim that home birth is outright safer than hospital--something which no data has shown, as far as I know.
From Liz:
And, of course, homebirth advocates are all sweetness and light - as you and Holly have been demonstrating.
Perhaps some of you might be interested in Erin's recent post Unplug your Ears, and the comments:
http://erinnewmanlong.blogspot.com/
Homebirth may well be here to stay, and some will no doubt learn the very hard way.
From Indy:
You know JZ, I fully support your right to gamble with your child's life! Have fun, chances are you won't need emergency care post haste. If you do? Must ... think ... flowers and sunshine ... flowers and sunshine ...
Like was said before if you guys wouldn't go around making stuff up I don't think you would get much pushback. I think a fair trade would be to fully license midwives with the requirement that you carry malpractice insurance. You don't have a problem with accepting responsibility for your own actions and medical advice, now do you?
From JZ:
I read Erin's posts and as a mother I feel for her and believe she had a tragic experience. What happened was horrible but that was her choice and she's taking the responsibility for it.
Indy~first of all there's no need for the condescending attitude, secondly, if the insurance policies existed for midwives most would take them, but thats not a possibility at this point. By the way, I don't hand out medical advice, I'm not a doctor.
From JZ:
Alexis, how many midwives do you know that straight up don't know neonat resus? I want a number and no guessing.
Anything that I've come across does not claim that homebirth is safer than a hospital they claim it is JUST AS SAFE AS, there is a difference. I am fully aware that there are risks. We risk our lives and our loved ones everyday when we get in a car. Are you all gonna start saying they should ban driving too? I mean so much that we do on an everyday basis is a risk to our lives and we know the risks yet we do them anyhow. HB is no different.
From Alexis:
Well, first of all, I said not certified: I'm sure all have seen it demonstrated (I sure hope so) but I have seen midwives say they don't have NRP certification. Or that they're "working on it".
I don't think it's true that "most" midwives would accept malpractice because there's a substantial minority of midwives who don't want the constraints on their practice that such insurance would entail. There is a pool in Washington, and I've heard complaints about the restrictions involved (I believe, for example, that it won't cover HBAC).
And I have seen homebirth advocates (many of whom are not professionals) say that homebirth is safer than hospital birth, at least for low risk women. Read MDC for 10 minutes and you'll see a dozen women making that claim.
Your analogy isn't very good, because I never suggested homebirth should be banned and I don't believe it should be. I said it can be made safer. It's the equivalent of requiring that we wear seatbelts and drive under the speed limit. The MDC/crunchy shit of "your OB won't agree to a VBA2C with an L-incision? just HBAC!" doesn't fly. (I use that scenario because someone did claim to do just that. No birth story, though, so I think she was full of it.)
From Liz:
that was her choice and she's taking the responsibility for it.
So does that absolve the people who encouraged her naivete? And she may be taking responsibility, whatever that means, but she is also telling people that after two years, her grief is still devastating, and warning others against making the mistake she made - believing in the fairy stories. What she says is:
"Unfortunately, my baby died very likely because of my choice to birth at home. So forever I am a Mama who will never ever be in support homebirth. It scares the shit out of me when I hear about someone that I or a friend knows who is considering homebirth."
I'm sure she would register your sympathy. Not sure what she would make of "What happened was horrible but...."
From Ericacrochets:
Oh, yes many homebirth advocates do claim homebirth is SAFER THAN the hospital.
According to Lamaze International,
"Is home birth really as safe as birth at a hospital or birthing center?
For most women with low-risk pregnancies, birth outside the hospital is as safe as—or safer than—hospital birth. The medical attitude of expecting trouble during birth, and the hospital policies that support this attitude, prevent women from giving birth easily and safely in the typical hospital. Routine medical interventions used at hospitals interfere with the natural process of birth and present unnecessary risks that can harm you and your baby. Home is where most women feel safest and comfortable. At home, there are no routine restrictions placed on a laboring woman, which make labor and birth more difficult. At home, you can choose your own caregivers, family and friends to support you, wear your own clothes, sleep in your own bed and eat your own food. Additionally, at home, there are no hospital-borne germs to endanger the health of you and your baby."
http://www.lamaze.org/Childbirth...54/
Default.aspx
From JZ:
Passing legislation to legalize CPM's is the first step into making things safer for homebirthers. Then the states can monitor education requirements, certifications, CEUs, etc.
From Liz:
Passing legislation to legalize CPM's is the first step into making things safer for homebirthers.
It is possible that, in the long term, it COULD be - which is not the same as saying it will be. Hardcore "birth is safe, transfer is unnecessary, everything is just peachy if you "trust" types won't use midwives who are regulated to a high standard, and it would probably take some publicized disasters for things to be tightened up. If midwives want more safety, get decent qualifications and oversight and agitate for a safer system overall - and yes, with responsibility through liability insurance.
From Caryn:
you're busy going off on a tangent about "having a lot of humans around *and* having a high rate of maternal mortality" and the maternal mortality rate in Afghanistan. I really don't see how this is relavent to the arguement.
You said I'm against those who pursuade women into believing that they are not adequate and their bodies are illequipped to have children even though their bodies have been doing it since the beginning of time. Surely if women have been *dying* from the beginning of time in the absence of modern medical care, then it isn't much difficulty to persuade women that their bodies are ill-equipped to birth children. What with it being a fact and all. And this makes medical care *relevant to the argument* in a way midwives and homebirth advocates seem very interested, these days, in denying.
if someone truly believes in homebirth and it's safety you're not going to change their minds. And states are going to continue to pass legislation and legalize them.
If enough people truly believe that global warming is not happening, and states continue to pass legislation that ignores the scientific consensus about global warming, does that mean it's a *good thing* that the state is acting according to the will of the people? Or does it mean the people are generally misinformed?
From Alexis:
Or, alternatively, we could remove the restrictions on CNMs attending home births and expand the CM credential, providing a route for non-nurse midwives that would be integrated into the broader healthcare system and would enable them to serve women at home and in the hospital.
From Adrianna Joanna:
"Home is where most women feel safest and comfortable. At home, there are no routine restrictions placed on a laboring woman, which make labor and birth more difficult. At home, you can choose your own caregivers, family and friends to support you, wear your own clothes, sleep in your own bed and eat your own food. Additionally, at home, there are no hospital-borne germs to endanger the health of you and your baby."
Wow. When I read that, I am almost convinced that it's true. It makes me want to try it. Homebirth advocates are very good not just at playing at people's ignorance, but laying on the charm. Many people have pointed out that pregnant women don't want to hear horror stories, or think that bad things could happen to them and their babies. Many people fear hospitals. So this seems very persuasive to them, and even to me, who is committed to having an OB, a hospital birth, and has no problem with medical intervention.
Liz:
I just want to say thanks for the feedback about ableist attitudes. You don't have to be disabled to be affected by ableism. Social justice issues affect everyone. I am at an advantage. I do not have a wheelchair or any obvious marker of a disability, but then that leads people to assume that I am not disabled. So there is the inevitable failure to conform and indignation that I didn't do so. "But you don't LOOK disabled!" Yeah, yeah. It's very complicated.
"And that is what I oppose, and will oppose, for ever and ever. I can see that there is a problem - pregnant women do not want to hear horror stories, and, maybe, should not. But selling them the idea that it is all a stroll in the park, homebirth is safe, UC is safe, is, in my opinion, just plain wicked. Sure, most can bask in the fantasy that a good outcome is due to their good management, but I have yet to see any convincing evidence that the Ostrich position is an asset to anyone. Give women real facts, and if they choose to risk it when in full possession of ALL the facts, then fine, I have no problem with that. But if one misguided optimist buys what NCB advocates sell, and finds out the hard way that it is false, then I believe they have a lot to answer for. And they don't - they shrug it off. And I believe it is a form of mass delusion let loose on the unsuspecting - Koolaid indeed."
Totally. I would never judge a woman who had a homebirth any more than I would judge a woman who had a C-section. It just doesn't matter to me. I actually would be very interested in hearing their story if they were willing to share, and it doesn't matter what kind of birth they had. And I believe the mother's experience during birth is important, although the paramount concern is the safety of mother and baby. (No, intuition doesn't count. A licensed medical professional with training and experience does, and you would do well to find one you trust.) That said, it's wrong to distort the risks and benefits of anything, which is exactly what HBAs are doing. Informed consent is key.
Here's another minefield: the "dead baby card." God, I hate that phrase! Yes, women's preferences and experiences are important. But there comes a point where you have to compromise, and that compromise may mean the health or life of yourself or your child. And yes, there are some choices that a mother can make that by definition put her preferences over the well-being of herself and her child. Yes, this is a scientific truth.
Anyway, the "dead baby card:" They make it sound so trivial, which makes you wonder what the priorities of some of these women are. A dead baby is no trivial matter, and it's not a game, guys. The OB sure doesn't seem to think so. So, here is my question: Is it really 'playing the dead baby card' if technically, it's true?
From Ericacrochets:
"Or, alternatively, we could remove the restrictions on CNMs attending home births and expand the CM credential, providing a route for non-nurse midwives that would be integrated into the broader healthcare system and would enable them to serve women at home and in the hospital."
But why should we since the entire homebirth movement is based on the false premise that homebirth is as safe or safer for low risk women? If this misinformation could be corrected, the number of women who still wished to homebirth would be miniscule.
From Indy:
JZ - condescending attitude? Read up at the posts you have made. 57 minutes earlier than my post you stated:
All of you can cry about homebirth ALL YOU WANT...it's here to stay
and a few hours before that:
Also, anything that Dr Amy posts is unreliable, especially her charts that she makes up.
From what I have seen in your posts you are going down the talking points of the homebirth movement as if you have a unique insight that we just simply don't get. Yes, we do. And you say I am condescending?
Homebirth has inherent risks for the mother and child. You accept those risks. Fine, you are one step ahead of the MDC crew that buried at least 14 babies in 2008 because they believed that being able to see their own wallpaper somehow made birth safer.
From Alexis:
I don't know about that. Some might choose to anyway.
In any case, I believe it should be up to women and care providers to decide. I'm speaking in terms of the state's obligation, such as it is, to provide women with a choice.
From flim flam:
only someone who has never lost a baby, or been close to losing one could possibly be as blase' and callous as you jz. how can you read erins blog without your heart breaking?. did you see the picture of her and her partner cradling poor little birdie?. so what would your advice to erin be? have another homebirth?. she had NO RISK FACTORS prior to going into labour.
HBA's dont want the truth, they want to live in magic golden fantasy land where all homebirths are perfect and bad things only happen to other women, hopefully those sheeple chicks who go to hospital.
newsflash!!!! shit happens!. complications strike without warning. and it can happen to any women. it isnt a punishment for not being crunchy enough.
i am often stunned at the level of cruelty and contempt homebirth propagandists have for other women.
as for my earlier comments about neonatal resus, it isnt enough to do a workshop once a year. to successfully perform neonatal resus you need to be doing it regularly, in real situations on real babies not dummies. for example, as a nurse i hasve to keep my CPR up to date and do a refresher every 6 months, in over 10 years of nursing i have NEVER had to resuscitate anyone. in contrast, my friend in an ED does it all the time. in an emergency, who would you rather have resuscitate you?. neonates are incredibly difficult to resuscitate. if you push air into their lungs too hard and fast their lungs tear and collapse. cardiac massage is also very tricky on a baby.
so imagine the scenario: a homebirth midwife catches the baby after a difficult birth, he's blue, not breathing..panic stations..where's the oxygen? is it set up?..(the clock is ticking..) quick, try and remember what they taught me a year ago...shit..i've never done this before...fumbles in bag..finally gets the oxygen working...mask keeps slipping off....(tick tock tick tock) baby still not breathing..(how long before the brain is damaged?)oh god..mums bleeding a lot...baby still lifeless and blue..someone call the ambulance..( you can expect at best a 15-20 minute wait if you are really lucky and don't live too far away from hospital and it's not rush hour and the weathers ok...)baby gets to hospital...neonatal resus team paged...too late maybe?
contrast this with the hospital: baby's out, blue, not breathing..neonatal resus team paged, arrive in less than a minute, a team of at least 4 nurses and doctors work on the baby, the dr ( who does this all the time) intubates, all the medication, equipment and skill is right there in the hospital, no transfer, no waiting. which baby has the best chance do you think? or like most HBAs dont you care? because it wont happen to you will it? no, only other women end up with dead babies, they're just collateral damage in the war against obs with their evil disempowering life saving medical interventions
From Yehudit:
The problem with the "Birth is Safe" vs. "Birth is Risky" debate is that, as much as one might agree that birth is NOT "as safe as life gets", knowing the risks of birth does not tell us what TO DO about those risks.
The evidence-based approach to that question is that the onus is on proponents of remedies to these risks to demonstrate that interventions do actually decrease the risks and have more benefits than harms.
An added complication is that people do not always agree about benefit/harm because they have different values.
Everyone can agree that a live, healthy baby and mother are the most important thing when we are talking about a 1:1 therapeutic intervention. Not everyone agrees when the intervention is prophylactic, with a large NNT and when there are large numbers of people undergoing minor harms, weighed against the rare major benefit.
So, saying that birth is risky is an insufficient answer to the "birth is safe" argument. You also need to show that a proposed intervention, or "package" of interventions, reduces those risks and produce more benefits than harms.
From Caryn:
So, saying that birth is risky is an insufficient answer to the "birth is safe" argument. You also need to show that a proposed intervention, or "package" of interventions, reduces those risks and produce more benefits than harms.
No. "Birth is safe" is an assertion. "Birth is risky" is a counterassertion.
Unless the people who are claiming the first go to the trouble of supporting *their* assertion further, the people supporting the second don't need to do any additional work.
From Yehudit:
Unless the people who are claiming the first go to the trouble of supporting *their* assertion further, the people supporting the second don't need to do any additional work.
++++++++++
However, as soon as "Birth is risky" is part of a larger argument for or against an action (in this case homebirth) then it does require some additional work. That is the working assumption of evidence-based healthcare - it is not sufficient to correctly identify a problem, you need to know that your proposed solution to the problem actually works.
"Birth is as safe as life gets" is simply, empirically, false. But so what? Just because something carries risks doesn't mean that reducing those risks is straightforward. Or that the weighing of benefits/harms involved in reducing those risks is straightforward.
For example: for neonatal resuscitation we may feel intuitively that hypoxia should be treated with 100% oxygen, but there is some evidence that this may be more harmful than air. The truth is we don't know, but we do know that our past certainties - based on what are apparently quite reasonable assumptions - were not justified.
From Liz:
"Birth is as safe as life gets" is simply, empirically, false. But so what? Just because something carries risks doesn't mean that reducing those risks is straightforward. Or that the weighing of benefits/harms involved in reducing those risks is straightforward.
I can't follow the logic of this. That may be because I am an "outsider", who does not understand the complexities of reducing risk, but that "So what" is troubling. I could accept "So what then?" It seems to imply that as birth in hospital is not foolproof, home is just as good. Or do you mean that hospitals carry additional risks? Or that the "trauma" of an unwanted CS is worse than the perils of an incompetent provider at home? I accept that there are incompetents in hospitals too, but the risk in homebirth is that even the most skilled and careful of providers cannot deal with an emergency as easily. That science doesn't have all the answers doesn't seem to me a good reason for cutting yourself off from those it does have. Denial of risk, or an assumption that one can deal with the consequences of a bad choice both seem to me very foolish. The website "Glow in the Woods" currently has a heartbreaking thread on the guilt, rational and irrational, women feel when things go badly wrong. The majority of women seem to grasp rather easily that it simply isn't worth it.
From Yehudit:
I don't know why "So what?" should be troubling. It is the question that follows ANY statement of fact. You can rephrase it as "So what then?" if you prefer.
Making the statement that pregnancy and birth have associated risks doesn't imply anything about place of birth. Therefore you should not take that statement to mean "as birth in hospital is not foolproof, home is just as good." The opposite statement ("as birth at home is not foolproof, hospital is just as good or better") is equally invalid.
"Or do you mean that hospitals carry additional risks?"
There appear to be some risks particularly associated with planned hospital birth - insofar as need for augmentation, instrumental delivery, caesarean section rise.
"Or that the "trauma" of an unwanted CS is worse than the perils of an incompetent provider at home?"
I don't think anyone should have an incompetent provider, whatever their place of birth. As to which trauma is worse, that is an entirely subjective matter which would be different for each woman, and of course according to how things turn out. A woman who has an incompetent provider and "gets away with it" may be completely untraumatised as compared with a woman who has a caesarean (unwanted or wanted) that results in uterine infection may be more traumatic. That wouldn't justify the incompetence of the provider in the former case, or undermine the necessity of the CS in the latter case.
"the risk in homebirth is that even the most skilled and careful of providers cannot deal with an emergency as easily."
This is true. But a related question is whether place of birth has any impact on the chance of an emergency occurring. Better outcomes in the event of an emergency doesn't necessarily mean better outcomes overall, if the likelihood of the emergency occurring is related to place of birth.
"That science doesn't have all the answers doesn't seem to me a good reason for cutting yourself off from those it does have."
I wasn't suggesting that at all. I think we do have a lot of answers on a great many questions in maternity care, and in addition we also know what many of the unanswered questions are. One of these unanswered questions is what are the real differences in outcomes associated with different places of birth.
From Holly:
From Alexis:
Or, alternatively, we could remove the restrictions on CNMs attending home births and expand the CM credential, providing a route for non-nurse midwives that would be integrated into the broader healthcare system and would enable them to serve women at home and in the hospital.
I think homebirth critics need to pick the lesser of the two evils- and they will have to or else you'll end up with women abandoning the CNM in favor of the CPM. There are several other women in my program who are going for their CNM. We have discussed (briefly) what we would do if CPMs are licensed and CNMs are still unable to attend homebirths. 2 of us definitely said that getting our CPM in those circumstances would be a very viable option. The same thing happened in Va. When Va. licensed CPMs, tons of CNMs decided to sit for their CPM just so they could attend homebirths and have less restrictions on their practice. That's what happens when you license CPMs but still refuse to change the language in the laws governing APNs to that of "collaboration" instead of "supervision".
From Holly:
From Liz:
And, of course, homebirth advocates are all sweetness and light - as you and Holly have been demonstrating.
Light emanates from my face and shrouds my body in a glow of glory. In the south girls are always taught to be sweet to everyone. You can always talk about them afterward, bless their hearts. Thankfully I'm growing out of that somewhat.
From Holly:
Look, it's like this:
Homebirth= risky behavior (well, sort of)
IV drug use= risky behavior
teen sex= risky behavior
How can we make it SAFER for these populations to do what they are going to do? Well, let's see. Safe needle exchange programs. Handing out condoms like candy to teens in all settings- schools, public health departments, etc. Licensing and training competent midwives- and enough of them to meet the demands of homebirthing women. So we've got the first two. I think every liberal alive is in favor of safe needle exchange programs and condom distribution to teens. What's the issue with # 3?
Of course we could say:
Well those drug users shouldn't be using drugs anyway, so screw them.
Well those teens shouldn't be having sex anyway, so screw them.
Well those women shouldn't be having homebirths anyway so screw them.
But that doesn't solve anything, does it? Having that attitude doesn't stop people from using IV drugs. It doesn't stop teens from having sex. And it doesn't stop women from homebirthing. It doesn't mean we should stop discouraging IV drug use. It doesnt' mean we should stop encouraging abstinence. It doesn't mean Dr. Amy should shut down her site. All it means is, for the people who are going to do those risky behaviors despite the public health measures to reduce those behaviors, what are we going to do for them? How are we going to make it safe for them? And if you ask that question, the honest answer is- train and license midwives. That will make it safer for homebirthing women. Those women have a right to homebirth and they are going to homebirth- and if we care about them and their health, we'll train and license providers sufficient to meet that demand.
From Emma B:
so what would your advice to erin be? have another homebirth?. she had NO RISK FACTORS prior to going into labour.
Yes, this. Had she come to you as a prospective client, what would you have advised her to do for her second child's birth? Try for HBAC, as so many of the homebirth crowd feel is perfectly appropriate?
Because if she'd tried for another homebirth, she would have been facing uterine rupture. Given the facts of the case -- mom stuck in labor at 9.5 cm after 24 hours -- would you have transferred before the bradycardia began to arise? Are you sure you have picked the bradycardia up with intermittent monitoring every 15 minutes? Once the bradycardia began, how confident would you have been that you could transfer and get the baby out in time? Bear in mind that Erin's previous transfer took over half an hour to get from her house to the OR, despite living within easy walking distance of the hospital, and that time was enough for her to go from bradycardia to dead baby.
The reason most of us have so little respect for CPMs isn't because we don't know about their training and experience -- it's because we do. We read their blogs, we see the advice they dispense on MDC, we've looked at their midwifery schools' curricula, and a few of us have even been their clients. By and large, we have come to the conclusion that the standards for the CPM credential aren't high enough; that the training CPMs receive is inadequate to deal with those cases where things do go horribly wrong; and that there are a lot of CPMs and homebirth advocates out there, including well-respected ones, who are really dangerous.
From Caryn:
However, as soon as "Birth is risky" is part of a larger argument for or against an action (in this case homebirth) then it does require some additional work.
*shrug*
The poster in question said, "People believe that birth is safe, therefore legislatures are going to license CPMs." I made the case that regardless of whether or not people believe that birth is safe, birth is not safe, therefore if legislatures license CPMs, they've done something misguided.
If someone wants to show up and make the argument "The best evidence that we have (and here is a link to it) suggests that homebirth with a midwife (with background and backup consisting of X) is just as safe for low-risk women (defined as Y), therefore states should arrange to provide that choice to women", well, then we'll be having a different discussion.
From Caryn:
Homebirth= risky behavior (well, sort of)
IV drug use= risky behavior
teen sex= risky behavior...
What's the issue with [homebirth]?
The state doesn't license a provider to supervise IV drug use or sex between minors.
From Caryn:
But a related question is whether place of birth has any impact on the chance of an emergency occurring. Better outcomes in the event of an emergency doesn't necessarily mean better outcomes overall, if the likelihood of the emergency occurring is related to place of birth.
So we're back to: how many post-op infections equal one dead baby at home?
From JZ:
"so what would your advice to erin be? have another homebirth?. she had NO RISK FACTORS prior to going into labour".
Absolutely NOT, and if there are midwives out there that would encourage that then they shouldn't be a midwife. Any well trained midwife will risk out her clients, if someone has had a previous fetal death, they are no longer low-risk pregnancies and are not candidates for homebirth.
"to successfully perform neonatal resus you need to be doing it regularly, in real situations on real babies not dummies. for example, as a nurse i hasve to keep my CPR up to date and do a refresher every 6 months, in over 10 years of nursing i have NEVER had to resuscitate anyone. in contrast, my friend in an ED does it all the time. in an emergency, who would you rather have resuscitate you?"
But that's the thing, neonates don't need to be regularly resuscitated. So how do you expect everyone to get the real hands on experience you talk about when it just doesn't happen enough?
Like I said before, a good well trained midwife will ALWAYS have her oxygen there and set up ready to go, she will review her neonal resus every month...the midwife I work with goes over in her head EVERY STEP of resus in her car on the way to a birth. In her 8 yrs of being a midwife has NEVER had a baby die because of her 'incompetence' that so many of you claim CPM's have.
In the rural hospital that I work in, it's been literally YEARS since they've had to resus a baby (to the point of intubation) because it's so rare. Neither the docs nor the nurses do it regularly. But we all complete our CPR and NALS as required.
The same could be said for midwives, with more regulation comes assurance that they will have the skills and training required to resus a baby. Actually there is a special cert for resus for out of hospital practitioners (cant remember what it is called). That along with CPR, NALS, etc could all be added requirements to the CPM's credentials if they had more oversight.
From JZ:
And Holly, very well said.
"The state doesn't license a provider to supervise IV drug use or sex between minors"
No they don't but that doesn't mean that women who choose to homebirth should be left to fend for themselves either.
From Emma B:
All it means is, for the people who are going to do those risky behaviors despite the public health measures to reduce those behaviors, what are we going to do for them? How are we going to make it safe for them?
Holly, the problem with the harm-reduction argument is that if you give something enough trappings of safety, more people will choose to do it.
Some women will homebirth no matter what, with non-CPM midwives or by themselves if they have to. Others wouldn't dream of using a "granny midwife", but are persuaded by the good press it's getting -- Ricki Lake made a movie about it! I read Jennifer Block's _Pushed_, and that article in the New York Times! They did a study in the BMJ! My midwife is a licensed CPM, just like the midwife (the CNM) at the OB's office! That depiction of homebirth sounds pretty good to women who want a natural birth to begin with, if you can override their safety concerns.
CPMs may make homebirth midwifery safer than it would be otherwise. However, if you accept that it is still somewhat riskier than hospital birth, the increasing pool of homebirthers may result in a net increase in bad outcomes.
Suppose non-CPMs have a perinatal mortality rate of 5/1000, CPMs' rate is 2/1000, and hospital rate is 1/1000. If you have 1000 dedicated homebirthers and 10,000 natural birth hospital birthers, you will have 15 deaths total -- 5 at home with non-CPMs in the 1000 true believers, and 10 at the hospital in the 10,000. Now say 50% of those hospital NBA group choose homebirth instead, and all homebirths use CPMs. You've now got 2 deaths in the dedicated group, 5 deaths in the hospital group, and 10 deaths in the group who was persuaded to choose homebirth, for a total of 17 deaths. The death rate in the dedicated group has gone down, but the overall death rate has increased by 2.
Obviously, those are made-up numbers used as an illustration, and it's certainly possible the homebirth numbers, if we ever knew them, could result in a net decrease in neonatal mortality. However, the take-home point is that it's not a given that harm reduction does result in a global safety increase.
From Yehudit:
regardless of whether or not people believe that birth is safe, birth is not safe, therefore if legislatures license CPMs, they've done something misguided.
++++++++++++++
Sign all you want, but this blog and this thread contains more than your posts Caryn. The debate over "Birth is safe" vs. "Birth is risky" is wider than the question of licensing of CPMs, and applies to the entire subject of homebirth. It was to this theme that I was addressing my comment, not as a reply to your comment in particular.
I have frequently argued here (with citations - such as the evidence exists) that homebirth, with a qualified midwife and arrangements in place for transfer, appears to be *safe enough* to be a reasonable choice for a woman who is at low risk of complications.
From Caryn:
I have frequently argued here (with citations - such as the evidence exists) that homebirth, with a qualified midwife and arrangements in place for transfer, appears to be *safe enough* to be a reasonable choice for a woman who is at low risk of complications.
And when you've made that argument, people have discussed it. All I'm saying is that the burden of the argument falls on both sides.
From Caryn:
"The state doesn't license a provider to supervise IV drug use or sex between minors"
No they don't but that doesn't mean that women who choose to homebirth should be left to fend for themselves either.
If the analogy is valid (if homebirthing is a risky behavior similar to IV drug use or promiscuous sexual activity) it probably *does* mean that the state has an interest in discouraging the risky behavior, though. Rather than licensing providers to advertise their services for it.
I mean, can you imagine an ad for the licensed drug counselor who'll come around while you're shooting up and help you to do it more safely?
From Yehudit:
But a related question is whether place of birth has any impact on the chance of an emergency occurring. Better outcomes in the event of an emergency doesn't necessarily mean better outcomes overall, if the likelihood of the emergency occurring is related to place of birth.
So we're back to: how many post-op infections equal one dead baby at home?
+++++++++
No, not really. Here's some hypothetical maths:
Suppose a particular obstetric emergency was much more successfully dealt with in hospital than at home. Let's say in the hospital only 15% have a long-term bad outcome, whereas at home that figure is 30%.
Now, suppose the incidence of this particular obstetric emergency is higher at planned hospital birth than planned home birth (all other things being equal) - let's say .9% and .3% respectively.
In this example, there is a big difference in relative risk of a bad outcome *in the event of the emergency occurring* - in fact, you have *double* the risk of bad outcome at home. However, if the *incidence* of that obstetric emergency is lower at home, then the relative risk of having a bad outcome from that cause might favour home birth. In the above hypothetical example, the chance of *any woman/baby* having a bad outcome as a result of this particular obstetric emergency is 50% less for planned home birth.
That is what I meant by "outcomes *in the event of an emergency* doesn't necessarily mean better outcomes overall." To have any force, you must accept the possibility that place of birth may affect the incidence of particular obstetric emergencies.
A real example of this would be from Chamberlain 1994 (last big UK study prior to the ongoing NPEU study). In that study, there was a significance difference in the Apgar scores of babies at 1 minute.
Planned homebirth = 5.2% apgar < 7 at 1 min
Planned hospital birth = 9.3% apgar < 7 at 1 min
This (not surprisingly) relates to the need for resuscitation. Bag and mask used for 5.6% of planned home birth babies compared to 9.1% of planned hospital birth babies.
So it seems incidence can vary depending on place of birth - although the mechanism for that is unclear.
From Caryn:
To have any force, you must accept the possibility that place of birth may affect the incidence of particular obstetric emergencies.
And to accept that possibility we need evidence for it. Which you provide:
A real example of this would be from Chamberlain 1994 (last big UK study prior to the ongoing NPEU study). In that study, there was a significance difference in the Apgar scores of babies at 1 minute.
And surely this leads next to the question: what *causes* that difference? Sure, it's *correlated* to place of birth. But there's no particular reason to think that place of birth is *causal* in this respect, and in fact I doubt you would argue that it's homebirth per se that accounts for the difference if such a difference continues to appear in our data.
You'd more likely argue that there's something different about the approach of the practitioners. And then you'd need to make the case that it was impossible for the difference in the approach of the practitioners to be retained in a hospital setting where the other benefits of a hospital setting were available. And if it's the case that hospital practitioners are making a tradeoff -- lower Apgars in exchange for lowering the risk of a catastrophic outcome or something -- we need to evaluate the benefits of that tradeoff as well as the costs.
From Yehudit:
"And to accept that possibility we need evidence for it."
Actually, no. To accept the possibility of something it need only be plausible. You need evidence to accept that something is in fact the case. That is different.
I'm not saying that home birth is safer than hospital birth (or vice versa). I'm simply outlining a mechanism (lower incidence of emergencies) by which better outcomes in hospital *in the event of an emergency* need not necessarily translate into better outcomes overall. I don't know that this is the case - but it may be one reason why one can have good outcomes for home birth in the UK, notwithstanding the obvious truth of the statement that there are emergencies that are more difficult (or even impossible) to deal with at home.
I don't believe that hospitals as a rule in the UK do unnecessary caesarean sections, instrumental deliveries, augmentation. Very rarely have I seen an intervention of this type that was not necessary at the time the decision was made. Rather there must be something in the management of birth in hospital that is creating the necessity for these interventions at a higher rate than is the case for planned home births (in case-control studies). Birth is complex, and it is difficult to isolate out all the different factors.
As for practitioners, it's clearly not down to training or regulation in the UK case - because hospital midwives and community midwives have the same training and follow the same guidelines. Indeed, there are NHS trusts which have 'integrated midwives' who rotate between hospital labour ward and community on a regular basis (two weeks in/two weeks out) or caseload midwives who do intrapartum care wherever the woman is. I'm not sure the data on the outcomes of these practitioners (who attend both hospital and home births) has ever been looked at.
Whatever the causal mechanism, I can assure you that hospital practitioners are not consciously making a trade-off between lower apgar rates as a consequence of some other beneficial intervention.
From Holly:
We're not talking about supervisors. We're talking about an intervention to make the action safer. An intervention. The intervention in the IV drug users is safe needles. The intervention in the teen sex equation is condoms. The intervention in the homebirth situation is a midwife. Interventions specific to the action. Safe needles aren't going to help the homebirther just like a midwife isn't going to help the drug user. So, it's ridiculous to assume that the same intervention (a "supervisor") is going to be provide the same level of safety for every action. We're talking about an intervention that would make the action safer. Different interventions for different actions. Maybe I'm knee deep in nursing process here, but you're not going to perform the same nursing interventions for "knowledge deficit" as you're going to do for "acute pain". In order for an intervention to be valid, it doesn't have to necessarily apply to all nursing diagnosis', only the one that the intervention is specific for.
From Holly:
Besides the government is not going to license supervisors for iv drug users because iv drug use is illegal. The state would literally be helping you commit a crime, not just make the action safer. However having a baby at home IS NOT ILLEGAL, and therefore by licensing "supervisors" the state would not be aiding you in committing a crime, but would only be making the action safer. Teens having sex is also not illegal and in fact the state does regulate teen sex education within our public school system so while these sex educators are not present at the moment of intercourse they are supervisors in that they teach kids how to have sex safely and equip them to reduce the risk when they happen to engage in sex.
From JZ:
"This (not surprisingly) relates to the need for resuscitation. Bag and mask used for 5.6% of planned home birth babies compared to 9.1% of planned hospital birth babies".
These rates could be attributed to 'pain magagement' during labor (epidural, narcotics, etc.) which are highly used in hospitals which can cause respiratory depression as compared to no artificial pain management in homebirths = less respiratory complications and less of a need to bag and mask. Which leads me to...
" And surely this leads next to the question: what *causes* that difference? Sure, it's *correlated* to place of birth. But there's no particular reason to think that place of birth is *causal* in this respect, and in fact I doubt you would argue that it's homebirth per se that accounts for the difference if such a difference continues to appear in our data."
It MOST definitely CAN be attributed to place of birth since midwives do not use narcotics and epidurals for pain control.
From Yehudit:
You are right that patterns of analgesia use are different at home than in hospital, and this may be part of the explanation.
You are wrong that midwives do not use narcotics and epidurals for pain control?
Midwives in hospital do manage epidurals (of course, they don't site them). Midwives at home births can administer opioids (usually pethidine, though I guess meptid, diamorphine too) - though it is not widely used. Entonox is a regular feature of homebirths in the UK.
From Yehudit:
JZ, you are making Caryn's point for her. If it is the fact that *midwives* do not *use narcotics* for pain relief that accounts for the difference, then place of birth is beside the point.
In any case, women can always transfer for the purpose of pain relief (at least they can in the UK), so the mechanism for lower analgesia use may be more complex, and may actually be to do to with place of birth directly. (e.g. if women are more able to do without analgesia in a familiar environment).
This is all speculation. But note that no RCT ever tells you the causal mechanism, only that there is a correlation that could not plausibly occur by chance.
From Alexis:
IIRC, CNMs in hospital have a lower rate of epidural use than OBs, but this is also a self-selection issue (patients wanting an unmedicated birth are more likely to seek out CNM care). Even with home birth, this is a huge issue--a woman who thinks she's likely to want an epidural simply won't choose to birth at home. There are multiple factors at play here.
From Yehudit:
Now, there is something that you could randomize pretty easily. Low-risk women for CNM or OB care within the same hospital. Has that been done?
From Caryn:
Actually, no. To accept the possibility of something it need only be plausible. You need evidence to accept that something is in fact the case. That is different.
We're using slightly different definitions here, actually. I would say that plausibility is a scale that slides with evidence and a good argument, but that even entirely implausible things are still possible. Just really, really unlikely. Logically impossible things are not still possible. But things that we accept as true today we may not accept as in fact the case tomorrow, if our evidence or our argument changes (see Newton vs. Einstein.)
Rather there must be something in the management of birth in hospital that is creating the necessity for these interventions at a higher rate than is the case for planned home births (in case-control studies). Birth is complex, and it is difficult to isolate out all the different factors.
It *might* be the case that management in hospital creates a necessity, or that might have been an artifact of methodology or population in that particular study, but surely we can go check. I think it's easy to confuse a single-etiology theory of causation for a single-etiology methodology, you know? We can determine whether that cause *or set of causes* is correlated; we don't just have to say, oh well, must be place of birth.
From Caryn:
We're talking about an intervention to make the action safer. An intervention.
An intervention necessarily attached to a conscious agent who's making judgement calls.
However having a baby at home IS NOT ILLEGAL, and therefore by licensing "supervisors" the state would not be aiding you in committing a crime, but would only be making the action safer.
Consensual promiscuous sex isn't illegal either; can you imagine the state licensing individuals to come 'round and help you put the condoms on first?
From Liz:
Yehudit, you have the training and experience to speak with an authority that I lack, but I do sometimes find your logic a bit less than convincing.
“you must accept the possibility that place of birth may affect the incidence of particular obstetric emergencies”
Which ones? It seems to me that what is implied here is your acceptance of the proposition that labour is likely to be safer and less problematic if a woman is happy and at ease in her own home – or at least in the care of a midwife not one of those nasty, interfering, uncaring OBs. And as this is in essence the central tenet of NCB, some of us remain to be convinced..
“To accept the possibility of something it need only be plausible”
Taken literally, this is true. But the assumption that if something seems likely it is OK to use it as the basis for a whole series of assumptions seems to me unwise in the extreme – but it is an increasingly prevalent approach. The one that makes the Brewer Diet so popular, perhaps?
“I'm simply outlining a mechanism (lower incidence of emergencies) by which better outcomes in 2hospital *in the event of an emergency* need not necessarily translate into better outcomes overall.”
Before you can get much further with this, you would have to define a bit more precisely what is meant here by “emergency”. It seems to me that this is a form of logic chopping that can be used because of a lack of clarity. Is haemorrhage or shoulder distocia less likely at home? Or simply less frequent because of the smaller numbers?
“Rather there must be something in the management of birth in hospital that is creating the necessity for these interventions at a higher rate than is the case for planned home births (in case-control studies).
Again, define which interventions. You are of course more likely to find yourself having a precautionary CS, but again, some of us are reluctant to accept that is necessarily the worst option.
It seems to me that there is a constant blurring of the distinction between a “natural” birth, and an easy, straightforward unproblematic birth, as if the desire for one can guarantee the other. The first may be more likely at home, or more easily achieved at home (remove yourself from the possibility of an epidural, and you are less likely to succumb
but I see no reason why place of birth should affect the second. Skimming on MDC, it isn’t difficult to come across descriptions of births that are “natural” in the sense of no interventions, but are not exactly easy. On MDC of course, the outcome is always triumphant. The labour may have have been protracted and painful, the baby may or may not be born in optimum condition – it was “natural” and that trumps everything.
From Yehudit:
Fair enough, Caryn (on plausibility).
I'm trying to address Liz's line of argument that "the risk in homebirth is that even the most skilled and careful of providers cannot deal with an emergency as easily." However we can't a priori assume that the incidence of emergencies is the same everywhere. And we certainly can't assume it given the evidence on the differing rates of necessary interventions according to planned place of birth - including emergency interventions such as neonatal resuscitation.
From Caryn:
However we can't a priori assume that the incidence of emergencies is the same everywhere.
*A priori* and *assume* are incompatible terms. A priori is a term referring to knowledge you can have about the world. Assumptions aren't knowledge.
Besides, you can't know *anything* about the world a priori, which is why we do empirical, a posteriori, science. Part of the scientific method is that you propose the most general hypothesis possible and revise the hypothesis in the face of empirical evidence suggesting a less general hypothesis is more likely to be true.
The assumption that emergencies related to pregnancy doesn't vary with location per se is the most reasonable hypothesis to propose in the absence of a reason to think that populations differ in a meaningful way just because of their location in space.
And we certainly can't assume it given the evidence on the differing rates of necessary interventions according to planned place of birth - including emergency interventions such as neonatal resuscitation.
So far, you've provided one fifteen year old study. That's insufficient to convince me to revise my belief that pregnant women are going to experience roughly the same rates of complications related to pregnancy and modifiable by things like malaria nets, tetanus vax, and provider skillset, because all the other studies into this show that the big changes in maternal and neonatal mortality worldwide have come with introduction of modifications like that, not modifications like relocating a woman from her home to the hospital per se. It's not location, it's what *happens* in that location.
I would say that if we have good reason to think that homebirths have lower rates of complications, that there's no good reason to hypothesize that that's *just because they're taking place at home.* It's because of something about the care provider, or something about the care provided, or the characteristics *of* those different locations, and so forth.
Presumably homebirthing advocates think that too. They think it's being attended by a provider who doesn't overreact, or feeling comfortable in one's surroundings, or having surroundings that are uncontaminated by foreign germs, or whatever. (No, I am not endorsing any of those.) The question is: what is it *about* being at home that you believe provides this benefit, and how will you find out whether or not you're right?
(And no, it is not just too complex to test under the biomedical model so we just have to throw up our hands and accept holistic care; we test multivariable stuff all the time. That's why all the preeclampsia research these days uses the word "multifactorial". Specify a hypothesis -- however complex it might be -- and then test it. If the purported benefit of being at home is something that results from the confluence of 15 different factors, fine; let's go test that hypothesis.)
And why in the world should any legislature act on the vague grounding we've got here so far given that it's contradicted by everything else we know about how to lower maternal and neonatal mortality?
From Yehudit:
I would say that if we have good reason to think that homebirths have lower rates of complications, that there's no good reason to hypothesize that that's *just because they're taking place at home.* It's because of something about the care provider, or something about the care provided, or the characteristics *of* those different locations, and so forth.
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The differences in rates of interventions (which, given that interventions are responses to complications large and small are a reasonable surrogate for complications) are there in every study.
It may not be the location per se, but the care provided in those locations, characteristics of those different locations etc... However, if we want a study to tell us about the real world (effectiveness as well as efficacy) we may have accept that the characteristics of different locations are not easily divorced from the location itself. For example, one of the characteristics of hospital care is the need for the labour ward to manage several patients, manage the space occupancy, manage the throughput. Obviously, a home birth service has to manage the labours of women in community, but the pressures are different. That has consequences for diagnosis of labour onset, for care received by women in latent labour, for when epidurals are recommended or not and a whole host of other decisions relating to a woman's labour progress. I'm not sure how you unpick all of that from the location.
From Caryn:
The differences in rates of interventions (which, given that interventions are responses to complications large and small are a reasonable surrogate for complications) are there in every study.
No, they aren't in every study; I have not seen, for example, a study showing that interventions for malaria are lower at home. Or a study showing lower rate of interventions for tetanus at home. The studies do show a clear correlation between use of a malaria net or tetanus vax and lower rate of interventions for those complications, though.
Besides, surely this is confounded by the availability of the interventions. What if all that we're seeing here is that the midwife can't, or won't (out of principle rather than prudence) intervene?
It's true enough that it might be hard enough to separate out all of that stuff, but not every home is the same, either. Why not compare different kinds of homebirths? Some might have no positive net effect on intervention rate, and some of them might. Some of them, for example, are closer to a hospital for a shorter transfer time. Might that not affect the likelihood that interventions are used?
What I'm getting at here is, sure: it's hard. That doesn't absolve the obligation to do it.
From Yehudit:
The assumption that emergencies related to pregnancy doesn't vary with location per se is the most reasonable hypothesis to propose in the absence of a reason to think that populations differ in a meaningful way just because of their location in space.
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Why would you think that though? To take just one counter example: hospital location requires making a judgment about when to get to the hospital. Many women attend the hospital not yet in active labour, and do not wish to return home having made the effort of coming into the hospital. There is a pressure to diagnose labour onset. A woman booked for a homebirth may call out a midwife when not yet in active labour, but the midwife will not stay. This small difference, which seems to me to be inextricably linked to location, would go some way to explaining higher augmentation rates in hospital.
From Yehudit:
That doesn't absolve the obligation to do it.
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I agree, and the obligation is on every 'side' in the debate, since there is lack of evidence on place of birth (and not just on homebirth).
From holly:
Consensual promiscuous sex isn't illegal either; can you imagine the state licensing individuals to come 'round and help you put the condoms on first?
| 03.12.09 - 6:29 pm | #
Might not be a bad idea in some population groups.
From Caryn:
Why would you think that though?
Because the molecular mechanisms underpinning pregnancy complications don't care where you are.
This small difference, which seems to me to be inextricably linked to location, would go some way to explaining higher augmentation rates in hospital.
But again, that doesn't associate higher rates of complications with place of birth. That associates higher rates of complications with particular actions on the part of the care provider under unspecified "pressure to diagnose labor onset" -- pressure by the mother? pressure by the insurance company? pressure from what source and how do we eliminate the source of the pressure to ensure evidence-based practice? Place of birth is again aside the point and the question becomes rate of use of particular interventions.
From Yehudit:
Pressure arising from the fact that she doesn't want to return home having made the journey into hospital, that there is a bit of magical thinking going on (if she is admitted she will, ta da, be in established labour) and so the midwife wants to do something for her, to accommodate her needs. Now, we can change that culture to some extent, and better antenatal education to prepare women for latent labour. But the desire to stay in the hospital when not in established labour is certainly connected to the very fact of going to the hospital and not wanting to make the journey home again.
The molecules argument would work if birth complications only took place at a molecular or cellular level. However, there is also a mechanical and a social component to birth complications that you are ignoring.
We can imagine ideal hospital environments as we would like them to be. (And indeed, ideal home environments as we would like them to be). But fair tests have to compare actual planned home births with actual planned hospital births.
From Caryn:
The molecules argument would work if birth complications only took place at a molecular or cellular level. However, there is also a mechanical and a social component to birth complications that you are ignoring.
No, I'm explicitly *not* ignoring it. I'm saying that insofar as a difference in the behavior of a care provider can be implicated in a particular complication, *that* is evidence-based.
So we'd need some evidence, not just oh, there are social and mechanical factors so homebirths are okay.
There are *lots* of social and mechanical factors. The question is not whether or not they exist, but whether or not they're actually implicated in any change in rate of complications, or they're just correlated, and if they're implicated, whether or not we can change them without introducing other complications.
The stats from the CDC Wonder database on neonatal death rate for OBs, CNMs, and DEMs sure suggest that homebirth per se isn't protective of anything at all.
From Yehudit:
The stats from the CDC Wonder database on neonatal death rate for OBs, CNMs, and DEMs sure suggest that homebirth per se isn't protective of anything at all.
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I know you know why the CDC Wonder database can't really be used for the purpose you are using it.
Which is not to say that fair tests would not demonstrate that homebirth isn't protective - they might well. They are difficult to do (as we have seen from discussions here), but as you've said - it doesn't absolve the obligation.
I'm not just approaching this from a homebirth perspective, but from an evidence-based perspective. And studies that compare outpatient treatment or community-based treatment vs hospitalization are done all the time. The molecules do not have to behave differently in order to believe that place of birth makes a difference.
Indeed, that is the very claim FOR hospitalization - that being in the hospital gives access to help in emergencies thus improving outcomes overall. That is the claim that has not really been tested. Archie Cochrane was pretty scathing that the opportunity to randomise place of birth had not been taken before committing the UK to a policy of 100% hospitalization of birth. He was not particularly concerned with birth at all. He would have been equally scathing about any activity previously taking place in community settings that then was hospitalized without fair tests.
When you say "So we'd need some evidence, not just oh, there are social and mechanical factors so homebirths are okay" you misrepresent me, because I do believe that evidence is needed (and have said so often).
From Liz:
I have found this last exchange quite fascinating and revealing. Arguments on here are, appropriately, generally based on disputed facts, statistics and approaches. Being, as I have said, an “outsider” in several ways – I am not involved in health care, have no advanced training in science and being past my child bearing years have no strong personal involvement. What I do have is an ability to focus on language, and an interest in logical thinking. And what has caught my interest here, and often does because it irritates me a lot, is the use of the word “interventions”. What is annoying to me is the way this word is used in a largely negative sense. Certainly, in places like MDC it is a very loaded emotive word. Do not go to the hospital! They intervene! Possible translation: interfere with a perfectly natural process that would otherwise proceed perfectly. Well, let’s try another word or expression: take precautionary, protective measures which may avert or avoid serious problems. These measures may be unpleasant and unwelcome as things which put paid to a dream of a “natural” birth; they may on occasions be used unnecessarily, but the only important question that needs to be answered is do they cause harm or damage in themselves? What are these loathed interventions? IV, monitoring, epidural? Certainly, induction and its methods is unpopular – but is it dangerous?
Yehudit refers to “magical thinking” and the set procedures in hospital. Certainly, I would accept that unimaginative rigidity can be a problem in hospital births. I just can’t see that cutting oneself off from medical care entirely in the optimistic belief that you won’t need it is the answer to that problem.
The discussion then shifts to the “mechanical and social” component of childbirth. As this is to some extent the crux of the NCB argument – that one’s psychological state has a powerful effect on outcome – I would be interested in hard – really hard – evidence in support of this. Yehudit’s claim that the behaviour of the care provide can influence outcome seems to me, to put it mildly, very suspect. That women are more “satisfied” with a patient and caring provider is hardly the same as saying she is safer and an argument that homebirth is “protective” frankly, preposterous.
I would not for a moment dispute that a women’s feelings are important. Childbirth does have a powerful effect on a woman’s psyche. If this were an argument about whether midwife care, homebirth was “nicer” then the NCB position would win hands down. But it isn’t. Life isn’t always nice. Disapointments and psychological traumas have to be dealt with in all but the most charmed life. Few of them are in the same league as a dead or damaged mother or baby. Argue from “nice” and I would be the first to agree that hospitals are a problem, and a problem that could and should be dealt with. Brainwash even a small number of women into buying the proposition that homebirth is protective, and you do them a great disservice. A core of women will always choose it, and it should be made as safe as is possible (which, in my opinion of course, is not very) But let them be very clear on what they are choosing.
From Yehudit:
Just to point out, I use the word "intervention" in a purely technical sense. An intervention is simply the "it" in the sentence "Does IT work?".
"Intervention" includes the Brewer diet, smoking cessation advice, evening primrose oil for cervical ripening, nipple stimulation for induction or caesarean section for breech - and basically anything else that we might do. Routine antenatal care is an intervention. The same questions apply to all of them: What is the effect of this intervention? Does it do what we hope it will do? Does it have any unwelcome side-effects? Does it work? Does it do more good than harm?
In the case of instrumental deliveries and caesarean sections, we don't do these things for fun. We do them when indicated, for particular complications of labour. Therefore, if case-control studies show that these interventions were required more often in the hospital group than in the home birth group it is reasonable to take the higher rate of interventions as a surrogate measure for higher rates of complications indicating the need for these interventions.
From Yehudit:
I just can’t see that cutting oneself off from medical care entirely in the optimistic belief that you won’t need it is the answer to that problem.
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I don't suggest that it is. I simply give an example of magical thinking operating in a hospital environment. It is particularly noticeable in relation to labour onset and admission to the labour ward.
From Liz:
To clarify even further: often, on here, there will be a poster who starts of arguing a coherent case for homebirth. Believe it or not, I read these with interest. If not exactly ready to be convinced, I am open to an argument that would convince me it is not an unwise choice. I can, easily, see its appeal - that is part of the problem. What woman would not prefer to feel safe and comfortable in her own environment, surrounded by love and care, far away from the unfamiliar terrors of hospitals and their often insensitive, uncaring workers? A "good" homebirth IS an ideal, a dream birth. So I start to be seduced - and then the poster frequently goes on to explain the lengths they have gone to "inform" themselves - from sources that lie and distort. They don't want their pristine infant "drugged" by epidural, their labour slowed down by monitoring, they can always transfer to the hospital a mere half an hour away, and I realise sadly that the safety of homebirth is a chimera, a dream with not much basis in reality. Fortunately, most births will not go wrong. So maybe it is a gamble worth taking, for some. Most of these posters end up by saying they "take responsibility" for their choice - and I am sure they do, in a way. It still seems to rest mainly on "It can't happen to me".
From Yehudit:
As this is to some extent the crux of the NCB argument – that one’s psychological state has a powerful effect on outcome – I would be interested in hard – really hard – evidence in support of this.
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That's not what I'm talking about when I say there is a mechanical and social component as well as a molecular and cellular one.
By social I am really referring to the entire context of how we organize maternity services, including who does what, the training, the management of labour wards, antenatal care, management of individual cases. There is potential for both benefit and harm in all of that.
From Liz:
Yehudit, a lot of the better arguments for homebirth stem from the fact that hospital care can be awful, and those are hard to dispute. But I get exasperated by a strand that says hospitals have their problems, so the answer is to stay away from them. In my opinion, the energy that goes into defending HB would be better spent on improving hospitals. Women do have the power to change things and a noisy and vociferous campaign could make a difference.
Let us look at why women turn up at the hospital early: it isn't always that easy for a women to be sure when her labour is established, and for the majority they will turn up too soon because they absolutely do not want to take the chance of running into trouble at home. If the hospital then "starts the clock" and (which I think is what you imply) pushes those dreaded interventions for "failure to progress" than that is simply unintelligent care, and not exactly hard to deal with.
From Yehudit:
I realise sadly that the safety of homebirth is a chimera, a dream with not much basis in reality
+++++++++++++++
I don't think we have the evidence to say.
It is not logical to say:
A) claims about effects of epidurals on babies etc...are false or exaggerated, therefore
B) homebirth is unsafe.
I share you frustration at the misrepresentation of various interventions (see my many comments on misoprostol up thread). That misrepresentation is not all on one 'side' though.
For everyone who says that continuous monitoring slows down labour (no evidence to suggest that this is the case) there is someone else saying that continuous monitoring reduces perinatal mortality (no evidence to suggest this is the case).
From Caryn:
Indeed, that is the very claim FOR hospitalization - that being in the hospital gives access to help in emergencies thus improving outcomes overall. That is the claim that has not really been tested.
Sure it has. You can't do a Caesarean at home; nearly all of the placenta previas need Caesareans. Removing those placenta previas from the category of "dead" improves outcomes overall.
Same goes for any number of other conditions, particularly prophylactic Caesarean for obstructed labor, prophylactic Caesarean for preeclamptics too symptomatic for induction, a theatre to manage accreta...
The null hypothesis had already been ruled out by the time the UK moved to a 100% hospitalization policy.
In the case of instrumental deliveries and caesarean sections, we don't do these things for fun. We do them when indicated, for particular complications of labour. Therefore, if case-control studies show that these interventions were required more often in the hospital group than in the home birth group it is reasonable to take the higher rate of interventions as a surrogate measure for higher rates of complications indicating the need for these interventions.
Only if the monitoring at home was entirely identical to the monitoring in the hospital, and so indications for intervention were picked up at the same rate.
From Yehudit:
If the hospital then "starts the clock" and (which I think is what you imply) pushes those dreaded interventions for "failure to progress" than that is simply unintelligent care, and not exactly hard to deal with.
+++++++++
You say it is "not exactly hard to deal with" - so I can only encourage a woman of your talents to do the NHS fastrack management course and help to sort out some of these practical issues.
In my experience, it is actually extremely hard to deal with for a number of quite intractable cultural, logistical and economic reasons.
We don't have enough antenatal education, and it's not clear that women want to take on board what is said in NHS antenatal classes about early labour.
Choice in the NHS means that women can come to a hospital from quite a large geographical area. (This is perhaps less of a problem in a high density area like London). The consequence is that you have women from out of area have travelled for an hour to get to the hospital, and it is less easy to send such women home - because she might well be in labour 90 minutes hence.
We also don't have anywhere suitable for women in early labour to be. The labour ward is for women in active labour - and the management of the ward depends on not filling all the rooms with women who in early labour who may stay there for who knows how long. The antenatal ward is for women who have a medical reason for antenatal admission (pre-eclampsia, placenta praevia etc...). It is not fair on those women - some of them long-stay inpatients - to mix them with early labourers moaning and groaning through the night. Women in early labour are not receiving any kind of care from us (for instance, we are not doing intermittent fetal monitoring).
One of the solutions is to diagnose active labour as soon as you have the first justification for doing so - she gets a room, she gets care. She might be only *just* 3 cms dilated with irregular and/or infrequent contractions. But it is easier than making the decision to send her home. The problem comes four hours later when she isn't 'doing anything' and the midwife then has to argue the case that that, retrospectively, she probably wasn't in active labour. The pressure to 'get things going' is built in to the high volume of maternity hospitals.
It's just an example of the practical realities that are not that easy to fix. While we're at it: can you tell me how we are ever going to reduce the use valsalva pushing, which should also be pretty easy to deal with....
From Yehudit:
The null hypothesis had already been ruled out by the time the UK moved to a 100% hospitalization policy.
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But no one has ever suggested that the alternatives are between 0% and 100% hospitalization. The alternatives are between 100% and < 100% hospitalization based on criteria of being at relatively low-risk for complications at the onset of labour. And of course planned home birth includes the possibility of transfer - and does not demand that you eschew hospital in the event of retained placenta or indications that labour may be obstructed (in fact, triggers for transfer would come long before that point, when labour first became prolonged).
In the UK, monitoring at home for low-risk women IS entirely identical to the monitoring in the hospital.
We use the same partogram (which is essentially your monitoring tool for prolonged labour) and do maternal observations with the same frequency as in the hospital. The same is true of fetal monitoring - same technology, same frequency. We also have the same indications for transfer that would transfer out of 'midwifery-led care' in the hospital.
From Caryn:
Yehudit, how is that not precisely "hospitals have their problems, therefore it is best to stay away from them"?
From Caryn:
The alternatives are between 100% and < 100% hospitalization based on criteria of being at relatively low-risk for complications at the onset of labour.
But critically, we *know* that being in the hospital provides access to interventions that improve outcomes in emergencies. What you're suggesting is that we have reason to think some women won't need that access.
So this isn't in any way a problem with failure to test the hospital as a venue appropriately.
From Yehudit:
How is *what* not precisely "hospitals have their problems, therefore it is best to stay away from them"? I don't know whether it is "best" for woman in spontaneous labour at low-risk of complications at labour onset to stay away from hospitals or not. I don't think you know either.
Hospitals do have their problems, and we urgently need to fix them. In particular, because there are large numbers of women for whom hospital are the best place to be and for whom home birth is clearly not a reasonable option.
From Yehudit:
What you're suggesting is that we have reason to think some women won't need that access.
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I'm suggesting that you can anticipate certain kinds of emergencies, including the ones you mention. Since home birth midwives use partograms and transfer for prolonged labour, your example of obstructed labour doesn't make sense. Similarly, if the placenta is retained (as it would be with placenta accreta) that is an indication for transfer. If a pre-eclamptic has already been assessed as unfit for induction, that suggests a pre-labour diagnosis - and then of course home birth would be inappropriate. (We don't do inductions at home either!). Women with placenta praevia will either have this picked up on scan (most likely) or will have some PV frank blood loss that prompts investigation of placental site. If picked up on scan, a woman with Grade IV placenta praevia will most likely be an antenatal inpatient (unless she declines care) for some weeks before having an elective (i.e. planned) caesarean section. So, in her case - we don't just recommend prophylactic CS, we recommend inpatient admission at the end of pregnancy.
The logic of your argument is that ALL women should be offered inpatient admission between viability and the end of pregnancy because we can't predict who is going to have an antepartum haemorrhage, a cord prolapse or any of the other antenatal emergencies where being in the hospital might make the difference.
To take an example, a woman came to the scan department to assess liquor volume following Preterm Prelabour Rupture of Membranes (PPROM) and ?reduced fetal movements. She had a cord prolapse in the scan department and came directly on a bed to theatre. The prompt actions of everyone involved saved that baby's life. Had she not been in the hospital (and particularly, a hospital with a NICU) at the time of the cord prolapse, in all probability the baby would have died. Indeed, not that long before, a woman did call in the labour ward in early labour reporting feeling "something" in her vagina and that baby did not survive, despite immediate telephone advice and despatch of an ambulance.
Is the moral of this story that every woman should be hospitalized from, say, 26 weeks?
From Caryn:
The logic of your argument is that ALL women should be offered inpatient admission between viability and the end of pregnancy because we can't predict who is going to have an antepartum haemorrhage, a cord prolapse or any of the other antenatal emergencies where being in the hospital might make the difference.
No. I am saying that whether or not the hospital is a better environment in which to have an emergency is not in question. You said Indeed, that is the very claim FOR hospitalization - that being in the hospital gives access to help in emergencies thus improving outcomes overall. That is the claim that has not really been tested.
So, we *know* that the hospital is a better environment in which to have an emergency.
What policies do we, as a culture or a state, want to put into place given that information? Different question.
From Yehudit:
It's the *thus improving outcomes overall* that has not been tested.
From Caryn:
It's the *thus improving outcomes overall* that has not been tested.
The outcomes for the whole population are better, and that's what the phrase *means*. The outcomes for the whole population are improved.
From Liz:
Actually, Yehudit, I wouldn't dispute that change is difficult to accomplish in large organisations with rigid structures, lots of vested interests and problems caused by lack of money. My point is that to some extent change is more likely from the pressure of public opinion than chipping away from the inside - which is slow, and often doomed to failure. My view, however, is that an enthusiasm for NCB, homebirth and so on plays into the hands of those who do not want to change the status quo. It is a distraction from the real problems. It is unfortunately true that bad things happen in hospitals, and some of them come from the same mind-set that says birth is now safe, warning signs can be ignored because most of the time, birth is straightforward.
To take your example above: fetal monitoring. Putting aside the meaning of "no evidence" there is a difference in these two findings. Those who have faith in hip swaying as a method of improving outcomes dislike having movement restricted. Is that a valid reason for avoiding monitoring? Or should there be more and better research on the role of gravity, more attempts to convince? You say there is firm evidence that it has no effect on labour. This is then countered by : but there is no evidence that it improves outcomes, either. Comparing apples and oranges. It may have no effect on the vast majority of women whose babies are coping well - it sure as hell has some effect on those who are in trouble. If CTG traces are hard to interpret, then get better at the interpreting, don't throw out the baby with the bathwater, so to speak. Supreme confidence that belly dancing is effective really needs to be deconstructed, not reinforced.
I do know that there huge and intractable problems that don't allow for easy answers. But I do sometimes think that the wrong questions are being asked.
From Yehudit:
The outcomes for the whole population are better, and that's what the phrase *means*. The outcomes for the whole population are improved.
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The contribution of hospitalization to that has never been tested. As you know, correlation is not causation. As Archie Cochrane wrote way back when, "It is instructive to recast [the Peel Committee's table] relating maternal and perinatal morality to mean length of stay in hospital. One could as wrongly or rightly conclude from this that the shorter the stay the lower the mortality, as that the higher the hospitalization the lower the mortality".
From Yehudit:
If CTG traces are hard to interpret, then get better at the interpreting, don't throw out the baby with the bathwater, so to speak.
+++++++++
The problem is not that CTG traces are hard to interpret. (Well, sometimes they can be - is it a high baseline with decels, or lower baseline with tons of accelerations? - but that is not the usual problem). The problem is that CTG has a very low specificity (as previously discussed ad infinitum) and that in a population that is unlikely to be having problems, the chance of a false positive is much higher than in a population already at risk. That is why CTG is the norm where there is a known risk factor (for example, if the mother has a raised temperature possibly indicative of infection, or the there is meconium-stained liquor, or some other cause for concern). And why we use intermittent monitoring in the absence of a known risk factor, of course changing to continuous monitoring if a risk factor develops in labour (including hearing decelerations on intermittent monitoring).
Continuous monitoring doesn't have to restrict the mobility of the woman - it depends a lot on the willingness of the midwife to facilitate what the woman wants to do in labour, notwithstanding any attachments. In fact, that's another bug bear of mine - women being told that having these attachments means they will have to be immobile.
From Susanne:
"The problem is that CTG has a very low specificity (as previously discussed ad infinitum) and that in a population that is unlikely to be having problems, the chance of a false positive is much higher than in a population already at risk."
That's only a problem if you think that the consequence of a high false positive rate (too many CS, etc.) is worse than the sequelae of a high false negative rate (a baby that was in trouble could have been saved, but is "missed"). Most people seem to feel that a missed false negative is a worse outcome, but hey, feel free to prioritize it differently.
From Susanne:
Yehudit: "I'm suggesting that you can anticipate certain kinds of emergencies, including the ones you mention. Since home birth midwives use partograms and transfer for prolonged labour, your example of obstructed labour doesn't make sense. Similarly, if the placenta is retained (as it would be with placenta accreta) that is an indication for transfer. (snip) Women with placenta praevia will either have this picked up on scan (most likely) or will have some PV frank blood loss that prompts investigation of placental site."
Maybe in the UK. THIS WON"T HAPPEN with DEM's / CPM's in the US who adhere to a smooshy-birth-is-perfect model.
From Yehudit:
That's only a problem if you think that the consequence of a high false positive rate (too many CS, etc.) is worse than the sequelae of a high false negative rate (a baby that was in trouble could have been saved, but is "missed"). Most people seem to feel that a missed false negative is a worse outcome, but hey, feel free to prioritize it differently.
+++++++++
That argument would have more traction if routine CTG monitoring did actually reduce neonatal mortality/long-term morbidity.
From Liz:
In fact, that's another bug bear of mine - women being told that having these attachments means they will have to be immobile.
Yehudit, a point of agreement! Yes, the kind of system that forces certain things on women "because that's the way we do it" is unacceptable.
From Liz:
That argument would have more traction if routine CTG monitoring did actually reduce neonatal mortality/long-term morbidity.
And here is where statistical studies come into collision with common sense. Are you saying (and can you prove) that monitoring that picks up a distressed baby in time to do something about it is worthless? I will concede it may lead to more CS, which may be unwelcome to some, but is a minor complication of surgery being given the same weight as a stillborn baby?
From Yehudit:
What I'm saying is that the studies to date do not show that routine CTG in low-risk cases improves neonatal outcomes. We don't know quite why that is, because it seems intuitively obvious that increased information should lead to better outcomes. That was clearly the intention of the technology. But it hasn't done what it set out to do. If you want the stats and scholarly discussion, the place to go is:
http://mrw.interscience.wiley.co...066/
pdf_fs.html
From Elizabeth:
She might be only *just* 3 cms dilated with irregular and/or infrequent contractions.
That was exactly my state when the DEM showed up to my house, about 22 hours after I began to have painful labor. When we transferred to the hospital another 23 or 24 hours later, I was 5 cm with contractions still highly irregular (and obviously ineffective) yet still frequent and painful enough that I was blacking out between them and screaming like the banshee during.
So, by your logic... almost halfway through my labor; after I had already been suffering for longer than it takes most women to deliver, just to make it to those 3 cm; in overwhelming subjective distress; I should still have been ineligible for hospital care? I would have been better off at home alone, without even the DEM, because my labor wasn't going well? How long should the hospital staff have continued to put off this hypothetical me, who did the sane thing and went directly to them for help instead of staying home with a granny DEM?
Because the costs and dangers of induction/augmentation are really that great? (Great enough to outweigh the physical and mental state I ended up in after such a prolonged ordeal? Who decides?)
Or because you have an axe to grind about concepts of intervention and normalcy?
Underneath all your fancy talk (at least 4/5ths of which, minus your prejudicial hand-waving, actually gives points to the other side!), you're not so different from the stupidest of MDCers: there's no such thing as failure to progress, just failure to wait! And women whose bodies don't birth well can eat Darwinian cake!
So you don't give two shits about all your countrywomen who died for lack of surgical care in the period before universal hospitalization. That's your prerogative - but you're going to need a better argument for why we should follow suit than this cheap reductio ad absurdum "but what?! we should just hospitalize everybody??!!" That begs the question; you're the one who has to argue that hospitalization is a wildly undesireable last resort. As modern medicine continues to chip away at the selective pressures around childbirth, there are only going to be more and more and more marginal cases who can only get through it with significant intervention, including longer and earlier hospitalization. It's not inconceivable that before the end of your working life you may actually see conditions approaching your absurd nightmare scenarios. Which only qualify as nightmares as a matter of your personal taste (opportunistically hitched to NHS penny-pinching, of course). What will you do then?
From Yehudit:
Wow! Well, I suppose there is no point in engaging with that diatribe.
From Elizabeth:
Right, because the actual experiences of women who would end up on the wrong side of your cost-benefit calculus are beneath notice.
Still, though: what's a woman who's already obviously having a bad time of it at 3 cm, despite no evidence of fetal distress, supposed to do? Other than suffer in solitude at home, hoping you were right to send her away? If her baby goes south, will she take comfort in the fact that at least she wasn't among the complications that perhaps could have resulted from augmentation and analgesia if you had done it?
From Yehudit:
No. Because I don't expect to be abused for expressing a view that is pretty much normative across the board in maternity care - which is that admission to labour ward is generally not advisable for women who are not in established labour.
I also don't personally have the facilities to create the appropriate facility in my own hospital for women who might benefit from being admitted before they are in active labour.
From Elizabeth:
Really, that's funny because when I finally showed up at the hospital over here I was admitted and augmented right away.
If a woman who isn't progressing well doesn't qualify for care, how is that anything but exactly equivalent to defining failure to progress out of existence, just as the NCBers would like?
But then isn't it the NCBers themselves who are complaining about mistreatment because they don't meet some medpro's narrow definition of normal?
How good at birthing does a woman have to be before she merits your attention (spare me the story about your facilities; I get dizzy watching you constantly switch back and forth between principle and possibility as it suits your argument)? Women and babies who die at home are an acceptable trade-off against the risks (and costs!) of hospitalization; but you only actually let them into the hospital if they either have a diagnosis on the short list of sufficiently serious pathologies (funny, the NCBers use that same list to enumerate exemptions from their standards) or are on the verge of delivering normally anyway.
How is that anything but a scheme designed to cull cases of CPD/obstructed labor/dystocia etc from the heard?
From Elizabeth:
I meant herd.
From Yehudit:
Really, that's funny because when I finally showed up at the hospital over here I was admitted and augmented right away.
+++++++++++
I don't want to get into the details of your case, but if you were 5cms dilated but contractions still irregular when you arrived at the hospital you were at that point in active labour, and they had good reason to augment on the basis of your history and contractions (incoordinate labour). You are reading a lot in which I have not actually written, and which are not my views.
From Yehudit:
If a woman who isn't progressing well doesn't qualify for care, how is that anything but exactly equivalent to defining failure to progress out of existence, just as the NCBers would like?
+++++++++
Failure to progress is only meaningful once a woman is in active labour (following Friedman and many many other researchers), because the process of labour onset is a gradual one that takes weeks (under normal circumstances). Dr Amy has written as much on posts here (referring to Friedman's definition of active labour).
From Yehudit:
but you only actually let them into the hospital if they either have a diagnosis on the short list of sufficiently serious pathologies (funny, the NCBers use that same list to enumerate exemptions from their standards) or are on the verge of delivering normally anyway.
+++++++++
1. The list of situations in which hospital birth is preferred is actually rather long - I posted it once in a thread on this blog.
2. Anyone who wants to give birth in hospital does so, we also offer a home birth service.
From Elizabeth:
if you were 5cms dilated but contractions still irregular when you arrived at the hospital you were at that point in active labour
Right, but if I hadn't waited that long before giving up on my NCB dreams and seeking real help? The only reason I took as long as I did, in a situation that was clearly going nowhere, was because I was brainwashed to the point of lunacy. Far from sniffing that I was barely even ready for admission yet, the attitude of the hospital was a wake-up call to how bad I had it. IOW, it wasn't because I had finally made it to real labor that I went to the hospital, but precisely because it was clear labor was going nowhere. Nobody checked dilation before admitting me, and I did not get the impression that dilation was a test I had to pass in order to stay admitted.
So.... imagine I'd gone in around the time the DEM showed up at my house. You've got a patient complaining of persistent 10 out of 10 pain over a period of 24 hours, and you observe that she is passing out from pain and exhaustion every few minutes. Otherwise she is screaming so loudly you can barely converse. Dilation is 3 cm (I actually went more like 36 hours in this state before the jump up to 5), maternal vitals and FHR are normal. You find it "not advisable" to offer this patient any treatment whatsoever. Can you explain why, without reference to the parameters for "progress" in labor? 'Cause when you explain with reference to them, it sounds an awful lot like you'll give help only once it's no longer really needed.
It's not that there's nothing you can do for her. I know there is because I had it done for me. It's that you don't want to. I'm trying to bring out why.
From Yehudit:
You've got a patient complaining of persistent 10 out of 10 pain over a period of 24 hours, and you observe that she is passing out from pain and exhaustion every few minutes.
++++++++
Then she's got a reason to be admitted, hasn't she? Because passing out from pain and exhaustion every few minutes is not normal. However, being in early labour is not, *in and of itself*, a reason for admission to the labour ward.
You are twisting what I said about this issue, and on top of some pretty unpleasant characterizations of my views.
From Elizabeth:
Because passing out from pain and exhaustion every few minutes is not normal.
But those were part of my stated facts from the start.
Also, I don't see what's so abnormal about passing out from exhaustion after a day or so of excruciating pain. I don't see what part of that constitutes a special case distinct from "labor in and of itself," as though only women for whom things go swimmingly count and the rest of us, however numerous, are negligible outliers. Just like all those women who were saved by emergency obstetrical surgery without performing random tests first!
I just get the impression that women's actual lives and concerns are vanishingly abstract for you.
From Alexis:
No, you're bagging on Yehudit for things she didn't say. She started speaking, generally, of management of patients in latent labor--no special circumstances. General management does allow for special circumstances. It doesn't mean you never "break the rules". It's about what you would, in routine situations, do. If a patient presents with something that is different from the norm, you treat accordingly. It's not about reducing patients to a simple treatment algorithm and removing all discretion from providers.
From Holly:
Passing out from exhaustion during birth is never, ever normal. Ever.
From Holly:
That was in response to this:
"Also, I don't see what's so abnormal about passing out from exhaustion after a day or so of excruciating pain."
From Caryn:
The contribution of hospitalization to that has never been tested.
Where else are you going to get a theatre?
From Jolene:
I rather regret the conversation dissolving there at the end. I wanted to say that I very much enjoyed following Yehudit and Caryn's exchange. I learned a lot. Thank you both for posting.
From Yehudit:
The contribution of hospitalization to that has never been tested.
Where else are you going to get a theatre?
++++++++++++++++
You seem to be reading what I'm saying as "Hospitals have never saved a life", whereas in fact I'm saying "We don't know if a policy of routine hospitalization of low-risk women in labour saves lives". (Low-risk is here standing for "women with no known risk of complications at the onset of labour". The risks I'm referring to are the long list of exclusion criteria for homebirth I have previously posted).
Irvine Loudon _Death in Childbirth: An International Study of Maternal Care and Maternal Mortality 1800-1950_ is very good on the causes of decline of maternal and perinatal mortality, and the possible contributions of hospital care as well as other factors.
From Yehudit:
Thank you Alexis.
From Liz:
Yehudit, I found a chunk of Loudon's book on Google books - but only the early chapters. I assume his conclusion was the familiar one of improved antibiotics, better nutrition etc - but could you outline them?
I also visited your homepage, and followed a link from there to a student midwives forum. This was a quick skim, but I have to say I came away from it feeling rather sick. So much starry eyed idealism may, for all I know, be quite justified in their real world, and a Good Thing overall. But an account I read from an independent midwife of her first experience of stillbirth horrified me. Her client, who had already had one high risk birth, wanted the full "natural" works - not much in the way of antenatal checks, lotus birth, the whole deal. What she got was an IUD. No doubt I am being unfair, but the long thread full of "beautiful" and "natural" turned my stomach.
From Liz:
Oh, and "hugs" for the midwife! Then there was the tearful young woman who was devasted that her more experienced supervisor had ripped her to shreds for pushing "natural" in a high risk unit. She got lots of sympathy. Fuddy duddy "medicalised" old bat, what could she know of the true beauty of birth?
Scares the hell out of me.
From Yehudit:
Discovering that a baby has died in utero antenatally is indeed horrifying.
It happens not that infrequently on our day assessment unit (when a woman has come in due to ?reduced/absent fetal movements) and it occasionally happens in community clinics or home antenatal visits where the woman does not suspect that the baby has died.
It may surprise you to learn that in these situations, in addition to caring for the woman and her family, some midwives do hug each other (physically or virtually), hug doctors, hug auxillaries, hug their students, go home and hug their partners. This is how many people respond to sad events.
From Yehudit:
Yehudit, I found a chunk of Loudon's book on Google books - but only the early chapters. I assume his conclusion was the familiar one of improved antibiotics, better nutrition etc - but could you outline them?
++++++++
That would not really do justice to the complexity of his argument. The introduction of antibiotics (and sulphonamides before that) played the significant role in the reduction of puerperal fever - but of course that was not the only cause of maternal mortality. He has chapters on understanding of Looking at google books, I think the majority of the book is available and certainly enough for you to sample his arguments for yourself. If you are interested in maternal mortality historically and international comparisons, it is worth getting.
(Obviously, someone like me who doesn't give two shits about all my countrywomen who died for lack of surgical care in the period before universal hospitalization wouldn't bother with reading such books - but you might be interested).
From Yehudit:
Sorry, cut off mid-sentence
He has chapters on understanding of pre-eclampsia in the period under discussion (1800-1950), postpartum haemorrhage, abortion.
There is a short article of his in the Social History of Medicine which is in large part based on the research done for the book. If you don't have access I can send you a pdf via email.
From Liz:
Yehudit, I do understand (rather too well) that bad outcomes are devastating for staff as well. I wouldn't have any problems with professionals looking for support and sympathy, and I realise that in such a forum, many things are left "unspoken". I am a somewhat hypersensitive, as is anybody who has personal experience of disaster is. (And I have a niece who suffered an IUD. A lot of years later, she has not "got over it".)But it was the juxtaposition of absence of prenatal care/lotus birth which jarred, and the assumption that that was not relevant. I am well aware that I may be doing the midwife an injustice. It is still an attitude of mind that bothers me. The giving and receiving of support is important; it isn't always enough.
From Liz:
And I noticed there was a chapter on stillbirth, too, which I would have found interesting. One sentence in his introduction struck me, as pretty well encapsulating the way I feel:
"Maternal mortality is, and always was, terrible in ways that other mortalities are not. Childbirth is a physiological process in which, as an American obstetrician said in the 1850s, death is a "sort of desecration."
Maternal mortality is, thankfully, much reduced. But anything that puts a baby's life at risk is anathema to me. Maybe that makes me the idealist, but as I have said before the category of "unexplained" stillbirth bothers me, as does the assumption that "low risk" is some kind of guarantee.
You are clearly a caring and conscientious young woman, and you do work in a system that is more cautious. But you have a faith in the value of "natural" that I simply can not get, and have reason to fear.
From Yehudit:
absence of prenatal care
++++++++++
Are you sure about that judgment? Some parents decline antenatal screening for abnormalities (maternal serum screening/ultrasound anomaly scan) - that does not equal absence of prenatal care. In fact, it seems that - due to previous preterm labour - there was additional screening for UTIs (aasymptomatic bacteriuria is a risk factor for preterm labour, and one of the few you can do anything about). Listening with a pinard is a dying skill, but arguably more accurate than doppler (since you are hearing fetal heartbeat directly, there is less chance of picking up maternal pulse which sometimes 'doubles' due to doppler technology - this is why we take maternal pulse, and why we also observe pattern very closely if maternal pulse is exactly half of fetal heartrate when using doppler). Lotus birth is kooky and unnatural, but some parents want to do that and it surely doesn't make a blind bit of difference in the case of intrauterine death.
From Yehudit:
But you have a faith in the value of "natural" that I simply can not get, and have reason to fear.
+++++++++++
I don't have a faith in the value of natural.
I take 'natural' (and that is a contested word if ever there was one), or perhaps better - non-intervention, to be the 'control' against which various interventions are tested.
If interventions improve outcomes (for entire populations, or identifiable subgroups) then I am all for offering them and even strongly recommending them (depending on the nature/degree of the difference to outcome that the particular intervention makes). E.g. I would strongly recommend anti-D prophylaxis in women who are Rh negative.
I am also aware that different people put different values on particular outcomes. E.g. Antenatal screening is offered because it gives the woman an option not to continue with a pregnancy where the baby is known to have an abnormality - it reduces the number of babies born with Chromosonal Abnormalities and Spina Bifida - which the government believes to be a good thing. (Incidentally, it also prepares parents who wish to be prepared and identifies those babies who might benefit from antenatal diagnosis - but these are not primary outcomes by which the 'success' of the intervention is measured). Some women do not value this outcome, and therefore are not interested in taking up this offer.
From Liz:
No, of course I'm not sure. And neither of us (or anybody else on the evidence of this thread) knows whether this comes under the heading of avoidable or unavoidable death. My reading of it was that this woman had had a bad first experience, and opted for minimal care with an independent midwife, who supported her choices. The reference to Lotus Birth gave some inkling of what those choices were. What was absent from the thread was any suggestion that those choices may not have been all that wise. Doesn't mean that the midwife concerned didn't think that, but it wasn't in the thread.
From Yehudit:
I should add, I am also aware that there is a huge void of evidence in many areas and that sometimes we do stuff because 'it makes sense' or we hope it helps or 'just in case'. I'm not against that across the board, but I think we have to be more honest about our uncertainties and also consider the unintended consequences of these untested interventions.
Also that women are individuals, and that clinical judgment is need to apply lessons from whole populations to individuals.
From Yehudit:
opted for minimal care with an independent midwife
+++++++++
It's worth pointing out that this did not occur in the UK, but in a country where regulated independent midwives are paid for by the state (somewhat like our self-employed GPs) per case.
From Yehudit:
And I'm not sure about the 'minimal care' either. Declined some of the screening/scans does not = minimal care.
From Liz:
Dear me, these things are difficult! I would agree that "natural" is a contested word, but I detect an implication in your post above that you want firm evidence that "interventions" are necessary. Now, if I were a midwive and I saw a woman distressed by a CS when she had her heart set on a vaginal birth, I might well feel the same. But can I say I was not all that convinced by the Cochrane report on CTGs that you posted earlier? Maybe that is down to my ignorance of statistics. I can see that a truly unnecessary CS is a bad thing - but is it that easy to classify in hindsight? Some of the studies were old, and I was a bit more startled by the high number of instrumental deliveries, babies with relatively high Apgar scores etc. Aggregated as it was, it is clearly significant evidence, but given that CTG probably stopped my baby from being dead (just about) and the five minute accurate readings without CTG seemed just as problemmatic in reality, in my biased, naive way I do wonder at the value overall of these studies. Do those who are not hung up on vaginal birth really mind CTGs that much?
From Yehudit:
I don't doubt that CTGs are very important in some scenarios - it is routine use that is at issue.
The issue is not that woman are 'hung up' on having vaginal births, but that interventions should be demonstrated to do what they claim/have benefits that outweigh harms. Caesarean Section carries some intrinsic harms and some intrinsic risks, we should only be doing them when those harms are outweighed by benefits. Obviously, that is not possible to ascertain in advance with certainty in the individual case (oh, to own a retrospectoscope) but the accumulated knowledge from other cases (research) can help us make judgments about the scenarios in which benefits outweigh risks.
In the case of normal labour (not your situation) the judgment of clinicians in the UK has been that demonstrable harms of CTG outweigh the theoretical (but as yet unproven) benefits. An entirely different clinical judgment is made in relation to women with known risk factors - and we use CTG a lot antenatally on our antenatal ward, in day assessment units, and for intrapartum care where there is a specific indication.
From Caryn:
But Yehudit, testing the set of low-risk women as a subset of all women to see if maybe they don't need access to hospitalization is something you do *after* moving everyone to hospital care, because you've confirmed that the population *as a whole* benefits from hospitalization in emergencies.
As I pointed out above, outcomes for the whole population are improved simply because hospitalization lets you move the obvious emergencies from the category "dead". Once you provide everyone who might experience an emergency -- and don't forget that our ability to detect things like accreta ahead of time has improved rather a lot since these policies were adopted -- with access to the standard of care, you can start checking to see whether or not some people might benefit from a change in that standard. Of course you'd have to propose some particular mechanism by which they'd benefit, run it past an IRB, etcetera -- but it isn't in any way a failure of the way we approach these sorts of questions to have failed to conduct such a test before moving to a policy of 100% hospitalization, and is rather precisely what ethics requires.
That Cochrane didn't understand this is interesting, but not really relevant.
From Liz:
Actually, I would take back the expression "hung up". It is reasonable, I suppose that a large majority would want to avoid surgery - but nevertheless it has oft been demonstrated here that there are some who have very strong feelings about vaginal birth that are not entirely sensible. And yes, I understand how the science works - and am beginning to grasp the NNT - what I struggle with, as someone who seems to make a habit of being a statistical anomoly, is that what makes sense in the abstract can be a bit of a problem, and that risk/benefit is not always clear cut or easy to ascertain. It may be a comfort to scientists to know that their figures are as good as can be, and that what happened shouldn't have happened, but it isn't always much comfort to the individual! I am also aware that scientific studies make sense in the context of other scientific studies, and some things do change over time.
From Yehudit:
outcomes for the whole population are improved simply because hospitalization lets you move the obvious emergencies from the category "dead".
+++++++++++
That would only be true if all other things remain equal, which you would have to be demonstrate was the case.
Hospital is now the preferred place of birth for the majority of women. Given the imperative to provide care that takes into account the preferences of individual women, we are unlikely to see home birth rise above 10%.
But your assumption that all other things equal were when hospital became standard of care is wide of the mark. It is worth reading Irvine Loudon on that subject.
http://www.pubmedcentral.nih.gov...97&
blobtype=pdf
From Caryn:
That would only be true if all other things remain equal, which you would have to be demonstrate was the case.
No, that's not the way it works.
If you've got an intervention that benefits some patients (although critically you don't know which ones) but it's the case that the intervention shows benefits for the population when applied to the population as a whole, you provide the intervention to the whole population unless you can demonstrate that the costs outweigh the benefits to some patients *and you can identify those patients*.
Which is what natural birth advocacy has been saying they can do for a good 40 years at least, but the problem here is there's no good evidence that the costs outweigh the benefits to some patients, nor good evidence that it's just as safe (let alone safer.)
Let me just point out the absurdity of following the policy you're suggesting. We can imagine two different rules for making decisions of this kind. We've got a claim that we can make for this large population: that, on the whole, on average, people do better in a hospital than out of it. We suspect (even know, perhaps) that this is false for some of them. We cannot identify those for whom it's false.
We could either adopt the policy you're suggesting, and say that we should identify some subpopulation and treat them differently in the absence of good evidence that they will benefit, or we could insist that treating people differently requires a reason. If you go with the first, that means that you don't have to give any reason to pick out *any* subset -- not just the one you're suggesting. I could pick the class of blondes, and say that they benefit from removal from hospital care, and what I am doing would be just as consistent with your proposed policy rule as pulling out the low-risk women and saying that they benefit, because in neither case do I have good evidence to support my claim.
From Caryn:
Liz, a Cochrane meta-analysis is only as good as the studies in it.
From Yehudit:
it's the case that the intervention shows benefits for the population when applied to the population as a whole
+++++++++
But that is what has not been demonstrated!
From Yehudit:
We've got a claim that we can make for this large population: that, on the whole, on average, people do better in a hospital than out of it.
+++++++++++
And again, that claim has not been supported by evidence - except for the kind of correlation that we know is invalid. Correlation does not equal causation, and you could equally make the claim that reduced length of hospital stay is the cause of decline in mortality (which is Cochrane's point).
From Yehudit:
a Cochrane meta-analysis is only as good as the studies in it.
++++++++
None of the individual studies have sufficient power to demonstrate the finding we are interested in. So there is little alternative to meta-analysis in these cases.
And the authors of Cochrane reviews explain their exclusion/inclusion criteria for studies and their analysis is transparent. So, if you want to rerun the meta-analysis with your own exclusions you are welcome to do so.
From Caryn:
Yehudit, we don't *have* to demonstrate benefit to each individual in the population. We have to demonstrate benefit *to the population as a whole*.
Fewer women die from accreta or obstructed labor or severe preeclampsia with access to theatre. We know this. Surgery is the only way to treat these conditions.
Having those women *not die* improves outcomes for the population *as a whole* because the rate of maternal mortality drops.
From Yehudit:
Fewer women die from accreta or obstructed labor or severe preeclampsia with access to theatre. We know this. Surgery is the only way to treat these conditions. Having those women *not die* improves outcomes for the population *as a whole* because the rate of maternal mortality drops.
++++++++++++
Firstly, each of these examples does not necessitate universal hospitalization, because they are not wholly unpredictable emergencies in the sense that would support your argument. Accreta will result in retained placenta (or uterine inversion if inappropriately managed, but let's assume that if the placenta doesn't come no one does anything stupid). Therefore transfer to hospital. In fact, it is at the point of removing the placenta that the greatest danger lies - to the point that with more extreme cases some obstetricians would prefer to leave the placenta in situ (which pretty much puts paid to breastfeeding, but may be preferable to massive PPH or hysterectomy).
You can use accreta to argue the other direction, given that previous caesarean section is a significant risk factor for placenta accreta (as it is for placenta praevia).
Planned hospital birth increases rates of caesarean section, which in turn will increase rates of both placenta accreta and placenta praevia in subsequent pregnancies - undoubtedly these women need access to a theatre. However, despite the best efforts of surgeons to manage these cases some women do die from haemorrhage related to placenta praevia and placenta accreta.
"Placenta praevia with a morbidly adherent placenta caused three maternal deaths where profuse bleeding was impossible to control. Cases such as those where a woman has an anterior placenta praevia and a previous caesarean section scar require all the energies and planning of consultant obstetricians, gynaecological surgeons, anaesthetists, interventional radiologists, blood transfusion specialists and on occasion, vascular surgeons and urologists." (CEMACH report, 2003-5).
"All four women who died from placenta praevia presented with bleeding. Previous
caesarean section predisposes to placenta praevia and placenta accreta. All four women
had at least one previous caesarean and three had previous accreta. " (CEMACH report, 2000-2002)
Having those women *not die* would presumably also improve outcomes for the population as a whole. I'm not claiming that the effects of universal hospitalization (which include, increased rate of caesarean section, increased risk of placenta praevia and accreta in subsequent pregnancy, increased risk of death from haemorrhage) outweigh the benefits of universal immediate access to theatre in case of emergency.
But equally you cannot claim that all other things remain equal when you introduce universal hospitalization.
It is also simply not the case that we have no idea who may have obstructed labour, placenta accreta or pre-eclampsia. That is the purpose of providing routine antenatal care, using a partogram, doing ultrasounds, transferring women to theatre if they have retained placenta.
From Yehudit:
To clarify, I don't mean that universal hospitalization increases risk of death from haemorrhage overall.
Simply, that placenta praevia with placenta accreta increases risk of death from haemorrhage. To the extent that placenta praevia with placenta accreta is associated with previous caesarean section, the number of women facing that particular risk would decline if the caesarean section rate fell. All studies show that planned hospital birth increases the likelihood of needing a caesarean section.
It is not the case that hospitalization only has winners - that it can only ever weigh on the benefit side of the scales.
From Caryn:
Of course there are possible downsides of treatment for everyone.
As we discussed earlier, the ability to pick out who, precisely, is going to need treatment changes with time. At the historical point when the decision was made to move to 100% hospitalization, some of the diagnostic techniques we can use now were unavailable.
Given what we knew at the time, and given that the hospital comes along for the ride when you offer effective treatment for some emergency pregnancy conditions, it's unsurprising that hospitalization wasn't tested per se, as there was no way to offer effective treatment of these conditions absent a theatre.
So, here we are, with everyone treated at the hospital, Then people start to make the argument that hey, some of these people maybe aren't going to need those sorts of treatments but are experiencing downsides from hospitalization that they don't need. Fine. Seems plausible. Can we make a compelling and plausible case for how to pick those people out of the population and do a study showing benefit to them?
'Cause that's what we're waiting on, here.
From Yehudit:
This doesn't work for me. Because the ability to use a theatre for emergency pregnancy conditions would only be dependent on 100% hospitalization if there are no recognizable indications for hospitalization antenatally or during labour. In the examples you cite (placenta accreta, pre-eclampsia, obstructed labour) that is not the case.
Prior to universal hospitalization in the UK, a proportion of the population was being offered specialist obstetric beds on grounds of risk factors in pregnancy. So, there was certainly a feeling that 'indications' for hospitalization could be identified and the awareness that benefits of hospitalization would not be distributed equally across the population. What policy-makers dismissed was the possibility that there may be parts of the population for whom benefits were balanced or outweighed by harms. This was in defiance of the information available to them (e.g. 1958 Perinatal Mortality Survey, 1970 Survey of British Births).
Anyhow, subsequently (in the early 1990s) it was recognized that the earlier policy of 100% hospitalization was introduced without adequate evidence, and was reversed - hence the existence of a home birth service in the UK. 'Standard of care' does not have to remain in place if it is not founded on evidence. On the other hand, it would be wrong to say that home birth is as safe or safer than hospital birth (or vice versa) for low-risk women, since we simply don't have the evidence to say that.
Women planning home birth in the UK should be (and are) told that in the event of an unpredictable obstetric emergency there are advantages to being in hospital with proximity to medical staff, theatre, neonatal services, as well as something about the indications for transfer in labour, the management of obstetric emergencies in community settings, and the incidence of those complications.
From Caryn:
Because the ability to use a theatre for emergency pregnancy conditions would only be dependent on 100% hospitalization if there are no recognizable indications for hospitalization antenatally or during labour. In the examples you cite (placenta accreta, pre-eclampsia, obstructed labour) that is not the case.
That's why there's an etc. on at least one of those lists. There are emergency conditions that can only be treated in theatre where you don't have time to move from home to hospital. AFE leaps to mind. Catastrophic abruption. Severe PPH.
What policy-makers dismissed was the possibility that there may be parts of the population for whom benefits were balanced or outweighed by harms. This was in defiance of the information available to them (e.g. 1958 Perinatal Mortality Survey, 1970 Survey of British Births).
Well, no. What they dismissed was the possibility that they could *detect* those parts of the population with sufficient accuracy. Instead, they placed some of the responsibility for detection on the women themselves; they've got to elect to be in the group of women who won't get adequate care if it's the case that they develop an unpredictable obstetric emergency. And then they warn them, hey, you might be more likely to die or have your baby die out there.
As you note, this really conflicts with the idea that it's "just as safe". At the moment we have no good reasons to think homebirths *are* just as safe, unless you're one of the lucky ones.
So we've got all these groups over here telling women that homebirths are *safer than the hospital*, if you're low-risk. And that's false, and unethical. I'm glad the UK warns homebirthers, but I'm not convinced either that the vast majority of homebirthers have really given informed consent.
From Yehudit:
but I'm not convinced either that the vast majority of homebirthers have really given informed consent.
+++++++++
What evidence do you base that on, and is there anything that would convince you?
From Yehudit:
AFE leaps to mind. Catastrophic abruption. Severe PPH.
++++++++++
Well, then we can talk about the incidence of those emergencies and what can and cannot be done in hospital vs. home.
For example, assuming that there are no predictive risk factors or warning signs for AFE, then based on current UKOSS (UK Obstetric Surveilence System) figures for incidence of AFE, and CEMACH for maternal deaths from AFE, we can estimate the additional risk of dying from AFE at home to be in the region of 1:100,000 maternities (UKOSS records incidence of AFE at 1.8 in 100,000 maternities, CEMACH record maternal deaths from AFE as .8 in 100,000 maternities).
How individual women feel about that magnitude of risk will depend on their attitude to risk.
From Alexis:
Yehudit, speaking from my experience with US home birthers, many (I don't know that I would say most) don't have informed consent. They may be aware that there are particular emergencies which cannot be handled at home, even by the best midwife (or possibly even an OB who didn't have a surgical team and OR handy). However, they tend to think that these risks are so small as to be negligible ("It won't happen to me") or that they are outweighed by the "risks" of the hospital.
From Jolene:
"However, they tend to think that these risks are so small as to be negligible"
You mean like the example of AFE directly above your comment?
"UKOSS records incidence of AFE at 1.8 in 100,000 maternities, CEMACH record maternal deaths from AFE as .8 in 100,000 maternities"
I would personally consider that risk to be so small it's negligible.
From Alexis:
The risk of AFE might be negligible, but that isn't the only thing that could go wrong at home. It also doesn't take into account an individual midwife's experience and training.
I don't think homebirth is insupportably dangerous, but I'm not sure women realize that there is a risk and it could happen to them.
From Caryn:
How individual women feel about that magnitude of risk will depend on their attitude to risk.
Mmm. Judging from the extrordinary lack of understanding of statistics we see posted to this blog routinely, why should their attitude towards risks they don't understand count as informed consent?
From Caryn:
They may be aware that there are particular emergencies which cannot be handled at home, even by the best midwife (or possibly even an OB who didn't have a surgical team and OR handy). However, they tend to think that these risks are so small as to be negligible ("It won't happen to me") or that they are outweighed by the "risks" of the hospital.
Or that they can eliminate them with the Brewer diet, so why worry?
From Liz:
I don't think the human brain is at all good at calculating risk- if it was probably most of us woulnd't dare get out of bed in the morning, given that the home is such a risky place. But I think the more dangerous assumption is that low risk is a fixed category and that any change will be announced in plenty of time, and couldn't possibly be missed. I think it was a CEMACH report that stated that half of stillbirths could likely have been prevented - if it hadn't been assumed that the risk was so low, no need for precautions. My "disaster" could have been prevented, my niece's dead baby could have been prevented - and Oops sorry doesn't help much.
From Liz:
If the risks of homebirth are so easily ignored, why are NCB adherents so paranoid about the risks of CS, epidural and those nasty hospital germs? Isn't it partly to do with the way they are presented? No-one wants to talk about dead babies the risks of CS are presented as if they were inevitable.
From Yehudit:
Judging from the extrordinary lack of understanding of statistics we see posted to this blog routinely, why should their attitude towards risks they don't understand count as informed consent?
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I don't know what you propose as the alternative? You give women information, you endeavor to do so in a form that can be easily grasped by a lay person (and that is why we talk in terms of "If 100 people have this procedure, X would have such-and-such complication" or use visual representations of risk), and then they make their choices. Unless they are to be judged not to have the capacity. I don't see that having a different set of beliefs or values from their care providers counts as incapacity. Otherwise we would be able to override the wishes of Jehovah's Witnesses who refuse blood transfusions.
From Liz:
Yehudit, a lot of the things you say make perfectly good sense. But sometimes, it seems to me that they make sense in an abstract, textbook way that leaves out the messiness of the real world. Your question is a good one - give women the facts, the choice is theirs. How could anyone possible argue with that? But it doesn't really work like that does it? If someone was given the "facts" about homebirth by you, or Kneelingwoman, they would feel reassured. If it were Caryn or Dr. Amy, probably not.
From Alexis:
I don't see how there's any real alternative, though. We could draw up a standard way to present risk, so you don't get the scenario I seem to see where women have been informed-but-not-really. We could try to minimize provider bias in portraying risk (a scenario that I feel often backfires when the provider goes too far in one direction--the patient then says "what they're saying makes no sense so I'll discount the whole thing".)
However, in the end, the choice does have to be up to the patient. The only question is how we choose to provide the information on how they make that choice.
From Yehudit:
No Liz, I talk in a way that tries to deal with the messiness of the world.
In the real world we know there is no such thing as 100% informed consent. NONE of use have complete information, complete knowledge. Most of all, none of us have the knowledge of the future that would help us make choices - and there are no guarantees.
Therefore, it is absolutely hopeless if you start getting into the philosophical question of how informed the informed choice actually is.
Instead, you need a consistent standard for what information women need, and a consistent attitude to the issue of who has capacity. Otherwise you would be driven MAD (in the colloquial sense) by the messiness of some people's choices - and unable to do your job.
From Caryn:
I don't know what you propose as the alternative? You give women information, you endeavor to do so in a form that can be easily grasped by a lay person (and that is why we talk in terms of "If 100 people have this procedure, X would have such-and-such complication" or use visual representations of risk), and then they make their choices.
In the absence of good evidence suggesting that we *can* identify that population of women who won't have problems in advance, why move their births back out of the hospital in the first place? Granted, not everyone is going to make it in in time, etc.
But what we've done here is say, well, there's a population who don't need the hospital and who will experience worse outcomes inside the hospital. But we can't identify them well, *and* (critically) we know that there are fewer of them than there are women who benefit from the hospital in emergencies. Let's just offer to some of 'em, under criteria that seem sensible to us but that aren't supported by the research evidence, an out-of-hospital birth in case that improves outcomes.
Also, take the way *you're* talking about risk, here, as an example of a way to skew consent. I mention multiple conditions that can have worse outcomes at home. You say, oh, but we always have time to get to the hospital with those. (Debatable, and unlikely in vast reaches of the US.) I say, well, that's why I stuck an etc. on the end of that list, as there are plenty more, and then I list a few of them. You pick out the one with the *lowest* probability and proceed to discuss just it.
Is that a fair characterization of the risks of homebirth per se, for those reading who don't know what can happen with a shoulder dystocia the midwife in question's never resolved, uterine atony, a solo practitioner, and a 15 minute commute to the hospital? (Also a not-unlikely scenario in the US.)
Or is that misrepresentation of the risks on your part, by de-emphasis?
From Caryn:
Also note that I specifically called out groups who are telling women that homebirth is *safer* if you're low-risk as unethical and false and a failure to get informed consent, and then you said, well, what else are we supposed to do but tell them the truth and let them choose?
Well, yes, *telling the truth* would be relevant here, wouldn't it?
From Morgan:
The Caryn/Yehudis exchange is really informative and prompted a question. An unforseen emergency, that requires immediate delivery, is a scenario often presented here in favor of hospital birth. Quick access to an OR and an emergency c-section is the advantage most often cited. Perhaps some of you hospital insiders could clarify something for me. In a real world emergency, what do you actually do when an OR or an anesthetist is not immediately available? I'm curious since modern OB's rely on the c-section to the extent that they don't appear to have the training and experience in other methods that their predecessors did back in my era. Without a c-section, would an OB really have much edge over an experienced and highly competent midwife in an emergency? I'm not taking sides, just wondering.
From Liz:
I suppose what disturbs me is some kind of paradign shift that not only presents birth as largely hazard free but turns a "natural" birth into some kind of feminist or feminine accomplishment. Up until relatively recently, all women had a pretty clear understanding that it was neither, and I guess the majority still do. But the rhetoric of NCB is prevalent and popular, not to mention very appealing to the ill-informed. Making things safer for the minority who, for one reason or another, will not use hospitals is one things. But if homebirth does get wider acceptance on the grounds that the problems are negligible, I am not sure that, in England at any rate, women won't end up (as in Holland) having a homebirth whether they want it or not. That happened to my sister. For a brief time, anyone who had had a straightforward first birth was discouraged, if not forbidden, to use hospital care, regardless of their "choice".
From Liz:
Pardon my ignorance, but how often can a catastophic haemmorhage be predicted in advance? I understand that placenta praevia can be picked up - what about the other things? The book Yehudit recommended started out with telling the story of such an event: an accomplished intelligent woman who could afford the best of home care died that way - suddenly and unexpectedly. I know that there are now better treatments - but has ante-natal care and transfer made it unlikely?
From Yehudit:
You pick out the one with the *lowest* probability and proceed to discuss just it.
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The reason I picked AFE is because it is very clear cut. Survival rate from AFE at home must be as close to 0% as anything can be. Survival rates in hospital are around 50% give or take. It is likely that the incidence of AFE is the same regardless of location. We can also pretty much take predictive risk factors, labour management, individual practitioner skills out of the equation - the key here is proximity to a large skilled team and facilities.
In the case of postpartum haemorrhage it is much more difficult to quantify additional risk. The cover a wide range of events: in terms of quantity, cause, effect of blood loss. Postpartum haemorrhage refers to
a) any blood loss > 500 mls and/or
b) a blood loss which makes the woman symptomatic. The incidence of 'severe postpartum haemorrhage' as a subset of all pph is unclear.
We know that oxytocin augmentation/induction, instrumental delivery and caesarean section are risk factors for postpartum haemorrhage - so incidence of PPH is likely to be higher in the hospital. We know that anaemia and low platelets are risk factors for PPH, and that we can (and do) screen for these antenatally. And that we can treat anaemia in pregnancy. The immediate treatment for PPH is the same at home as in the hospital: call for help, rub up a contraction, use uterotonic drugs, if uterus well-contracted and blood loss continues, check for trauma, treat as for any laceration in community setting. Blood transfusions used to be given in the home by the obstetric flying squad. Now a woman would be stabilized at home, transfered by ambulance and given a blood transfusion in hospital (partly because of risk of anaphylaxis and just better access to facilities for cross-matching etc..). In contrast, in the case of AFE there is basically nothing one can do in a community setting.
A similar emergency would be uterine rupture. If that happens at home then the survival rate for babies must be close to 0%, and touch and go for the mother.
It is very much harder to quantify any possible additional risk of dying from pph at home birth: given that incidence likely varies, risk factors can be identified, and immediate action can be taken at home. I think the incidence of PPH at home and in hospital respectively is one of the questions that NPEU will give clears answers on.
Abruption is more often an antenatal event than an intrapartum one. Obviously, we don't admit everyone as inpatients in pregnancy despite the fact that there would be a theoretical benefit in doing so once past viability. I have cared for a number of women who have very preterm babies on NICU due to placental abruption. I'm sure that they would all wish they had been in the hospital at the time of the abruption. I've also cared for women antenatally in community presenting with some PV loss (spotting) and abdominal tenderness - some of whom have been hard to persuade of the importance of attending day assessment unit for investigation and possible inpatient admission.
There are some risk factors for abruption, in particular hypertension. All in all, the additional risk posed by abruption at a planned homebirth is difficult to calculate. Again, it should become clearer from the NPEU study, because all complications at home births (some 17,000 of them) will be recorded and that will be compared with the incidence amongst women who would have been eligible for home birth at consultant units and birth centres.
When a woman who is planning a home birth rings up in labour, the same questions are asked of her as of a woman planning a hospital birth. Tell me about your contractions? Is the baby moving as normal? Have your membranes ruptured? If so, what colour is the liquor? Any vaginal loss? Just a mucous show or red blood such as you would see during a period or if you cut yourself? How much blood? Spotting or a pad full? If spotting, how does your abdomen feel between contractions. Okay, we need to see you on delivery unit, don't hang about, come straight here - bring your handheld notes and bag. If a pad full, or abdominal pain, tenderness, hardness: okay, stay on the line, we are ordering an ambulance to attend. Is there anyone with you? Are you downstairs? etc... I can tell you, when it happens the whole midwives station goes silent and listens to the midwife's side of the conversation.
So, even before a midwife attends a labour at home, we have already invited women in to the delivery unit for the following reasons:
reduced fetal movements
meconium-stained liquor
PV blood loss
And if the woman has a significant PV blood loss we are bringing them in by ambulance.
We advise women in the early part of labour to stay at home, and any one of them could have a placental abruption or cord prolapse. Arguably, a woman in active labour at home with a trained midwife in attendance is better off in the event of abruption or prolapse than a woman in early labour without a professional in the vicinity.
Are we wrong not to bring women in to the hospital from the first contraction? or even antenatally in late pregnancy? From viability?
From Caryn:
Again, it should become clearer from the NPEU study, because all complications at home births (some 17,000 of them) will be recorded and that will be compared with the incidence amongst women who would have been eligible for home birth at consultant units and birth centres.
Right. In other words, we don't know, but we sent them home anyway, cause hey, it might help.
From Yehudit:
Look - we don't know whether home or hospital is safer for women in this 'low risk' category (which I am using here as shorthand for the criteria used in UK recommendations about place of birth). That's the point.
And until we do, we can tell women that *in the event* of obstetric emergency during
labour at home or in a midwife-led unit, the outcome for the woman and baby could be worse than if they were in the obstetric unit with access to specialised care. But we cannot tell them hospital is safer overall (or that home is safer) or that either is just as safe as the other. Because we just don't KNOW that. The evidence is not there. And banging on about how *in the event* of obstetric emergency, hospital is the place to be doesn't change that, because hospital-based care may be a risk factor for experiencing some obstetric emergencies (postpartum haemorrhage, placenta accreta in a subsequent pregnancy, need for neonatal resuscitation - the background for each of these discussed above).
From Yehudit:
we sent them home anyway
++++++++++++
And we do you get that from? We do not "send women home" from hospital to have a home birth.
Women decide where they want to give birth during pregnancy, and are booked for a home birth, birth centre or hospital after discussion about their own circumstances, and reasons why they might need to change their plan. Etc....
*Generally* (there are exceptions, so as to avoid reopening the discussion with Elizabeth) we advise women who are not in active labour to remain at home (or go home, if they have come into the hospital). It is possible that they may have a placental abruption or cord prolapse outside the hospital - two obstetric emergencies that can happen in early labour or indeed antenatally. Are we wrong not to admit women in early labour? antenatally? from viability?
From Caryn:
But we cannot tell them hospital is safer overall (or that home is safer) or that either is just as safe as the other. Because we just don't KNOW that.
Yes, we can. Because we're not talking about *just* the low-risk population here. We're talking about the *whole* population.
Until you can a) identify the low-risk subset of the population successfully, and b) demonstrate that they're better off at home, you *cannot* ethically move them away from available interventions. Except we did, 'cause it just seemed intuitively obvious that they'd be better off at home. Which isn't evidence-based.
That's what evidence-based care *means*.
What you want to do is pull out the blondes.
Aside from that, as always, there are substantial concerns about homebirth in the US that don't apply to the UK, including that homebirth providers often have nothing like the UK midwifery background, and are practicing in a completely different environment wrt hospital transfer, and are clearly (see links above) in the habit of advising women that a) it's safer for them at home (which is false) and b) that they have special magic to prevent the complications that would send them to the hospital anyway.
From Caryn:
And we do you get that from? We do not "send women home" from hospital to have a home birth.
Because there used to be a 100% hospitalization policy.
From Caryn:
Without a c-section, would an OB really have much edge over an experienced and highly competent midwife in an emergency? I'm not taking sides, just wondering.
The advantage there is in the staffing. An OB can get way more hands on deck than a solo midwife for a shoulder dystocia, including a pediatrician to take the baby, multiple NICU nurses to help with resus, and labor nurses to help with the potential post-delivery hemorrhage. At home, if you get the baby out but he needs resus and the mother's hemorrhaging, what do you do first, if you're by yourself?
From Yehudit:
At home, if you get the baby out but he needs resus and the mother's hemorrhaging, what do you do first, if you're by yourself?
+++++++++
This is the rationale for two midwives for delivery at a home birth.
From Yehudit:
And we do you get that from? We do not "send women home" from hospital to have a home birth.
Because there used to be a 100% hospitalization policy.
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Which was replaced with a policy of women having a choice of place of birth. No women are told that they can't book for a hospital birth - it NEVER happens. Some women are told that they can't have a home birth. Though in fact, we have always had the right to be attended by a midwife at home, which has somewhat a cut across a policy of recommending hospital birth universally.
From Yehudit:
I don't want to pull out the blondes. I want to distinguish between women with known risk factors for complications at birth and those without. Here is an indicative list:
Medical History
Confirmed cardiac disease
Hypertensive disorders
Asthma requiring an increase in treatment or hospital treatment
Cystic fibrosis
Haemoglobinopathies – sickle-cell disease, beta-thalassaemia major
History of thromboembolic disorders
Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100,000
Von Willebrand’s disease
Bleeding disorder in the woman or unborn baby
Atypical antibodies which carry a risk of haemolytic disease of the newborn
Infective Risk factors associated with group B streptococcus whereby antibiotics in labour would be recommended
Hepatitis B/C with abnormal liver function tests
Carrier of/infected with HIV
Toxoplasmosis – women receiving treatment
Current active infection of chicken pox/rubella/genital herpes in the woman or baby
Tuberculosis under treatment
Systemic lupus erythematosus
Scleroderma
Endocrine Hyperthyroidism
Diabetes
Abnormal renal function
Renal disease requiring supervision by a renal specialist
Epilepsy
Myasthenia gravis
Previous cerebrovascular accident
Liver disease associated with current abnormal liver function tests
Psychiatric disorder requiring current inpatient care
From Yehudit:
Previous obsetetric complications
Unexplained stillbirth/neonatal death or previous death related to intrapartum difficulty
Previous baby with neonatal encephalopathy
Pre-eclampsia requiring preterm birth
Placental abruption with adverse outcome
Eclampsia
Uterine rupture
Primary postpartum haemorrhage requiring additional treatment or blood transfusion
Retained placenta requiring manual removal in theatre
Caesarean section
Shoulder dystocia
Current pregnancy
Multiple birth
Placenta praevia
Pre-eclampsia or pregnancy-induced hypertension
Preterm labour or preterm prelabour rupture of membranes
Placental abruption
Anaemia – haemoglobin less than 8.5 g/dl at onset of labour
Confirmed intrauterine death
Induction of labour
Substance misuse
Alcohol dependency requiring assessment or treatment
Onset of gestational diabetes
Malpresentation – breech or transverse lie
Body mass index at booking of greater than 35 kg/m2
Recurrent antepartum haemorrhage
Small for gestational age in this pregnancy (less than fifth centile or reduced growth velocity on ultrasound)
Abnormal fetal heart rate (FHR)/Doppler studies
Ultrasound diagnosis of oligo-/polyhydramnios
Previous gynaecological history
Myomectomy
Hysterotomy
There are no doubt some other issues that we might want to include/exclude. But it is simply wrong to characterize these kinds of considerations as "pulling out the blondes".
From Yehudit:
known risk factors for complications at birth
...Sorry that is better as "known risk factors for complications at onset of labour".
To which we can also add indications for transfer in labour:
indications for electronic fetal monitoring (EFM) including abnormalities of the fetal heart rate (FHR) on intermittent auscultation
delay in the first or second stages of labour
significant meconium-stained liquor
maternal request for epidural pain relief
retained placenta
maternal pyrexia in labour (38.0°C once or 37.5°C on two occasions 2 hours apart)
either raised diastolic blood pressure (over 90 mmHg) or raised systolic blood pressure (over 140 mmHg) on two consecutive readings taken 30 minutes apart
In addition to the obstetric emergencies we have been discussing.
From Caryn:
This is the rationale for two midwives for delivery at a home birth.
Yes. We don't necessarily do that, here.
From Caryn:
Which was replaced with a policy of women having a choice of place of birth.
Yes. You're allowing them to elect to get care that isn't evidence-based.
From Caryn:
I don't want to pull out the blondes. I want to distinguish between women with known risk factors for complications at birth and those without.
But as I keep saying there is no good evidence to support the idea that those women will experience fewer harms and more benefits if they stay home. There's just an intuitive argument.
From Yehudit:
A policy of purely elective hospitalization is also not evidence-based, and we also allow that!
From Alexis:
Caryn, I don't necessarily think that giving these low risk women the choice of home birth equates to saying the benefits outweigh the risks. It can be phrased, instead, as being safe enough that it's a supportable choice.
From Yehudit:
There is already good evidence that women are less likely to have caesarean section and instrumental delivery if booked for a homebirth. And looking at it objectively, this is a benefit, since those procedures have intrinsic harm (more pain, post-op recovery etc..) and also carry risks of complications of varying degrees of likelihood (postpartum haemorrhage, third and fourth degree tears, infection, placenta accreta in future pregnancy etc...). That's why every consent form for any of those procedures says "only recommended when the benefits outweigh the risks."
The question is whether this known benefit is outweighed by greater risk of neonatal mortality/morbidity or maternal mortality/morbidity. That is what has not been shown to date, largely on account of the fact that these are relatively rare events and studies to date have been underpowered to provide that information.
From Caryn:
A policy of purely elective hospitalization is also not evidence-based, and we also allow that!
I'm not sure what you mean here, but if you mean that women can decline medical care, well, sure. But if the medical care on offer is to be evidence-based, then
a) all pregnant women are at risk for complications that can only be treated in the hospital
b) we can't identify the ones who won't have complications
c) we are offering care off-site anyway, even though the ones who'll have complications will have worse outcomes then.
How are we doing this? By not calling it medical care and by letting them elect not to get medical care. 'Cause if we called it medical care, it'd be unethical to offer, because we can't pull a set of women out of the treatment pool, and not offer them a preferable alternative. By which I mean an alternative *known to be preferable*, of course.
(And look, here we are again!)
From Yehudit:
Caryn, I don't necessarily think that giving these low risk women the choice of home birth equates to saying the benefits outweigh the risks. It can be phrased, instead, as being safe enough that it's a supportable choice.
++++++++++
Quite! Just as you have the choice of giving birth in your local hospital which does not have an obstetrician or obstetric anaesthetist in the building 24/7, or going further afield to a hospital which has round the clock theatre cover. The former is presumably "safe enough", even though by your logic it would clearly be inferior to the latter.
From Caryn:
Caryn, I don't necessarily think that giving these low risk women the choice of home birth equates to saying the benefits outweigh the risks. It can be phrased, instead, as being safe enough that it's a supportable choice.
Actually, this is usually where the economic rubber hits the road. We can't afford to put a NICU everywhere, and it comes down to community standards at that point.
From Liz:
Given that "bad things happen in hospitals too" is a well worn trope for supporters of home birth, and hospital statistics are presumably more available, are there any stats anywhere on the proportion of poor outcomes in women at high risk versus low risk-until-everything-went-pear-shaped?
And, given that poor outcomes for a baby are often not apparent for months and sometimes years, any retrospective studies?
From pinky:
The more I practice and the more I see births, the more I think in order to safely deliver a baby, you need an OB on the floor or in hospital and Anesthesia in Hospital too. Also Nurses who can be trained as OR staff for C-sections. At present that is not the case. Nicu would be nice but the L&D Nurses have resuscitated babies long before Nicu even existed.
The worst case scenario is a woman having a homebirth and her back up hospital is a hospital with no 24 hour ob or 24 hour anesthesia. If a woman is having a homebirth, she may need a quick C-section to save the babys life. You just can never tell.
I read a statistic a few days ago that 50 percent of C-sections will be unnecessary. Heres the rub, which ones? You only know in retrospect.
From Yehudit:
a) all pregnant women are at risk for complications that can only be treated in the hospital
b) we can't identify the ones who won't have complications
c) we are offering care off-site anyway, even though the ones who'll have complications will have worse outcomes then.
++++++++++++
a) True. All *pregnant* women. Not just all women in labour. A woman can have an eclamptic fit before term. A woman can have cord prolapse or placenta abruption before term. Why don't we hospitalize all pregnant women?
b) Only half true. We can't say of anyone, you absolutely won't have a complication. Low-risk is not no risk. But we can identify women who are at higher and lower risk of complications at booking, identify new complications or risk factors for complications during pregnancy through routine antenatal care, and pick up risks for complications in labour through routine intrapartum care. There are particular risks that can be effectively ruled out provided someone has routine antenatal care. (e.g. placenta praevia).
c) The women who will have complications will likely have worse outcomes than they would have done in hospital, but that doesn't mean that outcomes will be worse overall (because you haven't addressed the issue of incidence of complications - despite my citing some examples of complications that appear to be less common with planned home birth than in equivalent women booked for hospital birth).
From Liz:
Well, it is nice that CS is "only recommended when the benefits outweigh the risks" But how often is it that obviously clear cut? This is a truism, not that helpful in decision making I would have thought.
From Yehudit:
This is a truism, not that helpful in decision making I would have thought.
++++++++++++
Actually, very helpful in decision making. It means you need an indication for proposing a course of action. That you need to communicate what the benefits are (or the risks of not acting) and what the harms/risks are.
Are you suggesting that we should simply shrug and say "oh well, its all merely worthless truisms anyway...so what's the point of trying to get a grip of where the balance of benefit and harm lies?"
The whole point of research into CS for this or that indication is to try to grapple with those issues.
From Yehudit:
We can't afford to put a NICU everywhere
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There's also a case to be made that specialization at regional centres with a critical mass of cots and staff is important in having the reaching a high standard of care, and that this is undermined if there are lots of small NICUs.
I know the arguments both ways, since our own Level III NICU has been growing exponentially while others in the area have become Level II SCBUs (from Level III NICUs). I think it is *very* hard on parents who are further from home - but we have the level of expertise we do because we serve that size of population, and have a big team of well-qualified staff able to work together - more than the sum of their parts. It's a tricky one.
From Liz:
Are you suggesting that we should simply shrug and say "oh well, its all merely worthless truisms anyway...so what's the point of trying to get a grip of where the balance of benefit and harm lies?"
Nope. I am very much in favour of trying to get a grip, and if there is a good chance that that will happen, I would be delighted. But in the absence of a crystal ball that makes it obvious which CS is absolutely necessary and which is not, the very negative view of CS seems unhelpful to me. The initial sentence seemed to me to translate to "only do it when you have to", and I think that is what happens now.
From Adrianna Joanna:
"I suppose what disturbs me is some kind of paradign shift that not only presents birth as largely hazard free but turns a "natural" birth into some kind of feminist or feminine accomplishment. Up until relatively recently, all women had a pretty clear understanding that it was neither, and I guess the majority still do. But the rhetoric of NCB is prevalent and popular, not to mention very appealing to the ill-informed."
I stopped visiting posts about childbirth on feminist blogs for just this reason. It really is remarkable to me how outraged they get over the "ridiculously high" rate of C-sections in this country, and how shocked they are when other people simply fail to see the travesty.
NCB advocacy absolutely privileges one form of birth over another. There are very few, if any, instances in which a woman must always have a C-section. It at all possible, a woman must try to deliver vaginally, regardless of what is safer, more effective, and, to a lesser extent, what the mother prefers. NCB advocates assume that all women want this ideal birth, and that one of their goals should be to reduce the number of C-sections.
How about reducing the incidence of complications that lead to C/S, but out of a desire to protect the mother and baby from the complications, not to reduce the rates of C/S?
How about making C/S safer? And performing them as needed, and, to a lesser extent, as desired, as opposed to obsessing over a fixed rate? ( already discussed the ableist connotations, but I can't emphasize enough how loaded it is.)
Keep in mind that these people aren't just providing women with information about all their options and giving them the resources they need to carry them out. They ONLY discuss options that favor natural childbirth-vaginal delivery if at all possible, reduce the rates of C/S, and that women should feel victimized by C/S, and if they're not, they must not know what really happened to them. Whenever they talk about increasing options for women, they only talk about specific options.
The problem is that the answers to their questions are irrelevant to most women. We really don't care that we COULD deliver twins vaginally if we wanted to. Many of us would still choose C/S. I just find it galling that people who are supposed to be advocates for all women's choices and well-being are privileging themselves over everyone else.
From Caryn:
c) The women who will have complications will likely have worse outcomes than they would have done in hospital, but that doesn't mean that outcomes will be worse overall (because you haven't addressed the issue of incidence of complications - despite my citing some examples of complications that appear to be less common with planned home birth than in equivalent women booked for hospital birth).
You appear not to understand that I *have* addressed that.
From Yehudit:
Actually, no you have no addressed that. You have ignored that incidence of some complications may be higher in hospital for women who are low-risk at labour onset. (I gave a couple of examples of where this may be so: postpartum haemorrhage, need for neonatal resuscitation). So, all we can say is "We don't know" - for women at low-risk of complications at labour onset is we do not have enough information about the possible risks to either the woman or her baby relating to planned place of birth. And we can explain that in the event of complications they may have a worse outcome if they are not in an obstetric unit. At the same time, while we can't say which is safer, we have good reason to think that home birth can be made safe enough to be a supportable option.
From Liz:
I am beginning to have some trouble here with the imprecision of some of the things you are discussing. As someone who had two CS, I am nonplussed by the devastating list of possible complications, none of which I had. The giving of informed consent may well have been different in my day, and given that I didn't have a choice, I am bemused. Given that not all CS are unnecessary, how exactly does it help with "choice" to be be given a long list of disasters without much of a guide to their incidence? The same mechanism comes into play as in homebirth - and optimistic assumption that it won't happen. The difference is it is seldom a choice between two equally viable options.
There is a strong strand in extreme NCB that bad things only happen to "bad" women, the careless, the genetically flawed, the "uninformed". This goes into reverse with CS. "Good" advocates of natural, vaginal birth are forced to become "lesser". This pisses me off. And what happened to "correlation is not causation"? Above you cite pph and neonatal resus. You lose more blood during surgery - I did lose 500 ml, I in no way consider I had a PPH. It seems to me to lump the two together may well be medically and statistically accurate, but misleading. And isn't it possible that more babies who were in sufficient trouble to merit a CS may need a degree of, for all I know, precautionary help?
Elsewhere I have been involved in arguments about the resus of very premature babies. There is a school of thought that says that this is a form of abuse, and useless because the statistics "prove" that most of them will have disabilities. Leaving aside what Adrianna (quite rightly) calls the ableist assumptions here, these "disabilities" can range from the devastating to the relatively trivial - sounds good though, and the statistics may be accurate. (They go out of date pretty quick). The anti-CS argument seems to me as unconvincing.
From Yehudit:
I in no way consider I had a PPH
+++++++++++++
The usual technical definition of a postpartum haemorrhage is >500 mls OR if woman is symptomatic regardless of amount.
That is what is used in research studies when assessing whether intervention X reduces or increases the incidence of PPH. The WHO want to stick to that definition because in developing countries where anaemia is prevalent, because in those contexts most women will become symptomatic at that level of loss. Some studies do give figures for both 500 and 1000ml loss.
My own unit (and I think most in the UK) classify pph as > 500ml or symptomatic. I know there are some units that classify pph as > 1000ml or symptomatic.
But whichever way you classify it, it makes sense that the definition of pph is the same for CS and vaginal birth. That's because, in terms of the *effect* of blood loss, it doesn't matter *how* that blood was lost. What matters is how much blood was lost as a % of blood volume and how able you are to cope with that blood loss. For example, if you start with a low Hb, then it takes a smaller blood loss to put your Hb below the treatment line (and you will more quickly become symptomatic) than if you had a higher Hb to start with. There is a reason why we do a full blood count for all women 2nd day post caesarean section, because they are more likely to have a pph (or >500ml blood loss, if you prefer) and more likely to have Hb below treatment line.
From Yehudit:
I am nonplussed by the devastating list of possible complications, none of which I had.
++++++++++
That's why we call them "risks"... caesarean section significantly increases your risk of placenta accreta and placenta praevia in a subsequent pregnancy. But you would still be very unlucky if it turned out to be you. Similarly, plenty of women have VBAC without any of the complications quoted, and they would be pretty unlucky to suffer uterine rupture. Doesn't mean that previous CS is not a risk factor for uterine rupture, it clearly is.
Sometimes caesarean section will be clearly the safest option for both mother and baby, it doesn't mean the risks of CS vanish. It just means that there are greater risks from not doing the caesarean section at that point. That doesn't mean we shouldn't take into account the risks of CS when thinking about whether and how we might reduce the number of women who find themselves in that situation of requiring CS.
From Yehudit:
And isn't it possible that more babies who were in sufficient trouble to merit a CS may need a degree of, for all I know, precautionary help?
++++++++++
The study I was referring to (Chamberlain) with regard to 'need for resus' compared women booked for home birth (the 'cases') with women booked for hospital birth (the 'controls') matched for parity and obstetric risk factors, demographic and socioeconomic markers. Maybe the reason that there was more 'need for resus' in the hospital group was that there was also more 'need for CS' in the hospital group. But then the question is why? And wouldn't a reduction in the *need* for CS be a good thing, all other things being equal?
From Liz:
Yehudit, I agree with what you say, and see the point of what you say. I still think it begs the question. I don't know whether it is appropriate to talk about a small haemorrage, and I take your point about being symptomatic, but when one talks about the danger of PPH at home, this is not what is meant. A slightly excessive blood loss at home probably can be dealt with without too much of a problem, catastophic bleeding could not, and if statistically they are treated as equivalent that may make sense for the statistics but it is misleading in argument. And I am trying to make the same distinction about the risks of CS. Yes, the risks have to be taken into account, and I am by no means arguing for casual use of CS, but the same "but you can't be sure it won't be you" argument applies to homebirth.The risks of CS are stressed, the risks of homebirth are minimised.
From Ericacrochets:
And the interesting thing is that most of major risks resulting from a prior c-section (uterine rupture, accreta in subsequent pregnancies) are much reduced by scheduling another c-section. Rupture rarely occurs unless in the mother is in labor, and accreta is much better managed in a c-section, so far as I know. Wouldn't we reduce the risks of rupture and accreta if we returned to "once a c-section, always a c-section?"
From Yehudit:
Liz, this was exactly my point when I said "The incidence of 'severe postpartum haemorrhage' as a subset of all pph is unclear."
In discussions about homebirth, pph is frequently mentioned as a relatively common event (around 6% of all deliveries says my copy of Mayes, using the >500 mls definition). But if we are going to only talk only about "massive obstetric haemorrhage" (various definitions used - it's a muddy area) then we are in a different territory in terms of incidence (as well as seriousness). I've seen estimates of 1.38/1000 (recent article in the AJOG) in hospital setting, which includes the difficult CS complicated by placenta praevia with accreta as well as MOH following spontaneous vaginal delivery.
From Yehudit:
Wouldn't we reduce the risks of rupture and accreta if we returned to "once a c-section, always a c-section?
+++++++++++
We might more effectively reduce the risks of rupture and accreta by reducing the primary section rate. The risk of haemorrhage from accreta is at the point when you try to remove the placenta from the uterus - whether that be manual removal of placenta following vaginal delivery, or during caesarean section. If you have anterior placenta praevia, you risk cutting through the placenta when doing a lower segment CS. (Surgeons will go for the same scar site). Then you have a very short time to get the baby and placenta out. If the placenta has grown into the uterus at the point of the previous scar and new incision, you really don't want the complication of not being able to remove the placenta quickly once you have cut into it. I don't know the stats, but I would think that vaginal delivery followed by manual removal of placenta in theatre might be safer.
From Adrianna Joanna:
"And the interesting thing is that most of major risks resulting from a prior c-section (uterine rupture, accreta in subsequent pregnancies) are much reduced by scheduling another c-section. Rupture rarely occurs unless in the mother is in labor, and accreta is much better managed in a c-section, so far as I know. Wouldn't we reduce the risks of rupture and accreta if we returned to 'once a c-section, always a c-section?'"
Absolutely. While I still believe women should have the choice to choose between elective repeat C-S or VBAC, I think a lot of women would shy away from VBAC if they knew the truth about it, and the truth about C-sections. But to inform women of this and be successful, you have to do more than just tell her the truth. You have to strip away the privilege that has been given to vaginal birth and, be extension, the sense of inferiority she may feel and that many people are all too happy to reinforce.
From Yehudit:
I would think that vaginal delivery followed by manual removal of placenta in theatre might be safer - assuming that the placenta is well clear of the os.
From Alexis:
Accreta is unrelated to choice of delivery for your current pregnancy, though. CS doesn't avoid the accreta. The only question is whether planned CS avoids the complications of accreta or not.
Since repeated CS increases the incidence of accreta and percreta in subsequent pregnancies (and we're seeing a rise in incidence) the advantages of CS in treatment (if they exist, I'm not in a place to decide) might be outweighed by the increase in incidence if we went back to "once a CS".
From Ericacrochets:
Well, if you have undetected accreta, it's going to be an emergency situation and much worse in a vaginal birth, I would think.
From Ericacrochets:
I think vaginal birth will no longer seem sensible within a few generations. It never worked so well to begin with. Mothers and babies are surviving who never would have in nature. Girl babies born by c-section to mothers with small pelvises who never would have been able to give birth in nature. Women like me surviving their first pregnancy in spite of a bad case of preeclampsia and passing those genes on to multiple children. Diabetics having children. There are probably other inheritable conditions that make childbirth difficult that we can now pass on.
The human species is rapidly becoming completely dependent on modern obstetrics, including c-section. Maybe only 15% or so in this generation NEED a c-section. But the number is going to keep going up.
It seems simpler to improve our surgical techniques and just get everyone out by c-section. As it stands, if a woman has only 2 children, the long-term risks of elective c-section and planned vaginal birth are about the same.
How are we going to make vaginal birth safer? Is there a pill that can be developed to improve placental development? Something we can do to make the mother's pelvis accomodate a baby's large head better?
From Caryn:
You have ignored that incidence of some complications may be higher in hospital for women who are low-risk at labour onset.
No, I have not. I said, Of course there are possible downsides of treatment for everyone.
As we discussed earlier, the ability to pick out who, precisely, is going to need treatment changes with time. At the historical point when the decision was made to move to 100% hospitalization, some of the diagnostic techniques we can use now were unavailable.
Given what we knew at the time, and given that the hospital comes along for the ride when you offer effective treatment for some emergency pregnancy conditions, it's unsurprising that hospitalization wasn't tested per se, as there was no way to offer effective treatment of these conditions absent a theatre.
So, here we are, with everyone treated at the hospital, Then people start to make the argument that hey, some of these people maybe aren't going to need those sorts of treatments but are experiencing downsides from hospitalization that they don't need. Fine. Seems plausible. Can we make a compelling and plausible case for how to pick those people out of the population and do a study showing benefit to them?
'Cause that's what we're waiting on, here.
From Caryn:
How are we going to make vaginal birth safer? Is there a pill that can be developed to improve placental development? Something we can do to make the mother's pelvis accomodate a baby's large head better?
If we improve placental development, fewer babies are going to fit out, because they're going to grow bigger.
From Morgan:
I think vaginal birth will no longer seem sensible within a few generations. It never worked so well to begin with.
Seems like a rather grim vision for future mothers. A good many of us consider a c-section a last resort and not a preferred first choice. If you want to speculate on the future, I would say it is more likely that artificial wombs will eliminate the need to even become pregnant. Deposit your sperm and eggs at your local lab and they will grow your baby and notify you when it is ready to pick up. They might even come up with a home model so you can watch it develop. Much tidier than a vaginal delivery or a c-section.
From Adrianna Joanna:
"Seems like a rather grim vision for future mothers. A good many of us consider a c-section a last resort and not a preferred first choice. If you want to speculate on the future, I would say it is more likely that artificial wombs will eliminate the need to even become pregnant. Deposit your sperm and eggs at your local lab and they will grow your baby and notify you when it is ready to pick up. They might even come up with a home model so you can watch it develop. Much tidier than a vaginal delivery or a c-section."
Sorry, but I just think that's an adorable idea. I hope that becomes a reality someday soon!
From Lies_DamLies_and_stats:
[shudder] O, Brave New World...
I don't think it's an adorable idea - in fact, it makes me rather ill. I can definitely understand how some people would find it appealing. I think there's a whole continuum of ways we might want to be removed from "nature," or from our humanity (and yes, I do differentiate the two, because I do believe it's in the scope of "human nature" to manipulate their environment, thus potentially creating "unnatural" situations). I am definitely not on an extreme end of that continuum myself - for example, I love (and sometimes depend on) my climate control. However, when touching upon issues of reproduction, I believe (and I know, YMMV) that those issues approach the connection between the human and the divine, and there are some things I really prefer not to mess with. Promoting the body's own natural abilities and health, and working with what we are given? Sure! Working against what we are given, and privileging artificial processes over natural ones for the sake of convenience, selfishness, "choice," what have you? Not for me, and I wouldn't condone it, either. Of course, being a realist, I understand that people will do what they will do, and I can only work in my own small corner of the world.
From Liz:
Convenience, selfishness - is that what it would be? I'm not so sure. What if it was better for the child? An optimising of its life chances, like breastfeeding? I don't see it ever happening, but it is an intriguing idea to play with. Like Adrianna, I can see its enchanting side. To watch it grow, marvel at it, keep it safe, know it intimately - how amazing. The miracle of the creating of a life would still be there. But what the psychological effect on women would be is something else. Bit hard to turn that into a competition - the focus would have to shift to child rearing, not bearing. Would men dispense with our services? Gender inequalities be wiped out? As this forum has often demonstrated, so much of our identity is bound up in this haphazard process. Then again, some of us have spent a couple of months sitting next to incubators. Doesn't change much about your feelings, except maybe to make a life seem more precious.
From Adrianna Joanna:
"Promoting the body's own natural abilities and health, and working with what we are given? Sure! Working against what we are given, and privileging artificial processes over natural ones for the sake of convenience, selfishness, "choice," what have you?"
What' wrong with privileging artificial processes over natural ones if the artificial one is just as good or better? What's wrong with wanting more of what you've been given is shit? And don't assume that we all have these "natural abilities or health" that we are supposed to work with, either.
As for convenience and selfishness, what's so bad about wanting to avoid pregnancy complications? To circumvent infertility. For some women, that may be the only safe gestation, or possible one if you are infertile. If you are transgender, pregnancy can be very painful emotionally, and those who haven't gone through it don't understand it. Yet they still very much want to love a child. And it's technology which allows many of us to express our identity.
Never mind that when it comes to selfishness, NCAs and HBAs as a group really take the cake.
Benefits to the baby? Obviously, there are the potential health benefits, but what if, maybe, there are other benefits to the baby's development? More developed brains at birth? More abilities at birth?
I don't think it diminished the miracle of life at all. I actually think it makes it more precious. If you pregnancy is causing you pain, discomfort, or ill health, or if the pregnancy is unwanted, it is unlikely that you will appreciate much about the "miracle" that is wreaking havoc on your life just by existing. But if you can place the baby in an incubator, the problem is solved.
Just think! Another benefit! There is absolutely nothing wrong with abortion, in my view, but if we could find a way to transplant naturally conceived babies into incubators, abortion would no longer have to happen. It's a nice compromise between pro-life and pro-choice people, and women who are uncomfortable having a TOP but who feel they need them can rest easy. They are also more likely to have them if TOP is truly what's right for them rather than risk a poor alternative choice.
I'm getting way ahead of myself, but I just think it's a wonderful idea!
From Lies_DamLies_and_stats:
Liz, I must say I truly enjoy the candor of your posts, even when I disagree with certain points of content. As someone who is scientifically minded and loves to observe processes, there's definitely a part of me that _would_ be completely enchanted by the opportunity to sit by a transparent incubator and watch life develop, day by day... to have a formulated schedule and maintenance process and know that I can strictly follow a routine of x, y, and z to truly optimize health and development... but it's not that way. And remove things as much as you want, in creating a human you will always be dealing with _some_ elements of nature, which will have _some_ complex variations beyond our control. If one can't handle that, one should go into robotics.
As to the convenience and selfishness, yes, I stand by that. And Adrianna's post has given us a shining example of selfishness and entitlement - I could hardly have asked for a better example! Here's a news flash - you're not entitled. Just because I speak of "natural abilities and health" doesn't mean that everybody has them, or to the same level. I have a friend who was born blind, but I could only wish for hearing as subtle and sensitive as his (he's one of the best music adjudicators in the state). Does it mean that he doesn't wish he could see? Not at all - but he focuses on what he can do, not what he can't. I myself struggle with infertility (funny you should have mentioned that), along with metabolic and hormone disorders. We have found natural means - working _with_ what I've been given, as opposed to against it - to circumvent those issues and have managed to conceive and bear children, multiple times. Easy? Not at all, and required a lot of compliance and commitment from me. But worth it. If we had not, through research, hard work, luck, and divine intervention, found these means of dealing with the roadblocks to having our own biological children, we were prepared to adopt rather than artificially create our own genetic children. In fact, I had already started researching paths to adoption. Yes, it was important and preferable to me to have my own biological children, because I felt that that was the way things should work. But "expressing your identity?" Give me a break! You express your identity _much_ more in how you raise your children than in what genes you give them - and that has nothing to do with technology, and everything to do with nurturing. Bottom line - yes, not everybody gets the "Greek God" ideal of life. It's not fair. Get a helmet. If you take your eyes off of that artificial ideal, rise above the "me me me my my my" entitlement of the culture we live in, and focus on what you have and can do, you get much further and tend to be much more content.
As far as the notion that an artificial process is truly better, safer, more beneficial than the natural one, you need to convince me. Can you point out even one routine process (and note that I said "routine," I'm not talking cases of pathology that are not the norm, but rather something that should be mainstreamed and offered/done to/by all women because the balance truly is on the artificial procedure for benefit over harm for the entire population) where the artificial is better/safer/more beneficial? Can you demonstrate its superiority in physical, emotional, logistical, and moral domains? I've looked around and I can't think of any offhand. Have you never noticed the tendency of science to point us toward nature and/or divinity (depending on the particular situation and your theist leanings)? Have you noticed how artificial processes tend to look up to natural ones? How there is tweaking, striving, improving, and all it does is try to more strongly imitate what we already had available in nature? Take breastfeeding vs. artificial feeding. Formula is constantly "improved" by making it more like breastmilk. Bottle nipples (and their non-nutritive friends, pacifiers) are constantly "improved" by making them more like breast nipples. Flow in bottles is "improved" by making it more like the flow from a breast. Or you could just save the money and effort, and breastfeed your baby. Can't do it from mom's end? That's what women have used wet nurses for since time out of mind. Can't do it from baby's end? Well, there are, for example, rare cases of galactosemia (and I know from galactosemia, I have a galactosemic family member, so this is not academic for me). Used to be an evolutionary dead end - like many other conditions. Fortunately (on a micro level), babies will now survive. Unfortunately (on a macro level), they can pass those genes onto offspring if they reproduce.
Another example would be infant sleep. We see research all the time about temperature, white noise, sucking needs, etc. Sure, set up an artificial environment that strives to imitate... ready for it? Sleeping at mother's side in a safe, firm environment. (Apologies to the moms who like their waterbeds.) I could go on with several other similar examples, but I think the point has been made.
Sure, there are devices that can increase our convenience. There are drugs and processes that can save cases of true pathology. These are not necessarily evil. However, replacing natural processes with artificial ones just for the sake of doing so is not necessarily best, just because they were invented by a person and may provide an illusion of greater control. Sometimes they are inferior (of course, then comes the battle cry of "it's good enough!" that's a whole other rant). Sometimes they are equivalent, but they are also a giant Rube Goldberg machine when one could simply use what's already available and purpose-designed/evolved (and hey, if you want to, go right ahead, but don't expect sycophantic admiration from me).
From Morgan:
Birth has always been potentially dangerous. The history of obstetrics is filled with attempts to thwart nature and make birth safer and less painful. In many instances, the results were an improvement and in many they weren't. The greatest limiting factor is the woman herself and the design of her reproductive system. An artificial womb would remove this obstacle. Birth would be safe and the process could be controlled. The advantages are many. The technical aspects are within our reach. Whether it is moral and where it would lead the human race is another matter. Many of our advances in science have ended in unforseen results. Some good and some bad with many being a mix of both. Artificial birth will be tried though. It is in the nature of Man to do such a thing.
From Yehudit:
Imagine the carbon footprint!
From Li:
Hi ladies,
NY Magazine has a big article on homebirth and I wanted to make sure you saw it:
http://nymag.com/news/features/55500/
From Li:
P.S. someone has a blog called http://cesareandebate.blogspot.com/
Seems to be covering a lot of the same issues that are (were?) debated here.
From Myriam:
Oh, is this debate over? Who won?
From Ericacrochets:
I subscribed to that blog. It's very interesting.
From Li:
I love that one of her blog tags is Birth Autonomy. Good for her for putting it out there.
My husband has a friend whose wife just had a home birth. The birth went smoothly even though the baby was in the asynclitic posterior. One disturbing little tidbit was that when the midwife saw the baby's position she said, "Get a camera! You almost never see that." Er, seems to me she should've been thinking, "This position is associated with increased shoulder dystocia and third degree tears, so my assistant and I should be on high alert for complications."
I don't have a problem with homebirth with a well-trained attendant but a lot of these lay midwives have too cavalier an attitude about potential complications. The midwife in the NY Magazine article exemplifies that for me.
From Caryn:
An artificial womb would remove this obstacle. Birth would be safe and the process could be controlled. The advantages are many. The technical aspects are within our reach.
Oh my goodness, no, they're not within our reach. We don't even *understand* what's going on with the immune system when it responds to the foreign trophoblast, nor how epigenetic processes are involved here.
From Yehudit:
Artificial womb = no immune system, right? So, it's an all round winner? I don't understand why everyone isn't signing up.
From Emma B:
Oh my goodness, no, they're not within our reach. We don't even *understand* what's going on with the immune system when it responds to the foreign trophoblast, nor how epigenetic processes are involved here.
We're not really even that good at managing in vitro fertilization and conception, which is the "easy" part.
The overall IVF success rate is pretty low, much more so than people tend to assume. On average, only about 50% of retrieved eggs fertilize, only 50% of the fertilized ones grow and divide for two or more days, and only a minority of those actually implant and become viable pregnancies. The overall success rate per cycle is about 40% (with significant variation for age, diagnosis, and clinic, but 60% is the top end of the range), but that is misleading. 75% of those 40% pregnancies are singletons, and since most IVF cycles involve two or three embryos being transferred, there's a lot of loss there too. It's hard to pin down the exact number, but you could call it a 10% chance that any given fertilized egg will turn into a pregnancy.
With such high failure rates in the earliest stages of pregnancy, it will be a very, very long time indeed before in vitro gestation becomes a reality.
From Liz:
it will be a very, very long time indeed before in vitro gestation becomes a reality.
And is anyone seriously trying? It seems to me (sometimes) that there is a lot of useful research into the present status quo that isn't being done/can't get funded.
From Liz:
Oh, is this debate over? Who won?
Well, I think you could say that Homebirth won, as their web sites can now dominate the internet. My own very personal opinion would then be that women in general lost.
From Liz:
Decided I should clarify the above, instead of going to bed, which is what I should be doing.
I don't know whether it is true or not, but the writer of the New Yorker article implied that films like Business of Being Born are "selling" the idea of homebirth as new, fashionable, safe, and that this is attracting more women to the idea. Now, I have no problem with women who, knowing exactly what they are risking, choose home over hospital. I do have much more of a problem with less experienced or well informed women being sold the idea that it is unproblemmatic, and/or being given biased or innaccurate information as so many of the homebirth websites do. The happy-clappy "complications are no big deal" sites drive me nuts.
From Morgan:
Oh my goodness, no, they're not within our reach.
Supply the funding for research and development, stoke consumer demand and stand back and watch it happen. Of course if consumers are content with the state of things today, then you can continue to get by with the plodding progress we have had to this point.
From Morgan:
So, it's an all round winner? I don't understand why everyone isn't signing up.
Make it available at an affordable price and see how long it would be before you'de be retraining due to lack of business. It was just a thought for a possible improvement on what to me is an industry that could use a little innovation. I doubt though that many who make their living from the birth industry would support the development of anything that could jeopardize their income. Sort of like the battle that brakemen and conductors put up when "End of Train" electronics did away with their railroad caboose.
From Ericacrochets:
I think the artificial womb will be on the horizon well after the point we can clone organs. I think for most women it would be a last resort, something done instead of hiring a surrogate. Making an artificial womb is one thing, and we're not really close to that. Making an affordable artifical womb I can't imagine happening for a very, very long time from now, if ever, as it would probably require a lot of resources, monitoring, and specialists to construct and operate. It would be great if we could transplant preemies into one, but that would likely even be harder than starting out with an artificial womb.
I see at as more as a last resort, possible an alternative to hiring a surrogate mother or not having children at all. It could be nice in situations of infertility, if the mother's health is not suitable for childbearing, and an option for gay men.
Would most women really want to give up pregnancy if they had a choice? As miserable and risky as it can be, most of us at least enjoy aspects of it. And I do think there is much to value in the process. Like being so large and miserable that caring for a squalling newborn after major surgery is actually preferable. : ) At any rate, pregnancy was an experience I am glad to have had.
I think giving every woman the option of c-section is much more likely to happen soon and be cost effective. Planned c-section in healthy women with no medical indication needs more research. It COULD even save money because emergency c-sections (much increased maternal complications) and situations where the baby needs a lengthy NICU stay after a vaginal birth complication would be avoided. I don't think it would take a huge amount of improvement to make c-section safer overall, since planned c-section already seems to be safer for the baby. And maybe there will be a discovery that can eliminate the risk of TTN in c-section babies at term. In a generation, it may be a safer choice for both, and it will be interesting to see what happens with that.
From Caryn:
Supply the funding for research and development, stoke consumer demand and stand back and watch it happen.
Wrong. Science is *not* a magic vending machine where you put in a quarter and place an order. Or even a quarter of a trillion dollars. It could be that such things will be in the cards in the long run, but we currently lack even the basic research that would be necessary to generate this kind of technological advance.
Epigenetic mechanisms are something we've only just begun to understand even a tiny little bit, and we *certainly* don't understand them well enough to turn them off or on on purpose, let alone how to regulate the genes critical for development.
From Lies_DamLies_and_stats:
And that hits on a very fundamental problem - people tend to jump in with both feet and implement half-baked, half-understood technology, and it spreads like wildfire under the illusion that it is better because it is "scientific," and it becomes the standard of care. For example, cEFM. Yes, there are cases where it is quite the boon, and we are grateful for it - but it is not fully understood, it is improperly used, and it does cause more harm than good in some cases. Talk all you want about type I vs type II error, and how you'd be grateful for it if you were the mother whose baby was saved, but mightn't you be upset at its misuse if you or your baby suffered greater morbidity or mortality because of it? Another example: vacuum extraction. Seems like a great idea - a new technique to avoid those nasty forceps, extending episiotomies, etc., and you can even do it with less training! Except now many OBs are actually moving _back_ to forceps in light of newer risk assessments that do not favor the vacuum.
I don't have a problem with the development and use of new technologies in and of itself; I do have a problem with the widespread acceptance of said technologies based upon insufficient evidence, particularly when bioethics are barely (or not at all) considered.
Oh, and as a random data point - I love my children, and I even like giving birth, but I _hate_ being pregnant. With the passion of a thousand fiery suns. At the same time, I do still value it as the means to an end, and I still believe in a system of values where the end does _not_ necessarily justify the means. I feel it's a symptom of our diseased culture that people feel they can use any means necessary to get the end that they want, and that this is all right because it works for them.
From Lies_DamLies_and_stats:
P.S. someone has a blog called http://cesareandebate.blogspot.com/
Seems to be covering a lot of the same issues that are (were?) debated here.
Doesn't seem like much of a debate to me, as there does not appear to be any interaction... just seems like the thoughts of one person. Sure, put your opinion out there if you wish, but don't call it a "debate" when it's completely one-sided.
From Yehudit:
Wrong. Science is *not* a magic vending machine where you put in a quarter and place an order.
++++++++++++
What we have here are just two ends of the "mind over matter" spectrum - whether that be "birth is as safe as life gets" or "the future is sci-fi".
If unassisted birth won't do away with the need for midwives (and it won't) then the not-on-the-cards-in-my-lifetime artificial womb certainly isn't. So, sorry to disappoint Morgan, my dreams of an incredibly lucrative career in NHS midwifery aren't about to be dashed by medical researchers tinkering with artificial wombs.
From Liz:
I didn't exactly enjoy my pregnancies, nor hate them, but as an experience, I wouldn't want to have missed it. Being home grown didn't make any difference to my feelings for my children, I don't think - but it did make a difference to my feelings about my body. First, amazement that it "worked" then exasperation that it stopped working - or took a not uncommon variation into high risk. Thinking about it, it is my womb, not my vagina, that makes me womanly. I would feel, even now, the same about a hysterectomy as some women feel about vaginal birth. So it would be the psychological and social change in artificial reproduction that would fascinate me. Still don't see it happening, but who knows? Would love to see some real technological advances in the old fashioned way, though. Fit us with zips and glass plates - or high tech equivalents. Remove the guesswork. Better placental function tests, better induction methods, foolproof pain relief. Make it safe for real, and an artificial womb would stay a niche concern, not a universal choice.
From Myriam:
"So it would be the psychological and social change in artificial reproduction that would fascinate me."
Liz, have you read the Dialectic of Sex by Shulamith Firestone? A fascinating and once very influential book but somewhat of its time (1970). I can't imagine today's bestseller list containing a Marxist feminist screed that argued that women's oppression is firmly planted in nature and therefore the only logical solution is to transform the "mode of reproduction" (snigger) through cybernetics.
Personally (and this is going to sound a bit smug) I found pregnancy a time of almost superhuman health and well-being (even when I had placenta previa). I've never functioned better, or been mentally sharper, although it's true that you can't run very fast at the end. So I've never understood why pregnancy and menstruation etc are often described as "women's ills". Looking after small children does make women vulnerable and dependent in many ways. Pregnancy? The least of our worries.
From Jen:
"So I've never understood why pregnancy and menstruation etc are often described as "women's ills". Looking after small children does make women vulnerable and dependent in many ways. Pregnancy? The least of our worries."
I think you're just lucky, lol. If all women felt "almost superhuman health and well-being" during pregnancy I doubt it would be called an "ill." I can't speak on pregnancy yet, but menstruation? Definitely an "ill" for me, lol. I have very painful cramps at least 2 days out of every period...painful enough that taking 800mg of Advil only takes the edge off. I usually end up curled up on the couch or bed with a heating pad, whimpering pitifully.
I had pain meds left over from a foot injury (tramadol) and used that last month...sweet relief! I'm thinking of asking my doc if there are some pain meds she can prescribe me to take only when Advil's not cutting it. So, yeah, it's an "ill" lol
From Liz:
I think you could argue a case that women's power is "planted in nature" and women's oppression stems, partly, from the fear of that power. I think it is true that one can feel invulnerable when pregnant - the carrier and nurturer of life itself - but very vulnerable indeed when responsible for children. An artificial womb would create a level of equality otherwise unthinkable, but until childcare became equal - and the economic structures that make it problemmatic now, I don't see that it would benefit your average women greatly.
From Caryn:
And that hits on a very fundamental problem - people tend to jump in with both feet and implement half-baked, half-understood technology, and it spreads like wildfire under the illusion that it is better because it is "scientific," and it becomes the standard of care.
Well, no. It doesn't become the standard of care because it's "scientific"; it becomes the standard of care *if the population as a whole has less mortality* when the technology is applied. *Then* you can start worrying about how to pull out the subset of people who might experience more harm than good from the application of the technology in question.
Artificial wombs, though, are such a developmental and ethical quandary that talking about them becoming the standard of care is just silly. First you'd have to have a plausible way to get a blastocyst through the embryonic stage into the fetal stage without any weird shit happening to it in the process, like extra arms or forgetting the eyeballs or rewiring the brain, and *then* you'd have to convince an IRB that it was ethical to take some blastocysts and try to turn 'em into fetusus in it, just to see if it worked, on the grounds that it would be better *for the mother*. Hah!
My (admittedly very minor) experience with both embryology and IRBs leaves me well-convinced that neither is terribly likely to happen, ever, regardless of how much money is thrown at the problem or how much consumer demand there is.
From Caryn:
(To make that a bit more clear: the word should be "fetuses", and the IRB would only do it if it was going to be significantly better *for the baby*, because hey, political liberalism and all. You might be able to make that case for preeclampsia/ IUGR, but we can't even think how to arrange for normal placental and embryonic development via technological means yet, much less make sweeping guarantees about how "this will prevent failed placentation!" And even if you've got a medium that is clearly growing healthier chimp babies with higher survival rates, that means *virtually nothing* when it comes to growing humans, because we are different from chimps precisely in the way that our placentas work.)
From Caryn:
Pregnancy? The least of our worries.
Well, for *you*. Us preeclamptics are sometimes a whole trimester out from labor when we get hospitalized in multiple organ failure...
From Emma B:
Supply the funding for research and development, stoke consumer demand and stand back and watch it happen. Of course if consumers are content with the state of things today, then you can continue to get by with the plodding progress we have had to this point.
As Caryn says, funding isn't the problem. There's funding available and research being done in a lot of the precursor areas, because these things are vitally important to women's health. However, our understanding of the in vivo gestation process has a very long way to go before we can start talking about applying it to in vitro gestation.
Why do some embryos implant, and others don't? Why do some embryos split into twins? What causes miscarriages of genetically normal embryos? Why do some placentas implant shallowly, and does that really cause pre-eclampsia? Why do some placentas implant too deeply and cause accreta? What stimulates surfactant production in the lungs, and can this be accelerated? What maternal-fetal interactions trigger labor? These are the types of processes we need to understand in detail, and obviously, they're important regardless of whether we want to grow babies in jars.
The Manhattan Project worked because we already had a pretty good grasp of the theory of nuclear physics, and all we had to do was engineer a bomb. (And, frankly, a nuclear bomb is a much simpler device than an artificial womb.) You can purchase applied science, but it's a lot harder to buy theoretical breakthroughs. Look at the Susan G. Komen Foundation -- hundreds of millions of dollars in research grants and funded fellowships, and our understanding of the causes and mechanisms is still far from complete.
From Emma B:
My (admittedly very minor) experience with both embryology and IRBs leaves me well-convinced that neither is terribly likely to happen, ever, regardless of how much money is thrown at the problem or how much consumer demand there is.
You're actually much more likely to see extrauterine gestation happen in the animal world first. Embryologists, especially the older ones, tend to have veterinary backgrounds rather than medical ones, because the ethical concerns aren't such an issue in animal research. Artificial insemination and IVF were both developed in animal husbandry years before human use began.
From Emma B:
If all women felt "almost superhuman health and well-being" during pregnancy I doubt it would be called an "ill."
I couldn't keep food or liquids down without medication my first trimester of my second pregnancy, and spent the entire third one on bedrest trying not to have the baby too early. That's pretty clearly an "ill".
I had pain meds left over from a foot injury (tramadol) and used that last month...sweet relief! I'm thinking of asking my doc if there are some pain meds she can prescribe me to take only when Advil's not cutting it.
Ask your doctor about prescription NSAIDs like naproxen or indomethacin or mefenamic acid -- these are pretty standard for dysmenorrhea. I have endometriosis, and I've been having some success with mefenamic acid.
From Yehudit:
it becomes the standard of care *if the population as a whole has less mortality* when the technology is applied.
++++++++++++
That is how it is meant to work, in an ideal world. That is not really the story of how technology has been introduced in the real world, however.
From Caryn:
That is how it is meant to work, in an ideal world. That is not really the story of how technology has been introduced in the real world, however.
Yes, our understanding of ethical approaches changes with time. Atul Gawande has an interesting article on technology in childbirth at the New Yorker.
But any novel artificial womb technologies would have to clear the hurdles I mentioned.
From Morgan:
I would like to clarify a few points.
I tossed out the artificial womb in response to a statement that c-sections should be refined and perhaps used for everyone in future births. A c-section is a bugaboo of mine. Maybe even close to a phobia. I wouldn't consent to one unless it was an absolute last resort. Even then they would have to knock me out so I had no memory at all of what transpired.
I'm old. I have seen so many things in my lifetime go from impossible to reality and then to common place that I don't accept that anything can't be done. Being possible and being easy aren't the same thing. I also didn't mention a time frame for development of an artificial womb. I just think it would be a worthwhile development.
Please bear with me while I try to explain why I hold the views that I do. I gave birth to twins at Sandia Army Hospital in April 1965. I had an early onset of Toxemia. My army captain OB put me on a 900 calorie low sodium diet. Maybe diets don't work but he got me to term without being hospitalized or having any further problems.
My labor room wasn't as fancy as a modern faux home bedroom LDR but it had a comfortable bed and a nice chair for my husband. I was the only one in labor and we had the whole floor to ourselves. I was also free to wander all I wanted. Delivery was in one of the OR style rooms typical of the times. They could be intimidating to a woman but I had a super staff supporting me and it didn't bother me at all. The only glitch was that Gloria, the night nurse, neglected to give me the required enemas and I pooped in the middle of their sterile field. A sterile field was viewed with almost religeous fervor back then and Gloria got one of the worst ass chewings I've ever heard. I really felt for her.
Two years ago, my neighbors daughter gave birth to a son in our areas most modern hospital. She had an ultra modern LDR that was nicer than my labor room. Her husband, mother, dad and sister were with her. My husband was scooted off to a waiting room. She had a fancy delivery bed. I had one of those stainless steel Shampaine style tables. I was on my back with my legs strapped into holders that kept them high and spread. She was on her back with two nurses holding her legs up and spread with her knees shoved back by her head. They put leather handcuffs on me to prevent me from touching the sterile drapes or my babies head. Her hands were free but she spent the whole time confined to her bed by the various devices they had attached to her. She had an epidural and I had nitrous oxide when they thought I needed it. She and her son were fine. My son, daughter and I were fine. A difference sure but really not all that much.
So what was the point of that? Simply to point out that in the forty two years separating those two births, the cosmetics and window dressing may have changed but the hard core reality is that almost nothing else of real importance has changed in the way we have babies. The old OR style delivery room worked just as well as the newest LDR and as has been mentioned often here, a healthy baby is all that counts. Doesn't matter how it got here. On the down, side all the hazards that existed back then are still just as dangerous today. So much for progress.
The lack of real progress in many medical fields, and obstetrics is only one of them, really depresses me. I lost my only daughter this past Christmas Eve to a seven year battle with Hodgkins disease. Right now I just don't have much patience with people who tell me something can't be done to improve the current state of things in medicine or that it is going to take a long time. Sometimes you just don't have a long time.
Sorry for the rant. My head is kind of messed up tonight. I'm not usually this bad.
From Ericacrochets:
I'm very sorry for your loss, Morgan.
From Liz:
Morgan, as someone else here who is "old", your post struck a chord.
First of all, can I say that for me to lose a child is the worst thing that life can throw at you, and you have my sympathy for the grief you must be feeling. No words can touch the pain of it, and the rage and impotence that nothing more could be done is more than understandable.
Against that pain, other points seem trivial. But I agree with you that your perspective does change with time. I can remember the amazement that greeted the first "test tube baby", and now it is commonplace. I also agree that not a lot seems to have changed in some areas. I was not impressed when my daughter had her first child that things were conspicuously better than when she was born, and some things - particularly the rather squalid indifference of post-natal care, staffing levels and, in England, choices based on inadequate funding and the need to meet "targets" seemed worse. I too believe that things could and should be improved - but that the "Homebirth Debate" doesn't do much to help. It diverts attention from the real problems, and allows attitude changes to take the place of genuine concern for wonen's welfare.
From Blend:
Excellent point made by Caryn, when one could be easily transported to a hospital, what is the point in it, that the state be providing license for the home birth....
From Myriam:
"Well, for *you*. Us preeclamptics are sometimes a whole trimester out from labor when we get hospitalized in multiple organ failure..."
And I had placenta previa and was at constant risk of unheralded catastrophic bleeding and was hospitalised antenatally for two weeks.
I'm talking about pregnancy per se not being a major factor in gender inequality now that we are able to control how many pregnancies we have.
Yes, complications can be debilitating. But pregnancy in general? There is still this perception that pregnancy must place us at a disadvantage. For example, women often complain that they suffer from muddled thinking while pregnant whereas tests find no objective cognitive impairment.
As far as menstruation is concerned, I'm reminded of my PE teacher (phys-ed in the US?) who used to tell us girls that we were excused from sport if we were having our periods, had just had our periods or were about to have our periods (tee hee).
From Jen:
"As far as menstruation is concerned, I'm reminded of my PE teacher (phys-ed in the US?) who used to tell us girls that we were excused from sport if we were having our periods, had just had our periods or were about to have our periods (tee hee)."
While I think it might be a little excessive for any girl to be excused because she may be near her period, I'm sure you would agree that any girl having pain from her period should be excused if she needs to be. There's no way I could function in any meaningful way as far as sports/games/exercise when I'm having my strong cramps. More like stand there, grind my fists into my uterus, and pay just enough attention that I don't get beamed in the head with a ball, lol.
From Ericacrochets:
"Yes, complications can be debilitating. But pregnancy in general? There is still this perception that pregnancy must place us at a disadvantage."
Well, many of us feel that it does. Are you saying that we are making it up? I'm delighted for women who can keep going for runs throughout their pregnancy and feel great the entire time. I felt wonderful for my 2nd trimesters and went walking 2 hours a day in my 2nd pregnancy. My 1st and 3rd trimesters I felt AWFUL. AWFUL AWFUL AWFUL.
However, I don't think pregnant women are making it up when they feel overwhelmed and have trouble concentrating, when they are exhausted and need to sleep 14+ hours a day, when they are queasy for months at a time, have terrible pain pain, ETC ETC ETC.
From Myriam:
"I'm sure you would agree that any girl having pain from her period should be excused if she needs to be."
Certainly, but a blanket dispensation? What sort of message does that send out to young girls? Fine by me, anyway, I hated PE.
From Caryn:
For example, women often complain that they suffer from muddled thinking while pregnant whereas tests find no objective cognitive impairment.
I think the jury's still out here; see this as an example.
I would say that some effects of complicated pregnancies don't end with delivery. In my pregnancy the placenta had successfully hijacked my metabolism, and burned through all my muscle tissue. At six weeks postpartum I had a BMI of 19 and was weak as a kitten, by which I mean I couldn't open the non-automatic doors at Target or walk for more than a quarter mile without getting winded.
If you think of pregnancies as the sorts of things that are likely to become complicated, and complications as the sorts of things that are, at least, not *unlikely* to have significant recovery time, doesn't the idea that pregnancy *can* place us at a disadvantage rather follow?
From Myriam:
"If you think of pregnancies as the sorts of things that are likely to become complicated..."
Hi Caryn
Yes, I was thinking that even as I was writing my previous post - that the phrase "normal pregnancy" perhaps makes just as much sense as "normal birth". I've spent two weeks on an antenatal ward, so I've seen it. However, even complicated pregnancies can have health benefits for the mother. So I think we'd have to balance the complications and problems against the health benefits before we decided that doing away with pregnancy was a good thing at the global level from a maternal health and well-being perspective in our utopian distant future.
Or we could approximate those benefits artificially, which is what already happens to some extent with the contraceptive pill.
From Karen:
For all of those who are interested, there seems to a link to low Vitamin D in early pregnancy and Preeclampsia.
http://jcem.endojournals.org/
cgi...ourcetype=HWCIT
This study was conducted with women in my area, (Northern United States) where half the year we get little Vitamin D from the sun, and unless you work inside you get little the rest of the year, (unless you are supplimenting).
As a Bradley teacher, I do not push the Brewer diet. I actually am always on the look out for new nutritional information, and would love any more that anyone here can give me. For some on my students, (esp. those going to Dr.'s I am sorry to say,) I am the only person talking to them about their diets.
The lady who came to every class with a Diet Coke in her hand was my favorite...
Karen
From Karen:
P.S.: I am desperately sorry about the spelling in my last post. I gave up coffee for lent, all morning related activities are suffering!
Karen
From Caryn:
Karen, keep in mind that a lot of autoimmune diseases affect serum vitamin D levels, and autoimmune diseases are associated with preeclampsia. It may well be that what they are finding here is not something that can be fixed with dietary supplementation or additional sun exposure, because it merely reflects an underlying condition which causes both things. (Notice that it's a difference in serum values and that they haven't tested yet to see if supplementation lowers rates. And that every time they've supplemented preeclamptics with some nutrient or other it hasn't worked, probably because it's dysregulated placentation that's causing the syndrome.)
Anecdote: I got severe preeclampsia in Phoenix, while drinking a quart of milk supplemented with vitamin D a day. But I also have psoriasis, which affects serum D levels.
I'm not aware of much at all in the way of good data connecting maternal diet to pregnancy outcome. It seems intuitively reasonable that a better diet leads to better outcomes, but that's not the same as evidence.
From Anonymous:
I carried twins and was struck with severe preeclampsia at 33 weeks gestation. What was strange to me was the fact that I had just seen my OB less than 7 days before receiving an ememrgency c-section, and my blood pressure was perfectly normal. I wonder if my intake of Vitamin D had anything to do with it? I will be trying again soon, and I want to try to avoid a second bout with preeclampsia.
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