From Basiorana:
I might call it failure to rescue if the midwife was a CNM or otherwise certified by the state.
If she is a DEM, it's medical fraud and more specifically, because a DEM is not a qualified professional, and she said she was a qualified professional to discourage the mother from getting real care, it is negligent homicide, at LEAST. In some cases, where the DEM actively fought against the mother seeing a doctor, it is more like second-degree murder.
From chris:
Good point Basiorana. If a Nurse was present in a home delivery and the Baby died, they would at minimum lose their license.
From Basiorana:
"If a Nurse was present in a home delivery and the Baby died, they would at minimum lose their license."
I don't know. I think an autopsy would be required to confirm that the baby died as a result of the homebirth, since, as Amy rightly points out, sometimes there are issues incompatible with life. And even then, if the death was a failure to rescue, and it was a licensed nurse, I think you would have to do an investigation-- was there any reason for the nurse to suspect a problem? Did they give full prenatal care, including all testing? Did they monitor the fetal heart rate during delivery? etc. If a CNM loses a baby at home, but had given proper care and monitoring comparable to a low-risk woman in a birthing center, I could see putting them on probation or preventing them from performing future home births, but maybe allowing them to keep their license, similar to any other malpractice case.
If the midwife actively discouraged a woman from seeking help when she should have known it was needed, then she should probably be prosecuted in criminal court.
From JJ:
"Problems in this category include shoulder dystocia and breech with trapped head or nuchal arms. Most of these babies will simply die at home."
Prove it! Show me in some way that is not mere extrapolation, conjecture and/or guesswork. Can we make this more fact-based, please? I'd like to see the #s. It's all well and good to state your opinion, but it doesn't mean much unless you can back it up.
"Unfortunately, if it does, the baby will most likely die as a result of failure to rescue."
Same thing. Where's the data?
I'm not saying you're wrong. It's just not terribly useful as long as your claims are unsupported.
From Susanne:
It's hard to make it fact-based, JJ, when MANA doesn't release statistics.
From Squillo:
JJ:
I was wondering the same thing, so I took a look at the CDC WONDER data for 2003-2004 for births in and out of hospital. I searched for deaths of infants < 1 hr to 6 days old, in the ICD group P00-P96 (certain conditions originating in the perinatal period).
For in hospital the death rate per 1000 was 2.74, for out-of-hospital it's 5.71.
Obviously, because of the problems inherent in using that data, it's an imprecise way of measuring, and doesn't prove Amy's assertions, but I would think it is at least suggestive of worse outcomes for complications that occur out of hospital.
From Amy Tuteur, MD:
JJ:
"Where's the data?"
In the homebirth papers, including those that purport to show that homebirth is safe.
From Aubrey:
"It's hard to make it fact-based, JJ, when MANA doesn't release statistics."
This is a conspiracy theory, and also...not fact based. You can blather the lack of a study having been done yet, as a willful attempt to hide the truth, or you can not spread conspiracy theory as fact.
But then you wouldn't you wouldn't have any ammo would you.
You peddling, that MANA is an evil corporation that hides its condemning statistics, is no better than HBAs yammering that doctors intervene for personal gain and disregard for mother and baby.
Your point is moot. Better find something new.
From Indy:
Really? So provide me with a link where I can pick up these statistics to peruse.
Don't worry, I'll wait ...
From Aubrey:
As I said Indy, a study has yet to be done on MANA's numbers. But don't worry, it will be. I don't know when, but I do know it will be done, good thing your so patient. In the event you get impatient feel free to continue to conspire away. Looks like it is getting you all super far.
From Alexis:
The stats we do have show that home birth has an increased likelihood of a bad outcome. I don't think, however, that Dr. Amy has come close to demonstrating that "most" incidences of complications result in death. That's a huge leap and she has offered no evidence to support it. It seems to me that, since complications are not uncommon even in low-risk women, that if most complications resulted in death we'd be seeing a lot more of them.
From Jolene:
Basiorana and chris,
DEMs are licensed midwives in my state (and others). It is within their scope to practice at home.
Therefore, it isn't medical fraud.
Is attending a birth (in any location) as primary provider within the scope of a nurse?
From Basiorana:
"DEMs are licensed midwives in my state (and others). It is within their scope to practice at home.
Therefore, it isn't medical fraud."
I agree. There, they should lose their license. If they don't have a license, or continue practicing, THEN it can be looked at as a criminal case. Not that that should mean states should license unqualified midwives.
From Basiorana:
"Is attending a birth (in any location) as primary provider within the scope of a nurse?"
I think it's definitely in the scope of a CNM, in the US. Nurse practitioners are basically doctor-level qualified until you get into specialties.
Unlike Amy, I don't object to homebirth with a CNM and a low-risk woman.
From Jolene:
"I agree. There, they should lose their license. If they don't have a license, or continue practicing, THEN it can be looked at as a criminal case. Not that that should mean states should license unqualified midwives."
Is that standard practice for other licensed practitioners?
From Basiorana:
"Is that standard practice for other licensed practitioners?"
If they have very easily preventable deaths occur under their care due to gross negligence, they will lose their license. Of course, there is an investigation, as there would have to be to determine a homebirth death was genuine negligence.
Then, if they continue to practice without a license, or if someone never had a license and practices, they are brought up on criminal charges, usually along the lines of assault and/or murder by deception or something.
The trouble is, DEMs have no real supervisory organization. Hospitals and malpractice courts will investigate doctors, nurses, and other medical professionals who fail to rescue patients when it is very possible. Who will do that to DEMs? MANA? I doubt it.
From vonnegut:
[quote]As I said Indy, a study has yet to be done on MANA's numbers. But don't worry, it will be. I don't know when, but I do know it will be done[endquote]
I thought that it wasn't studies that Amy and others are looking for, but just the raw numbers. Has MANA been keeping no records at all yet, and will start at some undefinable time in the future?
Perhaps I just don't understand.
From Ericacrochets:
I think the point is that if MANA's data was clearly positive for homebirth, they would be wanting everyone to see it ASAP, so they could prove how much better and safer homebirth is. Probably it doesn't show that, and they probably rationalize it somehow.
From Jolene:
"If they have very easily preventable deaths occur under their care due to gross negligence..."
Therein lies the rub, huh? Amy asserts it's gross negligence to be outside a hospital. But in states where DEMs are licensed, that can't be asserted.
"The trouble is, DEMs have no real supervisory organization. Hospitals and malpractice courts will investigate doctors, nurses, and other medical professionals who fail to rescue patients when it is very possible. Who will do that to DEMs? MANA? I doubt it."
The licensing board is responsible for pursuing malpractice, for any licensed provider under the board. Hospitals per se do not investigate. Those investigations are internal, and all the hospital can do is recommend an action to the licensing board (and revoke priv).
So I assert in states where DEMs are licensed, they have the same oversight every other licensed provider has, the licensing board.
Am I mistaken?
From Jolene:
"I think the point is that if MANA's data was clearly positive for homebirth, they would be wanting everyone to see it ASAP, so they could prove how much better and safer homebirth is. Probably it doesn't show that, and they probably rationalize it somehow."
MANA is collecting voluntary stats, and have been since the 2000 study. They are undergoing procedures now (the writing process?) for a study of their collected stats. It isn't going to be "authoritive" because it's been VOLUNTARY.
And organizations such as MANA have no legal obligation to release their raw data. We have established that many many organizations collect data that they are under no obligation to release.
MANA isn't doing anything LEGALLY wrong.
I will be interested to see the stats when they do release them. But I'm not holding my breath that they will be meaningful, since they are not collecting all stats from all CPMs.
From Ericacrochets:
"And organizations such as MANA have no legal obligation to release their raw data. We have established that many many organizations collect data that they are under no obligation to release."
No they are not legally obligated to release them. It's just kind of telling that they don't seem to be in a hurry to release them, since their mission is to promote homebirth. "Look how safe homebirth is! We've got the data to prove it" And since it's voluntary information, it's probably actually better than if you were collecting ALL data from ALL homebirths, right? I'm assuming people are less likely to want to report the bad outcomes.
From Jolene:
"No they are not legally obligated to release them. It's just kind of telling that they don't seem to be in a hurry to release them, since their mission is to promote homebirth. "Look how safe homebirth is! We've got the data to prove it" And since it's voluntary information, it's probably actually better than if you were collecting ALL data from ALL homebirths, right? I'm assuming people are less likely to want to report the bad outcomes."
I agree. since it's voluntary it's likely to be better than otherwise. But. At least it is prospective. Meaning, the patient and midwife agree at the beginning of care to report the outcome, and no matter if it's good or bad, it gets reported.
That means the data will be weaker because certain midwives will refuse to send in their stats. But it's a tad stronger, in that once you agree to send in the stat, it gets reported, even if it's a poor outcome.
I do believe 2008 is their last year of data collection. I read some time ago that data collection would continue through 2008. (have no idea if the process is changing, they're not collecting in 2009, or what) So once they work up whatever they are doing to the stats, we should be able to see it.
From Susanne:
"That means the data will be weaker because certain midwives will refuse to send in their stats. But it's a tad stronger, in that once you agree to send in the stat, it gets reported, even if it's a poor outcome."
@@ That doesn't make it "stronger". It makes it non-random and incomplete data. And MANA wonders why no one in the big world of medicine takes them seriously, and why they come across like a bunch of yentas with too much time on their hands and too little expertise and professionalism.
From Alexis:
I'm skeptical that the MANA stats will be meaningful. I've heard there was a big "custody dispute" over them as well, and the person who posted about that was very skeptical about the contents of the data. She also said there was a lot of peripheral data for the CPM 2000 study that would have been of interest to midwives (but didn't have a direct bearing on the outcome) but wasn't released either.
I think there's an enormous amount of paranoia and naivete about statistics and Big Bad Obstetrics amongst some midwifery advocates, though. They thought "well, if we keep the stats out of the hands of our enemies, they can't use them against us!", not thinking of how a cover-up would look.
From Jolene:
I agree Alexis.
Susanne, I was refering to the study (should one be done) in that the data being prospective makes it a "stronger" study than if it was retrospective.
However, being a voluntary collection of stats means it isn't going to be strong, no matter how you look at it. (again, assuming there is a study in there somewhere)
That is actually one of the strong points of the J&D study, in that the stats were manditory for certification, PLUS prospective.
From Amy Tuteur, MD:
Jolene:
"And organizations such as MANA have no legal obligation to release their raw data. We have established that many many organizations collect data that they are under no obligation to release."
No, but they are under a moral obligation to release them. The reason that they haven't released them thus far is that they almost certainly show that homebirth increases the risk of neonatal death. In other words, they won't release the data because they want to hide it from women. That is unethical.
From Karen:
Okay take a for instance that happened in our state...
Couple wants homebirth. They find a DEM to take care with an OB backup, although couple is relgiously opposed to hospital.
Baby is frank breech, and DEM believes that she can take care of this, (she has experience with breech). Mother insists on staying at home, despite DEM telling her it would be safer with the OB at the hospital, (although OB would have to oversee birth, since DEM have no hospital privlages).
Baby starts coming and is footling. Couple refuses to go to hospital and says they would rather stay home and do unassisted than go to hospital. DEM stays an trys to deliver, but realizes she cannot, calls ambulance over parents' wishes. Baby dies due to lack of oxygen. Who is at fault? Is the DEM criminally negligent for staying? Should she have left the couple in labor? I have my own opinions, but since this relates so cloesly with Dr. Amy's post, I would like to hear yours.
From Jolene:
What would be done in a hospital if the mother refused care (IE, cesarean for breech)?
From Ericacrochets:
"What would be done in a hospital if the mother refused care (IE, cesarean for breech)?"
Unless the hospital got a court order, which is extremely rare, the mother would not be forced to have a c-section.
From Rhiannon:
"DEM stays an trys to deliver, but realizes she cannot, calls ambulance over parents' wishes. Baby dies due to lack of oxygen. Who is at fault? Is the DEM criminally negligent for staying? Should she have left the couple in labor?"
---
Completely ignoring the fact that I think DEMs should be jailed for practicing medicine without a license...
I think that #1 the parents are at fault for going against the advice of their "medical professional". She told them she wasn't comfortable with the situation, that it was beyond her expertise, and did the only thing she could which is call 911.
#2 The DEM is at fault for agreeing to attend a known breech birth without the required expertise and equipment to deal with likely complications. Any "medical professional" that willingly attends a known breech home birth is taking a huge risk. Sure breech is a variation of normal, but so is fetal or maternal demise. Once she saw that foot she should have been calling 911 and not attempting to deliver. She didn't know what she was doing and a baby died.
From Alexis:
Family is at fault, IMO, for putting the MW in an impossible position. She can't just leave, because of patient abandonment, and she might be held criminally liable for the death then too. I don't relish being that midwife--or the OB in the hospital who gets the same case. Don't forget, a laboring woman could put an OB in the same position--and it might happen too quickly for a court order, which, despite MDC lore, are not that common.
The MW told the family to go to the hospital. They refused to do so. Further, she called the ambulance DESPITE the parents' wishes--I don't see this as a case of an MW trying to downplay risk. If you refuse treatment, the consequences are your own fault.
As for attending a known breech, there's a huge difference between frank and footling. The MW might well have been able to deliver a frank breech. There are OBs out there who will deliver a frank breech, but I've yet to hear of one who will willingly deliver a footling any more.
From Jolene:
"Completely ignoring the fact that I think DEMs should be jailed for practicing medicine without a license..."
Can't do that if she was licensed.... right?
From Basiorana:
Well, DEMs should not be licensed. They are, which is unfortunate and dangerous, but since they are, they have to be treated like other midwives. Including malpractice insurance, etc. Let parents sue the midwife who fails to rescue their child, instead of the hospital that tried their damnedest. Of course, malpractice insurance would be prohibitively expensive and would drive most out of the business. But they can't have the cookies without eating their vegetables. Real midwives have malpractice insurance and own up to their failings.
That said, in Karen's example the family is at fault. While the DEM shouldn't have agreed to do a breech, if it was a confirmed frank breech and the family was refusing the hospital, her hands were tied. In some cases, the midwife should not have started out with the patient, but even a DEM is better than no one, so once it became an emergency and the parents refused to go to the hospital, she did the right thing by staying with them and trying to convince them to get help.
From Antigonos:
Jolene: So I assert in states where DEMs are licensed, they have the same oversight every other licensed provider has, the licensing board.
Am I mistaken?
~~~It depends entirely on the state. Some states simply say that ANY person who attends a birth is legally a "midwife". Others regulate the practice of midwifery to a greater or lesser degree. Some, for instance, require a particular sort of qualification, such as CPM, without specifying HOW that qualification was obtained -- in other words, there is no oversight of institutions purporting to be schools of midwifery. No state, AFAIK, actually EXAMINES either midwives or schools of midwifery to ascertain standards of education and/or practice, such as is done with State Board Exams for licensing nurses and accrediting hospitals and their schools of nursing. So DEM "certification" can mean anything at all and states do not necessarily provide any oversight.
From Antigonos:
Jolene: Can't do that if she was licensed.... right?
~~~Depends on the conditions of her license. Midwives are not given blanket permission to perform as physicians. Breech is NOT low-risk or a "normal" birth.
This is where the states' reluctance to spell out standards of practice becomes more than just allowing a "free market" in obstetrics to operate. IMO, it needs a national agency, like the former Central Midwives Board in the UK [it still exists, but the name has changed] which oversees the profession, from education onwards. That way, you retain a midwife, you know what you are getting.
From Liz1:
Once upon a time in England, we had reports published "Why mothers die" and "Why babies die" These were very informative. Now that the Government has again decided that Homebirth might solve some of the problems with hospital staffing, these - at least the "mothers" one, has been toned down and renamed. But really, how difficult is it to amass hard information if the political will is there? And why isn't it?
From Alexis:
Antigonos: In New York State, you need to have graduated from an approved midwifery program. I don't know how rigorous the standards are, though, I think one or two of the DEM schools are accepted with supplemental education (and you need to take the AMCB exam for CMs and CNMs, not the NARM exam).
From Yehudit:
The reports of the CESDI (Confidential Enquiry into Still Births and Deaths in Infancy) were never called "Why Babies Die". They used to be called "Nth Annual Report" and now that they come under Confidential Enquiry into Maternal and Child Health they are called "Perinatal Mortality YYYY")
The name of the CEMACH report went from
Why Mothers Die
to
Saving Mothers Lives: reviewing maternal deaths to make motherhood safer
That is, a shift in focus from simply uncovering the causes of death to learning the lessons.
From Liz1:
...a shift in focus from simply uncovering the causes of death to learning the lessons...
Well, maybe. I am not a health care worker, or particularly well informed and I own up frequently to my problems with statistics - but I am a trained reader, and the shift from baldly descriptive to a more anodyne use of language seems a bit weasily to me. Still, all in favour of learning lessons. I am a bit less sanguine than Dr. Amy that "failure to rescue" doesn't happen in hospitals - or at least in sometimes iffy antenatal care.
From Yehudit:
Well it may seem weasily to you. This is what the reports authors have to say about it:
"Confi dential enquiries into maternal deaths began in England and Wales more than fifty years ago and have covered the United Kingdom since 1985. The triennial reports have become essential reading for health professionals, and a model for similar enquiries in many other countries. The Enquiry, however, is continually evolving and the present report has a new title, Saving Mothers’ Lives. The previous name, Why Mothers Die, failed to emphasise that these reports not only describe the reasons for maternal mortality but also make important recommendations to reduce the risk of death in the future."
Doesn't seem weasily to me. And CEMACH is not an arm of government.
From Chanel:
Alexis: ...and you need to take the AMCB exam for CMs and CNMs, not the NARM exam.
What is the difference between these two exams?
From Liz1:
CEMACH is not an arm of government.
Doesn't need to be, does it? My recollection is, admittedly rather vague, but wasn't there a bit of a fuss of some kind when this latest report was published?
Actually, I think it is brilliant that this kind of report is published and taken seriously, and I don't doubt that there are people of high principal and good intentions involved in all aspects. But principals and political expediency do seem to be somewhat at odds in the NHS and from where I am standing (London) with a daughter just embarking on another high risk pregnancy, it can be quite scary. The resources exist, but cannot be taken for granted.
From Jolene:
"But they can't have the cookies without eating their vegetables. Real midwives have malpractice insurance and own up to their failings."
The trouble is you are making a strong opinion statement, which of course you are entitled to do. But DEMs are not currently REQUIRED BY LAW to carry malpractice, sooo they CAN eat their cookies before the vegetables, as you put it.
"No state, AFAIK, actually EXAMINES either midwives or schools of midwifery to ascertain standards of education and/or practice, such as is done with State Board Exams for licensing nurses and accrediting hospitals and their schools of nursing. So DEM "certification" can mean anything at all and states do not necessarily provide any oversight."
I think you are wrong. In my state, the state uses the NARM exam as their examination for licensing midwives (DEMs). I am certain other licensing states use this and other measures to "examine" the midwives before licensing.
"~~~Depends on the conditions of her license. Midwives are not given blanket permission to perform as physicians. Breech is NOT low-risk or a "normal" birth."
Yes, I agree. If the license doesn't specify that breech is off-limits, then she was not in the wrong (legally)to attend one.
The problem as I see it, is that the rules for DEMs in the US are not consistant. I would think that the first step in regulation would be overhauling this hodgepodge of rules and licensing requirements.
But to do that, somebody has to come up with some set of regulations that everybody (homebirthing women midwives, hospitals, and society in general) can all live with. I think THAT is the hard part. Until we get that done, the rest of this is all gesturing.
From I am so wise:
Not carrying malpractice insurance is rather cunning. Lawyers will not touch a botched delivery case without some assurance of a big payout.
From Yehudit:
My recollection is, admittedly rather vague, but wasn't there a bit of a fuss of some kind when this latest report was published?
++++++++
No. I think a journalist (not a health reporter, a features somebody) jumped to a conclusion about the name change and made an unwarranted snide comment about it, and somehow linked it to the home birth issue (when in fact, they are quite separate). I'll try to find it if I can.
From Yehudit:
Actually, it may have started here: http://www.jessicastrust.org.uk/...-mothers-lives/
and then been taken up by reporters.
The point is that while Ben Palmer is entitled to be angry about the death of his wife, and what happened to him and his family, he is wrongly assuming the worst of CEMACH.
In fact, the introduction of the Modified Early Obstetric Warning Score (which might well have saved his wife's life) is a recommendation of the CEMACH report. And calling the report "Saving Mothers Lives" (as opposed to Why Mothers Die) is designed to highlight that these sorts of recommendations are central. That it is not just a summary tragic case reports.
It is a shame when people get the wrong end of the stick, and then spread the rumour that something like CEMACH is a load of politically-motivated spin. It actually makes implementing the positive recommendations much more difficult.
From Liz1:
Yehudit, I checked out your link. Sad and horrifying story. Paranoid as I sometimes am on the subject of the safety of birth, and attitudes to risk, puerperal fever was not something I would think to worry about. But, as he quotes from the CEMACH report, one sentence stood out for me:
"The fear and respect with which it as held in the past by obstetricians, midwives and patients has disappeared from our collective memory."
I do think this is central to my own concerns. Not so sure about fear - though it does still serve a useful purpose as a survival instinct - but I for one would be happier if respect for the dangers of childbirth was a bit more prevalent. But the dominant discourse now treats pregnancy and childbirth as a walk in the park, the only concern the quality of the experience and the degree of triumph and empowerment it brings. For the majority, of course, this is fine and dandy. And, I have to say, a year reading here has helped me to get a better perspective. For those of us who have stared disaster in the face the reality of the downside, the need for respect and caution becomes very clear, and the notion that birth is as safe as life gets seems very naive. Erasing that other reality from collective memory in favour of a romantic fantasy does not to me seem of benefit to anyone.
From Antigonos:
Alexis, NY State has always been a leader in certification: an RN license from NY is accepted in all the other states in the US [the only other state with total reciprocity is California, AFAIK] so it does not surprise me that NY also has rigorous midwifery standards.But for example, there is nothing to prevent a person who fails to get an NY midwifery license from moving to a state with less rigorous requirements [or no requirements at all] and setting up as a "graduate of school X in NY state" as it isn't criminal to do so.
From Yehudit:
Erasing that other reality from collective memory in favour of a romantic fantasy does not to me seem of benefit to anyone
++++++++++
Are you suggesting that this is what CEMACH is doing?
From Antigonos:
Jolene: I think you are wrong. In my state, the state uses the NARM exam as their examination for licensing midwives (DEMs). I am certain other licensing states use this and other measures to "examine" the midwives before licensing.
~~~Since we are using the situation of registered nursing as a comparison, you have to understand that not just anyone can take the State Board exams, in any state. First, the candidate for licensure has to show successful completion of nursing school, and that school has to be accredited [certain curriculum requirements, certain amount of clinical experience, taught by accredited instructors, etc]. Then, IF the candidate submits the necessary proof of educational requirements completed he/she is allowed to attempt the licensing exam.
Most DEM schools don't meet even the minimum requirements for a serious midwifery education, let alone even remotely approaching the requirements for CNM. In fact, many DEMs do no formal course in midwifery or any of the associated sciences at all, but learn via apprenticeship. I don't know precisely what conditions obtain where you live [where DO you live?], but NARM is not an official body at all, but merely a midwifery advocacy group, as far as I know, and accepts anybody who claims to be a midwife [whether all its members could pass its exam is a good question].
As long as the term "DEM" includes the entire spectrum of midwives from those who "study" with another midwife, and both of them are motivated solely by an agenda and/or ideology ["Christian midwifery" springs to mind] through to those who attend recognized institutions which train professional midwives solidly grounded in science and with full experience of all aspects of maternity care, there is going to be a major problem with credibility of licensure --and that's why CNM will remain the "gold standard" of midwifery.
From Caryn:
And given the fact that the primary reference list for the NARM written exam includes multiple texts that refer to an old theory of preeclampsia and no texts that discuss the current understanding of it in any detail, I'd say the exam assigns certification to people based on their understanding of a disproven theory. The theory they're teaching cannot handle the known data and makes predictions about reality that have been falsified.
DEMs are supposed to be care providers for normal pregnancies, not medically complicated ones, so they theoretically must determine which pregnancies are turning preeclamptic and transfer the care of those women to OBs. But unfortunately they are trained to believe false things about this very common complication of pregnancy, particularly that they can reverse it and restore a normal pregnancy by recommending a dietary modification to the pregnant woman.
This is like training the Mars mission planners to believe in geocentrism. Some of the rovers will crash/miss the planet entirely, and it's because the modelling is wrong.
From Rena:
Several very interesting birth-related studies have been published recently, yet Dr. Amy is nowhere to be found. C'mon, Dr. Amy. 
From Liz1:
Are you suggesting that this is what CEMACH is doing?
Of course not. As I said originally, I found the reports very enlightening - especially the comments on inadequate treatment - the diagnosis of pre-eclampsia in particular - and the latest's comments on "unexplained" stillbirths and the diagnosis of IUGR. But as Mr Palmer notes in his comments, pointing out what is going wrong is not the same as getting it fixed. It did seem to me that the latest report on mothers stressed obesity and maternal age - admittedly, important factors but not ones that require much in the way of Government finance.
Yes, the media love "bad news" stories - but I thought it went rather deeper than unjustified accusations of "spin". I thought I remembered that it was some members of the inquiry team who were objecting.
When my grandaughter was born three years ago it was not my impression that things had improved greatly since my day - except that the "birth suite" was rather posh, and Day Clinics, set up to pick up on warning signs, have been established. Both great. But the "silly mother with a vivid imagination" and the complacent, fixed assumption of low risk seemed to me worse. Fine, if you are a silly mother with a vivid imagination, but not too comforting if you are actually ill or in trouble. Miraculously "probably OK" is enough in the majority of cases, but it leaves a very bitter taste when it isn't OK.
From Susanne:
"DEMs are supposed to be care providers for normal pregnancies, not medically complicated ones, so they theoretically must determine which pregnancies are turning preeclamptic and transfer the care of those women to OBs. But unfortunately they are trained to believe false things about this very common complication of pregnancy, particularly that they can reverse it and restore a normal pregnancy by recommending a dietary modification to the pregnant woman."
And the women at MANA scratch their asses and wonder why OB's don't embrace backing them up. If they weren't so stupid, they'd get that it's not about "you're trampling on my livelihood," it's about "you don't know what the hell you're talking about, you have no scientific or medical integrity, you can't be bothered to learn at a real school like CNM's do, your schools are a joke, your certification is a joke ... and none of it seems to bother any of you at all." It's like having third-graders whine that they don't have the right to vote.
From Liz1:
Actually, on reflection, isn't Mrs. Palmer a classic example of "failure to rescue"? Rare, catastrophic - unnecessary. Women don't get puerperal fever any more, so who would look for it?
From Jolene:
Antigonos, I won't quote your whole post.... and I agree with what you are saying. But you are missing one point. Individual states have made licensing requirements that are legal in that state. They each have a way of examining the midwife (which differs) for a license. Some take the NARM exam as their examination, others instate their own exams.
States do this for RNs as well, the difference is, most (if not all) states have chosen the same testing method and exam as their watermark for licensure.
That is what I am saying needs to be done with midwifery (if indeed we keep DEMs)
But it does not seem to me that enough support can be drummed up for such move. After all, homebirthers are a small minority of birthing women. It will probably all come to a head when our health care system switches to single payer system, at some point in the future.
It is clear there are some big problems. But nobody seems to have any answers either (in enough numbers to actually create a movement to DO something)
From Li:
Several very interesting birth-related studies have been published recently, yet Dr. Amy is nowhere to be found. C'mon, Dr. Amy.
I think you may have to get used to Dr. Amy neglecting this blog. She's become something of a star over on Open Salon.
From Jen:
"Several very interesting birth-related studies have been published recently, yet Dr. Amy is nowhere to be found. C'mon, Dr. Amy."
I don't keep track of studies coming out, but I too would be very interested in what Amy's take is on them. It's getting somewhat slow and monotonous on this board without new posts to spark discussion :-(
From Jolene:
"I think you may have to get used to Dr. Amy neglecting this blog. She's become something of a star over on Open Salon.
We seem to be headed the way of her "Ask Dr. Amy" site. Maybe we can lure some of the old well-spoken HBA back for some sparks?
From JJ:
Someone asked about other boards - honestly, I think we could have awesome debates over at babycenter.com on the Childbirth Choices group. There are some NCB/HBAs over there who are intelligent, interested, etc. but that group is currently very slow and needs people to start talking on it again. Just a suggestion.
Honestly, I've reached the point where I really think that if you want to deliver babies, you should have to be a CNM. I don't understand the justification for midwives having LESS experience or education than the CNM degree requires.
From Emma B:
Women don't get puerperal fever any more, so who would look for it?
Women do, all the time -- I did. It's just called endometritis now, instead of puerperal fever.
From Morgan:
"I think you may have to get used to Dr. Amy neglecting this blog."
Perhaps she just finally ran out of different ways to make the same points over and over. Too bad she didn't elect to expand her subject matter. The regular characters on here were pretty interesting. Not the comments so much as the glimpses of the persons making them.
From Liz1:
"Women don't get puerperal fever any more...Women do, all the time..""
Really? I didn't know that. Is it just a name for infection? Could it be that was what I had? It was labelled "nephritis" at the time, but took three weeks of antibiotics to clear up, and scared me to death. To be ill when you have a new baby is entirely wretched, aand Emma, you have my sympathy.
I sometimes think that part of my attitude to childbirth was formed by reading too many Victorian novels at an impressionable age and I vividly remember a book about the history of puerperal fever. That it should still exist is not that surprising, but that it should go untreated and unrecorded is something else. In a way, the words themselves are a very potent signifier for the hidden dangers of childbirth and an attitude of mind that treats them cavalierly. Bit like the attitude to vaccination. Why worry about measles, diptheria if you can focus on Thimersol?
From Liz1:
Well, I for one would be sorry to see this forum disappear. I have learned a lot here - feel much better equipped to support my daughter this time round, and, time wasting as it is, it is a lot more interesting than most of the internet - which often seems like one huge vanity publishing project, or peopled by some very boring adolescents.
From Liz1:
While we are starting our own topics, has anyone read the thread on velamentous cord insertion on MDC. Fascinating! It is an old thread recently updated. It actually has some accurate (and scary) information on there, so is not entirely the usual ra-ra thread. I counted six dead and damaged babies, and a few close calls, but it still elicits this kind of response:
..."This will happen no matter where the birth takes place and no matter who is managing the labor and delivery.
The baby is healthy because the mom did a good job of caring for her before the birth, not because of who the healthcare provider is."...
Now I have said above that I find this place addictively interesting. Part of it is practical - I am somewhat belatedly trying to figure out what happened to me, and to support my daughter through her own far from straightforward adventures in mothering. But it is also strongly sociological and psychological, and I find the attitude of mind revealed in the above comment absolutely riveting. Being the mother of a conspicuously disabled daughter, I have been aware from the start of the complacent assumption that normal people have normal children, and to some extent my role is a bit like the woman who used to have a scarlet A emblazoned on her forehead. My very existence is reassuring to others. I have transgressed! But the above post is one of the most blatant expressions of this quaint view that I have ever come across.
In the olden days (1950's) women largely took it for granted that their role in life was to grow up to be perfect wives and mothers. Even in the 60s in my high achieving grammar school, we were taught to do laundry and embroider tableclothes as well as Latin. (Unlike today, perfection as a wife was judged by the cleanliness of your kitchen floor, not your prowess in bed) Wifeliness, fortunately, got laughed, argued and dissected out of existence in the 70s, but, it seems, the mother bit got left undisturbed. And in this quote and the attitude of mind it embodies, you have it in full glory. If you do not have an ideal birth, it is Your Own Fault. Nature's little tricks and wheezes are entirely under your own control.
It is a long time since the 70s. How on earth does this woman-punishing attitude still exist? It is far more repressive and damaging than the Perfect Housewive syndrome.
From Susanne:
"The baby is healthy because the mom did a good job of caring for her before the birth, not because of who the healthcare provider is."...
Great points, Liz. By extension, that means that Birdie's Mama didn't take good care of Birdie prior to birth, right?
They're ascribing personal pride to things that are the luck of the draw in many regards. Yes, of course, one can make sure to eat well, get appropriate exercise and rest, not do drugs or smoke, see a provider, etc. But with that as a baseline, there's really very little the average woman can "do" to head off certain complications. And that just shows their desire to Believe In Their Own Powers -- it's like crowing that you had 20/20 vision because you took the very best care of your eyes. Huh? No, stupid, the person next to you with 20/60 vision didn't take worse care of her eyes than you did. That was simply the luck of the draw and in the absence of something extraordinary (like stabbing yourself in the eye) your vision isn't under your control.
So many of them are so young, and from their postings sound very powerless in life, so I guess it's no wonder they have to pretend that their children's health (which of course most will have, because most children are healthy) is a function of their own Superiority. Particularly Superiority vs the Mainstream. The dirty little secret is that their children probably really aren't any healthier than mainstream women -- and there's a few more dead ones of theirs. No mainstream board would have anywhere near as many still births and birth disasters.
From Liz1:
To be proud of one's "achievement" is one thing. My daughter looks at HER daughter, and says "I can't believe I made something so wonderful!" (And my grandaughter IS quite something, in spite of pre-e and prematurity). I am proud of both my daughters. My first daughter's courage, equnimity and what is left of a remarkable brain, my second daughter's considerable accomplishments. I have no problem with the widespread idea that our children are the best and most special ever. But I cannot stand it being made into a competition, with winners and losers and adjudicators.
From Antigonos:
Jolene: It is clear there are some big problems. But nobody seems to have any answers either (in enough numbers to actually create a movement to DO something)
~~~As the numbers of OBs continues to decline, CNMs will become, as they are in Europe, the health care providers for low-risk women in hospital primarily, or at least, that's my opinion. Whether DEMs will be properly regulated or not is another question. Until they are, no hospital will ever use their services, it just exposes the hospital to too much liability. I don't think home birth will ever be a major part of the American obstetrical scene.
From Antigonos:
The baby industry has become immense. It has expanded exponentially since the days when I had my own babies. On another forum someone was asking about cloth diapers [at $32 per diaper!!!] and I looked at the Mothercare site because I couldn't believe it. There were 373 items under "nappies". When I bought my triangular terry diapers from Mothercare in 1980, they offered two kinds: both triangular, both terry, one a "deluxe" [thicker layer in the middle] and slightly more expensive than the other. No snaps or velcro, and all in white and in one size. And both kinds were a fraction of the price they are today. Now, of course, they are sized and in pastels. I remember Birdie's Mama going on about wanting her baby only in "organic cotton" diapers to prevent any possible contamination with harmful chemicals -- I'd never even known there was such a fabric, thought organic referred to food. Now I see there are bamboo fiber diapers, and micropore diapers, etc. What is the advantage? In pre-WWII China it was habitual not to diaper babies at all but put them in slit trousers and let them pee and poo at will.
The NY Times just ran an article on the various aspects of breastfeeding, going into considerable detail about all the kinds of pumps on the market, some of which cost well over $1000. Whatever happened to manual expression? Worked fine for me.
It seems to me that 90% of this stuff is completely unnecessary. The marketing is all about making Mother feel guilty, that she's not a good mother if she uses anything "cheap". It's always been around, but it seems to have gone off the wall completely in the last two decades, along with NCB going from being a way of avoiding infant sedation because the Mom was getting IV meds to being part of the "essential" Perfect Birth Experience that was every woman's "right".
From Squillo:
Liz 1:
Great points, all around. The interesting thing is that the same women who talk about good outcomes being associated with "taking good care of yourself" (which seems to mean a lot more than just getting adequate nutrition, avoiding known teratogens, not smoking, etc.)will admit that "sometimes things just happen" despite mama's best efforts. I wonder how they differentiate the things that "just happen" to the "good" mamas from those that happen to the rest of us?
Congratulations to your daughter on her pregnancy, and best wishes for an uneventful course.
From Emma B:
Really? I didn't know that. Is it just a name for infection? Could it be that was what I had? It was labelled "nephritis" at the time, but took three weeks of antibiotics to clear up, and scared me to death.
Yes, puerperal fever just indicates that it's an infection of the reproductive system that occurs shortly after childbirth. It's now called endometritis because that's the actual body part that's infected, usually, though it can go from there into the tubes, cervix, and peritoneum. Even "mild" cases can do a lot of damage and turn into chronic infection.
Nephritis is a kidney infection, so it's no joke either. Any bacterial infection can turn really scary in a hurry, and makes you realize just how valuable antibiotics are.
From Caryn:
It is a long time since the 70s. How on earth does this woman-punishing attitude still exist? It is far more repressive and damaging than the Perfect Housewive syndrome.
If you were born in the '70s, you're not yet 40. In the US there's a fairly large subset of women in their 30s raised in a more traditional household and expected to come up with some way of both contributing an income and being a good wife and mother, particularly in the Western states with more LDS. (I know a number of women with 3 or 4 children and an arts degree who teach privately to supplement the family income and who have husbands who are engineers.)
The NY Times just ran an article on the various aspects of breastfeeding, going into considerable detail about all the kinds of pumps on the market, some of which cost well over $1000. Whatever happened to manual expression? Worked fine for me.
Not for me, plus I developed resistance to my hospital-grade pump within the first week.
If you're working, and need to pump to continue breastfeeding, and have the money, instead of switching to formula you can try out pumps until you find one where you'll let down for it. (I believe this is generally referred to as "committment to breastfeeding.") That way even though you've transgressed from the traditional role, you can still provide the "gold standard" of breastmilk, proving that your work doesn't make you a bad mother.
Just my impression.
From Emma B:
Re the blog issue, Amy's been writing interesting posts on Open Salon. I just don't care for the comment threads over there, though I'm not sure I can precisely articulate why.
From Susanne:
Puerperal mastitis is what a lot of women experience with lactation. In fact, one might say that choosing to breastfeed raises one's risk of puerperal mastitis.
From JJ:
"The NY Times just ran an article on the various aspects of breastfeeding, going into considerable detail about all the kinds of pumps on the market, some of which cost well over $1000. Whatever happened to manual expression? Worked fine for me."
Did you work full-time? I work full-time and need a good double electric pump to make that work. I don't want to formula feed if I can breastfeed. I have never been able to get anything but a few drops from manual expression, but I've never really seen much of a use for manual expression, for obvious reasons. If you just need a little milk (say, for an evening out), a single handheld breastpump is $25 or less and has been considered standard medical equipment at least since the 1950s.
Caryn, your snarky attack on women who do pump seems to indicate you don't feel it's worth the effort or expense. Could you clarify your position? Obviously, I think it's well worth it. It's not from a sense of guilt. I like working and I like breastfeeding my baby when I'm not at work. Pumping keeps my supply up. There's no arguing that formula is inferior to breastmilk - it's a fact. What's the virtue in attacking women who choose to work (why shouldn't I work?) and choose to pump (why on earth wouldn't I do this if I can and want to?)? My husband happens to make a great stay at home parent.
Also, I never had any real trouble getting my milk to let down for the pump. You have to get used to it, but that usually happens quickly. I did some research and bought the pump most recommended by moms and the lactation consultants at the hospital - the Medela Pump in Style Advanced. I didn't spend thousands, I spent about $350. Using that one pump, Baby #1 had breastmilk exclusively until 6 mos, and I pumped until that baby was 14 mos old; Baby #2 same thing and still pumping at 10 mos old. I have saved hundreds of dollars on formula. I don't know what the cost of formula for a year for two babies is, but I bet it's more than $350.
I've never heard of anyone buying multiple $1000 pumps to try to find one that would work (the one I bought works well for nearly everyone) nor have I heard the phrase "commitment to breastfeeding" in that context (i.e. purchasing multiple breastpumps).
I'm getting the impression you're talking about something that you actually don't know much about . . . am I wrong?
FWIW, I don't care if women breastfeed or formula feed. Formula works fine. It's the mother's choice. Obviously breastfeeding is better for the baby in almost all situations, but it's not like formula is so bad that it isn't a valid choice. How a woman chooses to feed her child doesn't matter to me as long as she's aware of her options.
From Liz1:
...contributing an income and being a good wife and mother...
Actually, there isn't anything wrong with wanting to be a good wife, or a good mother. It is more the question of the definition of "good", and who is in control of it - the dominant stereotypes, and whose purposes they serve. Generally, I admire you younger women and your attitudes, far more assertive than my generation and less inclined to "put up" with the intolerable. But sometimes it seems that the bar of womanly perfection has been set even higher, and I don't think I would care to be 25 again.
From Jolene:
"It seems to me that 90% of this stuff is completely unnecessary. The marketing is all about making Mother feel guilty, that she's not a good mother if she uses anything "cheap". It's always been around, but it seems to have gone off the wall completely in the last two decades....."
Of course 90% of it is unnecessary. That's what our disposable consumeristic society is all about. Why wouldn't consummerism break into the "mother" area as well? What gear you use brings a label with it, in all areas of our lives. Sucks really.
From Jolene:
In that same line, I feel proud sometimes to be a part of a group of women (no less concerned with labels of course) who share, trade, and sew their own "gear".
Frugality is now considered cool in some niches.
From Alexis:
The only pumps costing $1000+ are hospital grade (Medela Symphony et al) and almost no one buys them for personal use. I could probably count the number of women I've heard of who bought them, and most were doing serious, serious pumping.
BTW, there was an interesting article in the New Yorker this week--is that what you meant, rather than the NYT? I don't remember seeing anything in the Times.
From Susanne:
Uh JJ, I think Caryn was being snarky when she said "That way even though you've transgressed from the traditional role, you can still provide the "gold standard" of breastmilk, proving that your work doesn't make you a bad mother."
From Caryn:
Caryn, your snarky attack on women who do pump seems to indicate you don't feel it's worth the effort or expense. Could you clarify your position?
Oh, I'm not attacking women who pump. I am pointing out that women who don't let down for pumps can only afford to try multiple pumps if they have the money to do so. Women who pump can only find the time to pump every two and a half hours *plus* feed the baby if they're sufficiently privileged to do so. And I've seen women suggest that women who *are* committed to breastfeeding would of *course* do this, regardless of whether or not they're working shift work on their feet and really only get a two fifteen minute breaks and a half-hour for lunch.
I breastfed my son for over four years. However, I never let down for a pump -- maxed out at 40 ml pumping every 2.5 hours with a Medela Lactina, dxed as pump resistance by two separate IBCLCs. If I'd been working at a job that didn't have hours flexible enough for me bf around my schedule -- luckily, I was self-employed -- I wouldn't have been able to afford the suggestions I see made, routinely, on breastfeeding support groups to "just try another pump" or "pump more frequently" (more frequently than half an hour every 2.5 hours around the clock?) or to, heh, use medication off-label.
There's nothing whatsoever wrong with pumping. There *is* something wrong with anything that's self-congratulatory about "succeeding" at breastfeeding, or pumping, or having a full-term baby vaginally. And why are women who've had the cerebral squeeze from preeclampsia compress their pituitaries so that their prolactin levels are off, plus who are Caesarean patients, plus who are mothers of preemies in NICU, be *apologizing* to me when they hear that I breastfed my preemie C-section preeclampsia NICU baby for years?
From Ericacrochets:
"Re the blog issue, Amy's been writing interesting posts on Open Salon. I just don't care for the comment threads over there, though I'm not sure I can precisely articulate why."
Pseudointellectual boomers?
From chris:
"Is attending a birth (in any location) as primary provider within the scope of a nurse?"
Yes, and no. I intervene with the Doctors approval. However most of my Docs have known me so long that they know I will call them 1)if a complication happens or 2) when the babys head is on the perineum. Old L&D nurses have a saying "don't call the Doc till the head is on the perineum." Why? Cause we hate for them to get antsy and maybe cut a epis. If he is not in the room, he won't have time to cut an epis. However, nowadays Docs don't do many episiotomys. IT is just good practice to wait till the head is on the perineum before I call. This due to the fact they might be helping other folks. I don't need anyone else to help me push with the patient. Just the patient and her spouse and any folks she wants in their.
So I am probably as qualified if not more qualified to deliver babies. I have caught one here and their. If all went well all the time, we wouldn't need the Doc. But when hell breaks loose I am very glad the operating room is a stones throw away.
If a delivery has no complications a bus driver can catch the baby. You would not need anyone. So I guess it is back to the old Clint Eastwood Question "Do you feel lucky?" When the gun is pointed at your head.
I would not play Russian Roulet. I would not plan to help deliver a baby at someones home. I would help if a baby was being born in a mall and the Woman needed help.
The Board of Registration of Nursing would probably take my license away if I planned to do a homebirth. WHy? Because I would be taking unnecessary risk for Mom and fetus. The Board of Registraton of Nursing is not a DEmocracy!!!! If they don't like how you practice, they can take your license away and you have little recourse.
Let me ask another question, How many times have DEM instituted NRP with chest compressions and full on code? Well probably never! Why because you would need at least 1 airway person, 1 chest compression person 1 medicaton person and 1 Advanced person who can intubate, push meds and insert and umbilical cath. These measures have been studied ad infinitum. How do I know this? I am an NRP instructor. I get boat loads of email from the NRP folks. It is just physically impossible to full resus a baby who needs it. Guess what you don't always know who is going to need it.
So read your NCB homebirth literature and feel warm and fuzzy and pray to the G-d of your choice but at the end of the day ask yourself "Do you feel lucky?"
From Jolene:
"So read your NCB homebirth literature and feel warm and fuzzy and pray to the G-d of your choice but at the end of the day ask yourself "Do you feel lucky?"
Is that directed to me?
Chris, I asked if being the primary caregiver at a birth was within the RN scope of practice. I didn't ask if RN's conducted deliverys under the "supervision" of an OB.
Does your license allow you to be the primary caregiver at a birth? If so, do they stipulate in hospital only?
From chris:
It used to be that some medical insurance companys would help pay for breast pumps. That was a number of years ago so I am not sure if they still do it. It is worth a call to your insurance company nontheless.
From Holly:
In NC it is illegal for any nurse who is just an RN to attend a homebirth unless it is her own. A CNM (who is also an RN) can attend a homebirth if she has the backup of an OB. However, this is just in NC. In TN CNMs are autonomous and so can attend homebirths regardless.
Anyway, anyone heard the NEWS??? The legislative study committee overseeing the licensure of homebirth midwives in NC has RECOMMENDED to the NC legislators that homebirth midwives be decriminalized and licensed. I am very happy about this. I attended 3 out of 4 of the legislative committee meetings, as well as several North Carolina Friends of Midwives fundraisers and meetings. The midwifery professors at my school of nursing have very loudly supported the efforts of NCFOM and I agree with them 100%. This is one glorious step closer to licensing CPMs in NC and making CNMs autonomous in this great state.
From Holly:
In the above comment I don't mean "JUST an RN", I mean "ONLY an RN". It's not meant derogatory towards RNs. It came off different than I intended. Just putting that out there ahead of time. 
From Liz1:
Pseudointellectual boomers?
Didn't strike me that way. Bland, and dull, like so much of the internet.
From chris:
To answer the question, Yes an RN can be the primary hcp if she is a CNM. In the begining this was not a Master's degree but availible to RN's who studied under another CNM. Now it is a Master's degree program and the CNM has the power of prescription. All CNM's need OB back up in the hospital I work at. Why? Cause they can't do a C-section. And every woman who goes into labor may need one. They don't have a big sign on their forehead saying "Needs C-section. Baby will have prolapsed cord." My comments are not directed to anyone specifically. I just decided to spout off my opinion. I have been reading this blog for ad-infinitum years now and feel comfortable with the occasional tangent I may go on. If that insults you, I apologize unreservedly.
From Antigonos:
BTW, there was an interesting article in the New Yorker this week--is that what you meant, rather than the NYT? I don't remember seeing anything in the Times.
~~~You're right; my mistake.
From Liz1:
Going back to why Dr. Amy has gone off us, I read her post (more than one, come to think about it) about people being "nice" to each other in comments. While it is distasteful when comments degenerate into pure abuse and the plaguing of trolls, I have never understand this appeal for a high level of courtesy. The type of discourse that consists of "You are so right" and "I respecftfully disagree" has always seemed to me quite pointless, and it has been the robustness of the arguments that go on here that keeps it interesting. Perhaps I have spent to much time around academics - who definitely do not go in for niceness - or I am insufficiently civilised or something, but I thought the openness and honesty of the opinions expressed here was part of its attraction. I would agree there is a difference between argument and personal attack, but the internet is a playground for grown-ups, isn't it?
From Antigonos:
I think the big problem is that right now there isn't much new material. We've pretty thoroughly dissected not only homebirth, but breastfeeding, circumcision, and various parenting approaches [such as AP], and also argued about the pros and cons of DEMs, medical liability, how hospitals could be more user-friendly, as well.
From Holly:
Dr. Amy is closing this site? I've seen this coming. She gets much more attention and traffic from the Open Salon community. I like Open Salon. A lot of people from here have moved over there, not just me. Squillo is over there and Erica I think. Anyway, it's a more happening place so I don't blame her for letting this die a bit and moving on over at that community...If that's what she's doing.
From chris:
"I have never understand this appeal for a high level of courtesy"
Thank you. I really got a kick out of that. You also may have a nice English Accent. I find folks who have English Accents here in the US can get away with more than the fellow with the Accent from NY. Why? I don't know.
From Myriam:
Maybe we all talked about our personal childbirth stories just once too often. Perhaps that terrible masturbation-during-labour thread was the final nail in the coffin. (:
From Ericacrochets:
"I like Open Salon. A lot of people from here have moved over there, not just me. Squillo is over there and Erica I think. "
Yup, it is I. It is cool to see what you look like, Holly, after "knowing" you from this board.
From Holly:
I feel the same way, Erica. It's a nice community I think.
From Ericacrochets:
Well, here is a very sad story:
http://www.mirror.co.uk/news/top...15875-21013171/
Basically a premature, footling breech baby died in the UK for lack of an anesthesiologist to do a c-section, the result of cost cutting measures.
My question is this. Can OB's do c-sections with only local anesthesia? I've heard of this (on Midwife with a Knife's blog) and heard that it is horribly traumatic to the mother, OB, and all who witness this procedure. I wonder why this wasn't done? Is it just considered so inhumane that it is too terrible for most consultants/OB's to consider? Or perhaps it isn't ever done at all?
From Amy Tuteur, MD:
Holly:
"Dr. Amy is closing this site?"
I'm not closing it. I'm just trying to figure out what direction I should take it in. It seems to me that the posts have been getting rather repetitive, perhaps because there is essentially no new research in homebirth. Homebirth advocates don't do research, or, if they do, they keep the results secret, as in the case of MANA (Midwives Alliance of North America).
For the next few days I will be busy; I am very fortunate to be able to attend the inaugural of President Obama, so I will be doing minimal posting.
I'd be very happy to hear any ideas that people have for a fresh direction to take.
From ElizabethP:
I'm so jealous, Dr. Amy. Have a blast!
From A Sarah:
Emma B: Yes, puerperal fever just indicates that it's an infection of the reproductive system that occurs shortly after childbirth. It's now called endometritis because that's the actual body part that's infected, usually, though it can go from there into the tubes, cervix, and peritoneum. Even "mild" cases can do a lot of damage and turn into chronic infection.
This is interesting. I spiked a sudden fever (103.5, I think) a week after my first son was born. No breast tenderness or redness or anything boob-related at all. The midwife just prescribed some antibiotics over the phone so I never got seen. Might it have been endometritis, do you think? I know nobody can give official diagnoses, so I won't take it as that. I'm just curious if endometritis would fit what I experienced.
From A Sarah:
Ohhh, Dr. Amy, I'm so excited for you!!! Hey, if you need a place to eat, you might check out Ellis Island in Brookland. I love it, but I can only imagine what a neat place it would be around the time of the first
You asked about new directions for the site. I have loved finding a community of people who answer back to the sanctimommy/perfect mother expectations with intelligence and wit and occasionally by blowing a big fat raspberry. I think Esther's blog would also make a great place for that (if you don't mind my saying so, Esther) so if enough people migrated over there en masse, perhaps we could continue the community vibe?
From A Sarah:
Um, yeah, I didn't finish my sentence, did I? Dr Amy, Ellis Island in Brookland (near CUA) is a really cool casual restaurant and bar with a lot of history, that I think would be a NEAT place to visit around the time of the first black president's inauguration. Or at least it was in 99-00, which was the last time I was in DC.
From A Sarah:
Sigh.
Apparently Ellis Island is closed. Google *before* recommending a restaurant, self. *Before*. Sorry everyone... I'll stop serial posting now!
From Susanne:
angela's blog is also extremely well written.
From Caryn:
A Sarah, if you haven't found it yet, I think you'd enjoy Dr. Isis's blog over at ScienceBlogs rather a lot -- particularly the recent discussions on combining academic work in the sciences with mothering.
From Elena:
I had an attempted homebirth with a prolapsed cord. My homebirth doctor (an MD who attended homebirths) found it, and we transported to a hospital. The baby was born via C-section and is now a 9 year-old, active little girl who is perfectly fine.
So I didn't "ensure" that if an emergency happened nothing could be done.
I took precautions that on the slim chance that something happened, we had a backup plan. It did and we worked the plan. If every homebirther was given the opportunity to have a back up plan maybe there would be fewer homebirth deaths, so maybe that's what you should be working for instead of scaring everybody into hospital births, which don't always go as planned either.
From Jen:
"So I didn't "ensure" that if an emergency happened nothing could be done.
I took precautions that on the slim chance that something happened, we had a backup plan. It did and we worked the plan. "
I agree with your first sentence. Not every emergency that happens at home will result in a bad outcome. But, some of them will. Even if every homebirther who wanted a back-up plan had one, there would still be cases of babies or mothers dying who would have been saved if they were in the hospital. For that reason, it is too big of a risk for me to take. But everyone has their own "risk threshold" so to speak. I'm very happy it worked out for you and your daughter.
From Rhiannon:
Elena, you also had your HB attended by a doctor. Someone who has not only trained in medicine and anatomy, but someone who has had to prove a (pretty high) minimum level of competence.
That is a far cry from a lay midwife who has observed 10 or 20 routine births.
From Liz:
OK, doing an MDC here (though hoping for a more reliable answer) Can anyone add to my education on the subject of adhesions? My daughter, in very early pregnancy (8 weeks) is suffering some pain. Ectopic has been ruled out, but unfortunately having had two surgeries (one botched, one not) for an earlier ectopic and laser treatment for endometriosis, we fear her womb may not be that hospitable a place. She has been told that adhesions are the probable cause, but this is one of the many things I don't know much about. I can remember some pain myself between pregnancies, but as far as I remember, it just went away. Piling on reassurance with a shovel (spade?) at the moment, but any aid to getting me "informed" welcome. Hoping to line up an appointment with a pre-eclampsia specialist soon, but may have long waiting list.
Dear me. It must be nice to be supremely confident that nothing could possibly go wrong!
From Amy Tuteur, MD:
Just a brief note from Washington, DC. while awaiting the inaugural:
The atmosphere here is extraordinary. The air of pride and promise is everywhere. People are fully aware of the precarious state of the American economy and foreign policy, but hope is the emotion of the moment. It is as if everyone in the city, residents and visitors, are attending a celebration for someone we know personally and admire. The streets are filled with people who are cheering spontaneously, and there is no reason to look around for the source of the cheering. It is simply a sign of happiness.
From Antigonos:
Liz, it's not uncommon for women with prior C/S. Between the 8th and 12th week the uterus becomes large enough that it "rises" from where it usually sits inside the pelvis and begins to press on abdominal organs and muscles. If there are significant adhesions she might feel some pain because this kind of tissue doesn't stretch. It usually isn't significant.
From Liz:
Antigonos, thank you. Daughter had a vaginal delivery, but several other surgeries. I was/am hoping it might be temporary stretching, but given that her care through the ectopic and the last pregnancy wasn't great, we are both nervous. Given the state of her tubes, it is a minor miracle she has conceived. Funnily enough, I do find it easy to fall into the "everything will be fine" stance, but as I reassured her last time that she would NOT get pre-e, and then she had it worse than I did, I find it a bit difficult to find the line between nervous nellie and complacent granny.
I can understand how and why people make a great family romantic drama out of pregnancy and childbirth, it can be so thrilling, but I could use a lot less drama myself, and think there is much to be said for the Stork.
From Squillo:
Liz:
Glad you got some reassurance from Antigonos. I know that adhesions can be very troublesome. DH ended up with an unnecessary appendectomy after he presented in an ER with abdominal pain that turned out to be adhesions.
Here's hoping your daughter feels better and has a healthy pregnancy.
From Mandi:
Ah...I understand. As an OB/GYN you are a trained surgeon FIRST, which would explain the 30% c-section rate as the national average, and my guess is that your rates are even higher. A homebirth with a trained and qualified Certified Professional Midwife is just as safe if not safer than hospital birth for low risk women who have had prenatal care throughout their entire pregnancy. CPM's sit for the NARM exam and must pass the same rigorous qualifications. In fact CPM's are held to higher standards than even NARM, which is to say your claim of "uneducated and ignorant homebirth midwives" is not a universal statement. (all midwives are not created equal)
What are your thoughts on free-standing birth centers? CPM's bring everything that a free-standing birth center would have to the home, so are you denouncing that type of institution as well?
You would do well to support some type of homebirth protocol as women will continue to have babies where and how they want, often unattended if people like you continue to fight against qualified homebirth midwives.
From Jen:
"Ah...I understand. As an OB/GYN you are a trained surgeon FIRST,"
Incorrect. Surgery is such a small part of what OB/GYN's do. Caring for non-pregnant women actually make up the bulk of what they do. Then there is the smaller proportion of their patients who are currently pregnant, of which only a percentage end up with some kind of surgery...so how is an OB/GYN a surgeon FIRST? Many other TRUE surgeons laugh their asses off when someone makes a comment like this.
"which would explain the 30% c-section rate as the national average, and my guess is that your rates are even higher"
If you want a look at why the CS rate is 30%+, you can find posts on here discussing it in detail. Dr. Amy actually AGREES that a 30% CS rate is too high...but she also knows there is not an easy way around it. As long as we don't have a perfect view into the uterus and can't predict complications with certainty, CS will continue to save lives, even when some are unnecessary (but ALWAYS in retrospect). Plus, Dr. Amy, when she was still practicing (decided to stay home with her children instead), had a rather low CS rate, certainly WELL under 30%.
"A homebirth with a trained and qualified Certified Professional Midwife is just as safe if not safer than hospital birth for low risk women who have had prenatal care throughout their entire pregnancy."
Well, there seems to be plenty of people and some studies that claim this, but all the studies are pretty deeply flawed. When looking at what available raw data we have, it actually seems like HB is much more dangerous for babies. And CPM's run the gamut from competent to very dangerous. How can a CPM be considered safe to care for women, when she was TAUGHT that the Brewer diet will prevent and treat pre-e??
"all midwives are not created equal"
That's one statement I would agree with, lol!
"What are your thoughts on free-standing birth centers? CPM's bring everything that a free-standing birth center would have to the home, so are you denouncing that type of institution as well?"
I believe that Dr. Amy only disagrees with FSBC on the basis that there is still no availability to do an emergency CS, if necessary.
You would do well to read past discussions here before you bring up points that have been discussed quite thoroughly before.
From Holly:
"You would do well to read past discussions here before you bring up points that have been discussed quite thoroughly before."
EVERYTHING has been discussed AD INFINITUM here before. That's why this blog is going extinct. There is nothing left to discuss.
From Ericacrochets:
If you're still looking for suggestions, Dr. Amy, I think the best thing to do with this blog would be to expand it to other issues in reproductive ethics. I think this is a better forum for it than Open Salon because the atmosphere there tends to be too ideological.
From Emma B:
I think the best thing to do with this blog would be to expand it to other issues in reproductive ethics.
I think this is a great idea. One of the hassles of arguing reproductive ethics is that many participants really don't understand the science, especially that of infertility treatment. Posters around here have a habit of getting their biology right, which makes for a higher class of discussion.
Of course, the downside is that the regulars here trend strongly pro-choice, with a few notable exceptions like sarahz. From the previous discussions, I think I'm one of the few here who will own up to being anything other than solidly pro-choice, and I'm pretty moderate (in my own estimation, anyway).
There are even reproductive topics which don't have anything to do with abortion. We could talk about HRT, and the overuse of hysterectomy, and pregnancy discrimination, and paternalism in medicine, and the easy labeling of diseases as psychosomatic.
From Ericacrochets:
I'm not solidly prochoice, Emma B. I won't detail my position right now, as I don't want to start an abortion debate on this thread. But I do like discussing the issue.
I really find these issues to be fascinating though, and there is no place to talk about them, very few books to read on the topic. I liked the topics you mentioned.
Some I can think of:
infertility, prenatal testing for disabilities, sperm and egg donation, embryo adoption, surrogacy, birth control, prematurity, cloning, artificial wombs, stem cell research, sex education
All of these and more we could analyze as we have homebirth.
From Liz:
This morning, I find myself a bit irritated at the idea that we have said all there is to say on the topic of safe choices, and should quietly disappear. The internet is absolutely choc a bloc with sites that sing the siren song of blissful birth, and they are a good deal more repetitive and duller and bloody dangerous. Listening glumly to a news report yesterday about the dire state of maternity services in England, and hoping that it was exagerated (while fearing it is not) I think the NCB message should be countered loud and often. Women and babies still die, things look set to get worse not better. Low risk isn't a category, a badge of merit, it is an attitude of mind, a retrospective verdict. It is low risk women who have the "unexpected" stillbirths, because it is assumed that care isn't needed. I was a low risk disaster, and then I was high risk and cherished to a safe conclusion. And so should everyone be.
From Myriam:
Amy: "I'd be very happy to hear any ideas that people have for a fresh direction to take."
Guest contributors?
From Yehudit:
Listening glumly to a news report yesterday about the dire state of maternity services in England, and hoping that it was exagerated (while fearing it is not) I think the NCB message should be countered loud and often.
++++++++++++
Why do you assume that these two things are related? The dire state of maternity services has to do with the fact that it is very difficult to make "targets" for maternity care in a "target-oriented" NHS. And because the resources are not being made available (there was a report that a lot of the money intended to go to maternity care is being sat on by PCTs). I don't know what you think this has to do with NCB.
From chris:
There is always more to discuss. There is always more to say. What I like about this site is that I can go off about L&D, use specific terms and be understood readily. That does not happen on other sites. Also I have been prompted to look up information that was brought up. So I think this is a useful site. I hope Dr. Amy does not abandon it.
From Caryn:
One of the hassles of arguing reproductive ethics is that many participants really don't understand the science
Well, and this is really more a complaint about their epistemology.
From Liz:
Yehudit, I do think the two are connected. I am not so naive that I think one causes the other - the problems in the NHS are deep and complex, and go way beyond Obstetrics. But I do most firmly believe the "It isn't an illness you know" approach leaves women - some women - vulnerable. In the report I heard, part of the compaint was that women were being monitored by students who may not have had the experience to spot bad signs, or the confidence to act on them. This was part of the problem in my daughter's second pregnancy - senior staff acted promptly, but you had to get past the "gatekeepers" first, and that was a bit of a nightmare. (Not to mention the total cock-up that was the Northwick Park version of maternity care in her first) The report continued with the case of a woman with a severe case of IUGR who was told to come back in six weeks. It was only the bloody-minded persistence of her husband that got her attention before it was way too late. The woman was both upset at the casual attitude, and relieved that she did finally get someone to act. The interviewer turned it into a "miracle baby" story, this 3 lb scrap born in the nick of time. Happy ending, right? Well, maybe. The woman, like me once upon a time, had little idea of what had happened to her, because birth is safe and there are only happy endings. Other views go very much against the dominant paradigm, that collective amnesia, and I think that needs to be challenged vociferously and often. Good maternity care does not mean a "cascade of interventions" and women being disempowered, or at least it should not.
From Liz:
And anyway, I think this is a very useful place to discuss the absolutely mind-boggling stuff that appears elsewhere – particularly MDC. Kneelingwoman and others feel that this is out of order – that it is women attacking/ridiculing other women. But is it? I confess I am not sure. In real life, I would never ridicule even the most inane point of view. I do believe that people are entitled to hold the most bizarre of flat-earth theories if it makes them happy, and that we are all capable of believing some very strange things. But I cannot see that I am obliged to defend or validate views which are actively damaging to other women.
What I have in mind is a thread currently running on MDC, in which a mother asks plaintively what she should say to enquires about her latest birth. She states plainly that if she had had the blissful homebirth she was expecting she would be happy to “shout it from the rooftops”, but unfortunately, it turned out to be “tragic”. Hmmm. Perhaps I am uncharitable in believing that shouting it from the rooftops would translate to Na na na na na na, I am Superwoman and you are Not. Perhaps I am ridiculing if I find the suggestions that she should disguise her “failure” – the birth of a healthy child – by saying "We trusted our instincts and she was born exactly how she needed to be” ludicrous. The woman helpfully posts a link to her blog, where her “tragedy” is described in detail. It was, of course, an entirely straightforward CS at 43 weeks . Now, disappointment, fear, loss of face and confusion I can understand. Just about. I can feel sympathy for the loss of something anticipated with pleasure which goes pear shaped. But to treat it as tragedy and defeat, failure, is not just to lose perspective but never to have had in any the first place. The rising CS rate may or may not be a problem, but this increasing tendency to treat it as some personal defeat seems to me unwise in the extreme. Fear of surgery, fear of hospitals is to some extent rational. Fear of Loss of Face seems to me crazy, and the fetishizing of vaginal birth very misguided. This woman says she cannot bear to be told “At least you have a healthy child”. Why not? Is it because it trivialises her distress, undermines her feeling that she has suffered? Or because something is becoming more and more skewed, so that outcome is secondary to performance not just in those who are committed to “natural” but generally. Of course the feelings of women matter, of course it should be a happy experience, but if the limits of what makes women happy get reduced to being Birth Goddesses, everyone loses.
From Alexis:
Having been through some of the worst of the NHS myself, I don't think NCB is to blame except perhaps for some bloody minded midwives who deny pain relief. It is a lack of funding, staff, and attention. It was a consultant OB--not a midwife--who dropped the ball for me. NCB was a non-issue.
From Liz:
To reiterate, I don't think NCB is to blame. Someone a while back pointed out that some aspects of of NCB had been beneficial to women generally, in focusing on women's needs and preferences. It is that the aspect of NCB that plays down some risks and exaggerates others feeds into other discourses, other agendas, so that, say, rationing CS and/or epidurals can be repackaged as "what women want". And, of course, it often is. A nice easy birth is what we all want, but a lot of unnecessary grief comes from what my mother would have called confusing wanting with getting. In my own early days of optimism, I went to NCB classes, used NCB networking resources, and met some very nice people. Fortunately, I didn't buy all that they were selling, or my heart might have broken.
From Tsu Dho Nimh:
"The lackadaisical monitoring, and the minimal knowledge base of most direct entry midwives dramatically increases the risk of failure to rescue due to failure to recognize the problem. That's why there are unanticipated homebirth deaths. The midwife has literally no idea that the baby is in serious trouble and therefore does nothing to prevent the death. A dead baby drops into her hands, a situation that is virtually inconceivable in a hospital setting."
It's almost as bad as the "walk-in wonders" who come into the ER well along in labor ... having had no prenatal care at all for financial or personal reasons (no med insurance, or hiding the pregnancy).
After many years I still remember one, who went into the coag problems, etc, and ended up costing the taxpayers a quarter of a million dollars in hospital charges because they were too cheap to pay for indigent prenatal care.
From Yehudit:
part of the compaint was that women were being monitored by students who may not have had the experience to spot bad signs, or the confidence to act on them.
++++++++++++
But again, this is not because of NCB.
No student should be caring for women unsupervised and beyond her capabilities. The responsibility lies with the student's mentor to ensure that the student is practicing safely. Midwives know this, because it is their registration is on the line if something goes wrong as a result of what their student does (or doesn't do). So, it's a judgment that midwives make about student's capabilities from experience of working with them. But that is exactly the same with medical training. You aren't a hopeless clot one day and then magically transform into competent professional on the day of qualification. It's a process designed to make you competent from qualification. But learning certainly doesn't stop at qualification!
Midwifery students, like nursing students, are now supernumerary (that is, not considered part of the "workforce") - that came in the 1990s. Previously, NHS students were considered part of the workforce - so in that respect you could say things have got better.
From Liz:
.you could say things have got better.
..
Well, yes. In the same way that you could say that things are better now for pregnant women, who can no longer be treated as mindless zombies. The trouble with the NHS, and for all I know the American system, is it ranges from the superb to the truly awful, and, like birth, not many ways of controlling what you get.
From Kelby:
Amy: "I'd be very happy to hear any ideas that people have for a fresh direction to take."
Have you noticed that things have gone to pot around here ever since you kicked me out?
My advice: reinstate Kelby!
(I'm at the library with my kids again)
From Rena:
Thank goodness you're back, Kelby. I've really missed your incisive, realistic commentary. It added a lot to the dialog. Or... not.
Dr. Amy, there is lots of data being published about practices in hospital birth. You've commented about those practices here (c-section rates, use of delayed clamping, and so on). The dearth of published home-birth data should have no effect on your ability to continue commenting on those studies and their relationship to care at home birth. For example recently a NEJM article, I believe, discussed the outcomes of maternal-choice c-section prior to and after 39 weeks' gestation. Certainly something worth discussing.
From Jen:
I have to second Rena, here. I have no real concept of statistics or access to new studies, so I've always loved to come here and hear what everyone had to say about them, and being able to keep up with even a little of the new findings was pretty cool
From Alex:
Amy,
I think Rena has a good point above. There is a lot of room to talk about maternity care standards and what is evidence-based vs. what is not evidence based. There are a number of practices which are frowned on by some members of the HBA community: prenatal ultrasound, Rhogam injections, glucose tolerance testing, any vaginal exams during labor(or during pregnancy) are just a few that come to mind. I would love to know what the best evidence supported practices are, and to see a piece that would foster a discussion about this. And likewise, there are things we do in the hospital that I believe are not evidence based--like AROM, which as far as I know, has not been shown to decrease the length of labor. Amy has written some informative pieces in the past that challenged the BS HBA's spout about gestational diabetes, GBS, and management of post-dates pregnancy, so I would love to see more along that vein.
I have not commented here in ages, as I have returned to the world of gainful employment, but I would hate it if this forum disappeared!
In the 5 months I've been back at work I've seen many, many fetal deaths, one percreta which led to severe hemorrhage and left the woman with an open hysterectomy and transfused with at least 40 units of blood products (later complicated by necrotizing fasciitis), a maternal death in an 18 year old, postpartum day 2 from a vaginal delivery (threw a PE,) a 16 year old who's parents didn't even know she was pregnant who came in abrupting at 26 weeks, a term delivery of a previously unknown case of hydrops, and last week a transfer from the community hospital I used to work at, 33.5 week primip with BP's averaging 210/115 2 days after her delivery, who was pissed at me every time I reappeared in her room to recheck her BP or push more labetalol because she "felt fine" and I was "bothering her". I'm more sure now than I ever was that childbirth is inherently dangerous. I also feel that when the occasional low-risk patient strolls in, we don't do as well as we should to promote normal birth. I also feel like it's not all outcome over process in the hospital--an induction for "pending post-dates" in a primigravida with a cervix that's long, thick, closed and posterior and is a c-section waiting to happen, and I would wager that this scenario happens on a regular basis in most American hospitals. So while I am firmly on the side of hospital birth, I think there is a lot to talk about.
So yeah, that's my plea that this site is not abandoned.
From Liz:
I'm more sure now than I ever was that childbirth is inherently dangerous.
Apologies for being stuck on the publish button this morning - but one value of this site is that these things are so interesting and thought provoking.
That childbirth is inherently dangerous is, for reasons I do not really understand, axiomatic to me. Now, with my daughter, I am trying to go into reverse and believe it is as safe as life gets. Maybe the truth is that birth is safe, so long as you start from the premise that it isn't!
From Indy:
Kind of OT, but since the conversation is sort of sparse ...
In typical MDC fashion, the thread about the recent death of a child from Hib B was removed for "review". Anything that doesn't preach the party line gets blown away.
Of course, they left the thread complaining about getting too many Hib B shots.
Combined with the stuntbirth thread moderation one has to wonder if their liability lawyers buy antacid by the case.
http://www.cnn.com/2009/HEALTH/0....cdc/
index.html
From Li:
Hi everyone,
It's been a long time since I've posted here but I wanted to share a story and why I think this forum has value. My son was recently diagnosed with a speech delay due to apraxia. The good news is that he's not autistic and doesn't have any other developmental delays, and he is already responding very well to speech therapy. The therapists predict he will have caught up to his peers within a year.
During my son's evaluation, I mentioned that I was not able to breastfeed him and the therapist said "Oh, you were never going to be able to nurse him. He couldn't coordinate the movements in his mouth. It had nothing to do with you."
I can't begin to explain how I felt when I heard that. Not once did the lactation consultant or any other breastfeeding advocate I spoke with acknowledge that some children simply can't nurse. I suffered from terrible guilt when I had to bottle feed--I felt that I had failed the first test of motherhood. It made me feel very insecure about my mothering abilities all through the first year. And now I know that all of that guilt was completely a waste of time. It had nothing to do with me at all. And the reality is that even if my son didn't have apraxia, it would've been perfectly fine to say, hey, I just don't want to fucking breastfeed and it doesn't make me a bad mother.
The emphasis on performance-based mothering--on nursing, vaginal birth, cosleeping, baby-wearing, etc.--as a measure of a woman's worthiness to be a parent is incredibly damaging. We really need to challenge these assumptions. I want women to be able to make decisions that are right for them and their families and not be chained to these cultural scripts that require them to be masochists.
Dr. Amy's blog is one of the few places on the net that does challenge those assumptions. I often find Dr. Amy's rhetoric to be too extreme, but the posters are just so damned smart and thoughtful that they keep me coming back.
From Miss Belle:
I was just thinking about the risks of
owning a pool or spa to your child vs homebirth. Perphaps Amy might like to write about it. Of course your child is exposed to the pool/spa risk many more days than homebirth issues. But I am interested in the starts how Amy would compare it.
Also great posts everyone!
http://www.consumeraffairs.com/
n...cpsc_pools.html
From Kneelingwoman:
Hello Everyone: I decided to pop in for a moment as someone wrote and told me that Amy was folding up shop here. I see from reading through the posts and finding her comments that she is doing what I've been doing; trying to find a way forward. I'm glad to hear it because there is a lot of good that could come from the basic premise here IF anyone can move past the "critique and try to prove that we're right and they're wrong" kind of schtick balanced atop going after bereaved young families within days, sometimes hours, of their infant loss. Homebirth or no, that's just not kind, or useful ( which is why I stopped commenting here; I don't want to contribute to it, or support it ) but, since you ( Amy ) and regular readers here are wondering what to do with this blog, I might suggest that you join forces with a broader notion of maternal and infant health and well being and work alongside people like me who are trying to educated about a more sane and balanced approach to childbirth that acknowledges the risks but also understands that many, many women truly need a more human-scale, compassionate and yes, for many, more natural and straightforward approach to birth. Hospitals and Birth Centers can accomplish these goals with no loss of safety for mother or baby. Home Birth can be made more safe by improved attention to educating and training midwives in recognizing and dealing with emergency situations. There are so many babies and women dying in childbirth in developing countries, and I truly think that more women would be willing to being open to a more balanced view of birth and parenting if that balance were PRESENTED. As it stands, everything here is extreme, polarized and seems to exist not to educate and inform, but to attack and encourage dissent and disunity. Why not try to find the common ground and grow from there? Sometimes, you have to meet people where they are to make any change. The reason that this blog is "fading out" is not because "there is no new research on homebirth" but because you've lost sight of your purpose here: If you are wanting to save lives and you believe that the current system of home birthing care is harming women and babies then stick to education and add a willingness to truly listen when young women come here to ask questions; listen and perhaps set on your hands for a few minutes before deftly slicing her apart at the seams sending her away with nothing new except a belief that people in authority can't be trusted and that she is probably right when she concludes that Dr's are control freaks who don't care about women. If you don't want to grow the attitudes that encourage a certain sub set of NCB advocates to become extreme in their views and actions---don't feed it by giving them exactly what they think they're going to get. Show some kindness and hold your ground at the same time. I've been getting a lot of e mail from young women contemplating home birth who've come from here. They want information and they want someone to respond to them as though they are intelligent people with the ability to make up their own minds . Just for the record, the "stats' go as follows: I've had 23 such emails in the last 6 weeks. All the women were pregnant. 18 were in the care of Midwives in homebirth practice and 5 were currently under OB care with one under OB/CNM combined care. Of the 18 women under the care of homebirth midwives, 7 decided against having homebirth, based on my questions and responses to their concerns. Only 1 of those young women ultimately chose OB care, however, the rest chose CNM care. Now, my sense of this handful of women is that they were probably already unsure about their choices when they came here and then came to me. I don't think I should be credited with any decisions but, they did get something from my conversation with them that they didn't get here and all used the same word, or nearly so: respect and a willingness to help them sort through the issues of risks and potential problems without feeling defensive or overwhelmed. So, there are good things that can happen if you keep your eye on what you are trying to accomplish. If you want to change lives and minds, you have to give people information in a way that doesn't knock them off their own center. The battering ram/bullying approach only makes them withdraw; nothing changes. Amy, decide how you want to use your education, training and good heart and then your blog will take care of itself. You have loyal and interested followers and they'll hang in there with you and enjoy the process. Peace, everyone. Happy New Year and blessings on you all.
From Emma B:
I was just thinking about the risks of owning a pool or spa to your child vs homebirth.
Homebirth is far more dangerous than swimming pool ownership. CDC shows 52 deaths with "other midwife" out of 17,786 births, for a rough death rate of about 3/1000 (back-of-the-envelope, but all we're after is orders of magnitude here). The article you linked states that there are about 280 deaths in swimming pools. For pool drownings to occur at the same rate as homebirth, there would have to be only about 93,000 pools a year. Obviously, there are a lot more pools than that in America -- this source says 10 million pools, which is probably fair. So homebirth is roughly 100 times as dangerous as swimming pool ownership, even without factoring in the days of exposure.
We considered moving in the summer of 2007, and as parents of small children, we never would have considered a home with a pool (although I confess I didn't run the numbers).
From Susanne:
"The emphasis on performance-based mothering--on nursing, vaginal birth, cosleeping, baby-wearing, etc.--as a measure of a woman's worthiness to be a parent is incredibly damaging."
It's all those women on MDC and the like have, though.
From Miss Belle:
Emma- thanks I appreciate that someone has already thought that out for me. I have always lived in swimming pool stats and personally knew two toddlers who drowned and two who nearly did. I agree I could not live with a pool. The death at least of one of the children was of a child of a woman I consider the most careful, intelligent and wonderful of mothers. We all have that momement in a store or where we know we were lucky. Not judging women with pool either. The analogy of the death of a fetus so often makes me think of drowning. Particularly the minutes count term deaths.
From KW thoughts- when I found this blog it was purely because these questions boggled me most of my life. I had very few people not defensive enough of the homebirth world or o the among doctors or nurses who cared enough to research homebirth to debate it. Amy has answered a lot of questions and all the smart women of this board just as many. It is a great source of discussion with so many very smart voices here.
From Lee Passman:
"It's all those women on MDC and the like have, though."
If that were all they had, they wouldn't need a blog. They'd need a sentence.
"I agree I could not live with a pool."
Why? You're heart would stop? Don't you mean that you would not risk having your toddlers live with you near a pool because you fear their drowning?
This blog is not homebirth debate. This is homebirth conclusion!
I heard a rumor that Liz and Suzanne are really just posts by Amy when she wants to let her hair down and her tongue wag.
From Anonymous:
Thank you Kneelingwoman. So nice to hear a voice of reason and compassion here once in awhile.
From Anonymous:
By the way, many of the regulars here may want to read Dr. Amy's newest post on her other blog.
And this is said with no snark at all- Without naming names, a few of you might learn something.
From Anonymous:
The one titled "Snark, the Language of Loseres"
From Liz:
Just goes to show how reliable rumours are! We all have different personas for different occasions, but the idea of Dr. Amy, me and Susanne inhabiting the same consciousness is a bit weird. No, I am me, honest, and own my opinions,confused as they are, and my tendency to "talk" a lot.
Personally, I am a bit confused by the idea that a "debate" should be looking for middle ground, consensus. Far as I know, a debate puts forward a proposition - that homebirth is not a great idea - one side attacks, the other defends, and the interest is in the strength of the arguments. I have shifted my ground since I first came here - I no longer think people who choose homebirth are insane, but have not yet been persuaded that they are not unwise.
From Kneelingwoman:
Hi Liz: For the record, I agree that the idea of "debate" is one of making and assertion and then trying to prove one's point, and disprove the other side. My statements here have been about the stated purpose of this blog by Amy which has been that she wants to do something to impact what she views as "preventable deaths" of infants due to home birth practice. This has been the "defense" offered time and again, by Amy and by those who support her when someone "attacks" her; the inevitable cry is "Dr. Amy really, really cares about women and babies and can't stand to see babies dying..." The point I have tried to make here many times goes to the idea that someone has to question, somewhere along the line, whether those efforts are bearing fruit ie. are minds being changed or are you only preaching to the choir while everyone else, presumably those you claim to be trying to reach, run away feeling more beaten up, more defensive and more convinced that those who object to what they are doing are far more interested in "proving their thesis" than in changing lives, let alone saving them. I feel in my own heart and mind that Amy does indeed care deeply about women but I'm not always sure she knows how to go about communicating with them in a way that is authoritative without being authoritarian and there is a world of difference in those two designations! Being authoritative simply means not being doctrinaire and being respectful, always, always respectful, in how you approach the other person. If there is any name calling, derision, ridicule and the like, or if someone takes advantage of a tragedy to exploit it in order to set in motion the ridicule,derision etc. then I think you've lost your most important audience and sometimes, the respect of people who might like to join forces with you to make needed changes but who give up because the "noise" in the room obscures the objective and makes it impossible to communicate.
From Yehudit:
Liz,
Maybe you should consider getting involved in your local Maternity Services Liaison Committee, or if your trust doesn't have one, the Patient and Public Involvement Forum (your trust will certainly have one of these). Here, debates impact on large and small decisions made by local hospitals about the maternity services they provide.
From Caryn:
Personally, I am a bit confused by the idea that a "debate" should be looking for middle ground, consensus. Far as I know, a debate puts forward a proposition - that homebirth is not a great idea - one side attacks, the other defends, and the interest is in the strength of the arguments.
Right. What, precisely, is the claim, and is it true, or false?
I'm quite sure that at least *some* pregnant women find rational argument compelling and interesting. And engaging in rational argument is, frankly, as respectful as matters get, because it's taking a claim *seriously*.
From Emma B:
I heard a rumor that Liz and Suzanne are really just posts by Amy when she wants to let her hair down and her tongue wag.
Wow, I feel left out. I never get accused of being an Amy sock puppet like all the cool kids!
From Liz:
I have to say I find Dr. Amy's repeated pleas for civility a bit baffling - and Open Salon deadly dull. Reminds me a bit of being reprimanded by the headmistress for failing to be sufficiently lady-like. Someone over there said us Brits are a bit more robust in our arguments, so maybe this is one more transatlantic difference. Oh well, it was fun while it lasted. I like the internet, think it has enormous potential for open communication across, through and over all sorts of barriers, but genteel journalism I can do without.
From A Sarah:
Wow, I feel left out. I never get accused of being an Amy sock puppet like all the cool kids!
Emma B, don't worry, I heard a rumor that you are really the re-animated body of Harry Houdini come to life again as the result of scientific knowledge gained through ghoulish experiments conducted by Nazis who changed their identities after WWII to evade prosecution for war crimes. You're currently being held in a facility run by Islamist terrorists, undergoing extensive brainwashing. Their plan, when you are completely under their control, is to release you and send you on missions to free imprisoned sympathizers with your mad escape skillz. Currently they have you posting on the internet so that you can get acclimated to 21st-century life; they wouldn't want you to prompt suspicion when you're out in public.
And by "heard a rumor" I mean either "pulled straight out of my ass" or "was told by someone who had no reason to believe it was true but liked the sound of it and thought that was good enough reason to state it emphatically in a conspiratorial whisper." Unfounded assertions FTW!
From Caryn:
Well, and she says: Denby lays out three criteria that differentiate snark from biting commentary. Snark is anonymous; it is ridicule; and it makes no argument of any kind, intellectual or otherwise.
What's with all that posting with one handle, Liz, and making arguments, and failing to ridicule individuals personally? I think you're probably off the hook, here. (Failing to respect *bad arguments* is an entirely different sort of problem...)
From Liz:
Wasn't entirely taking it personally, but still don't understand. Snark is too ill defined a word. Sneering comments with no other intention than to sneer, or personal attacks that degenerate into abuse I don't much care for. But excessive politeness or striving for consensus is too wishy washy for me. I can see the logic of Kneelingwoman's position: a confused young woman afraid of hospitals might be gently persuaded to take a more realistic view. Don't think sweet reason has much effect on Birth Warriors. Dr. Amy herself has a neat line in blunt put downs, too.
What I liked here was that participants seemed to be striving for honesty, not writing for effect.
From melissa:
"A dead baby drops into her hands, a situation that is virtually inconceivable in a hospital setting."
"The key advantage of the hospital is the ability to rescue babies who need to be rescued."
Wow. Major, arrogant, grandiose assumptions here.
My baby dropped into the hands of an OB in a hospital 3 years ago - dead. Not because of "abnormalities incompatible with life", but simply because of fetal hypoxia and bradycardia from which the doctor/hospital were NOT ABLE TO RESCUE HIM.
Would you call a baby with heart rates in the 40s to 80s for 20 minutes "lackadaisical monitoring"? Because that's what happened in the HOSPITAL. Perhaps the nurse who was monitoring all 12 laboring women from her nurse's station was too harried to notice my monitor.
The hospital also wasn't able to get me into an emergency C-section in time to save my baby's life. Would you say that's an example of "inability to provide appropriate care"?
Sometimes babies die. Some babies are able to be rescued - at home and in a hospital - and some aren't.
Unless you can claim total omniscience, maybe you should have a care when claiming to know which babies would have lived if only they had been born at a hospital. If my baby had died at home, you would have chalked it up to a "preventable homebirth death."
You would have been wrong.
From Liz SUPW:
As another mother whose baby wasn't protected in hospital, I know how you feel. And you have all my sympathy for the worst experience a mother can have.
But I don't think it is arrogance - I think it is optimism. what happened to us shouldn't have happened. Living with it is hard. But it reinforces the argument about homebirth, it doesn't undermine it.
From CharlotteDad:
How does it reinforce the argument for homebirth? Are you suggesting that since monitoring and hospitals can't save every baby we should just toss them in the waste can?
Would a homebirth midwife have been able to fix that 40-80 heart rate? If not then you aren't reinforcing, you are just saying that sometimes the results are no better. That isn't exactly a glowing recommendation.
You know, back to the old car seat analogy. There are car accidents where a car seat did not save the child. Does that mean we should repeal all car seat laws?
I'm sorry for your loss, but you are the one that decided to use a personal anecdote. When a homebirth advocate can convince me that the comfort of home and being oblivious to possible complications is better than knowing about them and having a chance to fix them then I might support it.
From Jolene:
"You know, back to the old car seat analogy. There are car accidents where a car seat did not save the child. Does that mean we should repeal all car seat laws?"
That is like suggesting that becuase the hospital failed to save her baby, all hospitals should close. Is that what you were saying melissa?
"When a homebirth advocate can convince me that the comfort of home and being oblivious to possible complications is better than knowing about them and having a chance to fix them then I might support it."
I'm fairly certain that no homebirth advocate cares very much if you personally support homebirth.
I wonder if you believe that caregivers at home would be "oblivious" to possible complications? If so, then you're wrong.
From CharlotteDad:
When Liz SUPW states "reinforces the argument about homebirth" she indicates that a death in the hospital makes the argument for homebirth more attractive than hospital birth. My point is that if your argument against a case is that the case is sometimes as bad as your own case then it is not a very convincing argument. Do you disagree?
I vote in a state that does not legally support homebirth. Maybe they don't care about me, seeing as who that is who you seem to be focused on but they do care about public opinion - of which I am part of. Are you suggesting homebirth advocates in my state do not care about public opinion? I'm pretty sure they do. Laws don't get changed unless they do.
Ok then, do you believe that a homebirth midwife can evaluate a heartrate issue better with her stethoscope than a monitor that cotinually watches this? If the hospital staff was neglecting their job, then she should sue for malpractice. A midwife can do a bad job just like a hospital nurse can.
Now for kicks, let's contemplate how the situation would have been improved at home. The aware midwife detects the low heart rate. What does she do? Roll up her sleeves and get started with a battlefield C-section? Or does she transfer to the hospital and then the same result happens (remember this went downhill in under 20 minutes).
How is this better? How does this reinforce homebirth? Or did you just want to argue?
From Jolene:
"I vote in a state that does not legally support homebirth."
I vote in a state where homebirth is legal and midwives are licensed. So what?
Were you saying then that you are willing to throw your support behind homebirth if X was met? X being "When a homebirth advocate can convince me that the comfort of home and being oblivious to possible complications is better than knowing about them and having a chance to fix them..."
Sadly, that's a nonsensical statement.
"Ok then, do you believe that a homebirth midwife can evaluate a heartrate issue better with her stethoscope than a monitor that cotinually watches this?"
Maybe, seeing as the example was one nurse to 12 monitors which turns out she couldn't watch. But why can't the midwife use the same monitor as in the hospital? Why not make a little more sense in your offer to home birth advocates by saying something like "If you can show me that you use the same monitor as the hospital, and can achieve a C section in the same amount of time, then I will support it"
From Liz:
I failed to make myself clear. I meant it reinforced the argument against homebirth.
From Jen:
"I failed to make myself clear. I meant it reinforced the argument against homebirth."
That's how I read it, Liz, for what it's worht
From Susanne:
"But why can't the midwife use the same monitor as in the hospital?"
Uh, because the midwife can't afford to rent / buy / maintain those kinds of monitors to use one-at-a-time and then sit dormant the rest of the time? Because they can't get wheeled in and out of a private home? Because they require specialized maintenance?
Why not ask while you're at it, how come your midwife doesn't bring her own mammogram machine or ultrasound machine to your home? ROFL!
From Susanne:
"But why can't the midwife use the same monitor as in the hospital? Why not make a little more sense in your offer to home birth advocates by saying something like "If you can show me that you use the same monitor as the hospital, and can achieve a C section in the same amount of time, then I will support it" "
But that will never be, because -- let me spot you a clue here - if you are in a hospital with an OB who is qualified to do a CS, then you don't HAVE to go transport-the-mother-from-home-to-hospital, hunt-down-someone-who's-qualified-to-do-a-CS and waste precious time getting the OR ready. My dh can get a baby out within 2 or 3 minutes of determining the need. Because he can say all hands on deck, push the mother down the hall, yell to have everyone mobilized, and it happens. And it's happened. How can that be replicated even with the Bestest Midwife in the World at home?
Why choose a provider who can do A only imperfectly and B not at all, when you can choose a provider who can do A and B AND is in the setting that accommodates both A and B? Seems rather dumb to me.
From CharlotteDad:
I apologize Liz, thank you for the clarification.
Jolene, I think even Dr. Amy would support homebirth if it met certain qualifications. Not sure what's nonsensical about the statement, but it appears it wasn't too hard to understand for other people.
Susanne covered your other point pretty effectively.
I guess I shouldn't be surprised considering last time I debated you a couple months ago. What was it about .. oh yeah you were "offended" at me suggesting that people should not intentionally try to have children they can't afford. Hmm, that's come up in the news recently hasn't it? It's just futile to debate with someone that wants to disagree simply for the purpose of disagreeing.
From Mama Liberty:
"My dh can get a baby out within 2 or 3 minutes of determining the need. Because he can say all hands on deck, push the mother down the hall, yell to have everyone mobilized, and it happens. And it's happened. How can that be replicated even with the Bestest Midwife in the World at home?"
Susanne, this can't be replicated in some hospitals.
From Susanne:
So what? It can be replicated in many, particularly in urban areas, and that's what counts. Just because every single hospital can't mobilize to 100% in 60 seconds doesn't mean that being in a hospital has no value.
And, it's not even just mobilizing for a CS, it's mobilizing for a shoulder dystocia, a mother with pp bleeding, a baby who needs resuscitation or an NICU. It's sort of common sense that you have more access to those things if you're in a place set up to deliver those things, versus your comfy bedroom which isn't set up to deliver any of those things and an attending midwife who doesn't know what to do anyway.
From Caryn:
I wonder if you believe that caregivers at home would be "oblivious" to possible complications? If so, then you're wrong.
With respect to preeclampsia, direct-entry midwives are trained, and their certification test through NARM reinforces this, in a false understanding of the preeclampsia syndrome that leads them to be oblivious about the actual characteristics of the syndrome unless they've done additional work on their own. And there is no institutional requirement for them to learn the current understanding of the syndrome instead of the falsified theory they are taught.
So I would say that some home birth attendants are institutionally oblivious to some complications, particularly preeclampsia.
From Susanne:
Jolene, how can you argue against that? DEM's are taught a WRONG THEORY OF PREECLAMPSIA. That's like saying that a direct-entry electrician who believes that faulty wiring is caused by naughty fairies caught in the wall and that the cure is to say a magic spell over the fairies is "just as good" of an electrician as, well, a properly trained and vetted electrician who understands how wiring works according to reputable science, physics, and engineering principles.
From Verna:
"And, it's not even just mobilizing for a CS, it's mobilizing for a shoulder dystocia, a mother with pp bleeding, a baby who needs resuscitation or an NICU. It's sort of common sense that you have more access to those things if you're in a place set up to deliver those things, versus your comfy bedroom which isn't set up to deliver any of those things and an attending midwife who doesn't know what to do anyway."
Some of the discussion here has been interesting, but the unbalanced and caustic attitudes are disappointing. I have experience as a paramedic, have a background with many friends and family having homebirths, and have myself had 3 hospital births. I have seen both sides of the coin. Excellent and skilled OBs and OBs who don't know what they're doing. I have seen homebirth midwives who are cracker-jack and had to "show" the OB what to do when he didn't understand the medical maneuver that she asked him to do. You speak of your bedroom not being set up to deliver "those things" including mobilizing for a shoulder dystocia. The homebirth midwife is the one who saved the baby with shoulder dystocia, not the OB who didn't know how to do the maneuver. Homebirth midwives can be extremely well-trained, conscientious and diligent with a significant amount of lifesaving equipment (really as much as they have in an ambulance). Many midwives are certified in American Heart Association's Neonatal Resuscitation Program and Advanced Pediatric Life Support just like all hospital OB staff have to be. I have also seen poor homebirth midwives who sit back and are content to hope that a positive mentality and believing in the woman's inherent ability to birth will carry the day. This is just as bad as OBs that don't know what they're doing. I guess I would just like to see a little more honesty that bad things can happen in both places (hospital and home) and there can be bad practitioners in both places. Even the guy that graduates last in his class in medical school gets called "doctor". Mediocrity exists in all fields. I would also admit that with birth there is always the element of and possibility for surprise complications which could result in death outside the hospital environment. There are also complications that will result in death no matter where you are. There are also complications that result from inappropriately used hospital interventions, and occasionally deaths. I have seen this with my own eyes. I think that parents should have the right to make informed choices and that all options should be available and fully explained. There is great failure to adequately inform parents both in hospital and out. I have seen that too. The whole argument of hospital vs home is so fraught with complication and difficulty and trying to make a general statement one way or the other that one is evil and one is good is just a mistake. I have been present for several c-sections and they are a miracle of modern science that is truly lifesaving. However, they have their own risks and complications and like all interventions should only be used when truly necessary. I am going to continue to have my babies at the hospital for safety's sake because of the complications I have had, however I respect the carefully weighed choices of my friends and family who choose to have their babies at home.
From Emma B:
Even the guy that graduates last in his class in medical school gets called "doctor".
The guy who graduated last in his class still had stellar undergraduate grades, high scores on his MCAT, passed two grueling years of academic med-school courses, made passing scores on the hellaciously difficult USMLE STEP exam, spent 60-80 hours a week in clinical settings for the last two years of medical school, passed another STEP, got into by a residency program, spent 80-100 hours a week practicing there for another four years, passed another STEP, and finally convinced a group practice to hire him or a hospital to give him privileges.
Getting into med school isn't a golden ticket to doctorhood -- people flunk out or drop out at all stages along the way, especially during those first two years of medical school and that first STEP exam. Even someone who barely made it through those hurdles has demonstrated mastery of some very complex material and has put it to use under a wide variety of real-life clinical situations. It's not quite like barely graduating from high school.
From Indy:
And yet Verna cannot even master the concept of a "paragraph".
Finishing last place in the Masters is still infinitely better than winning a free box of golf balls in local public golf course tournament.
From Leigh:
I check in about once a year and my reaction to the commenter's is always the same: "Have any of you ever attended a homebirth (or two or more) with a licensed midwife?" And conversely "Have any of you ever attended a hospital birth (or two) with an OB?" Many of these commenter's seem to lack very important knowledge about a midwife's training, experience, legal boundaries, crucial equipment, thorough care and knowing of their clients, and total knowledge base. It seems quite unjustified to make such comments, just as I wouldn't dare make comments about an OB's standard of practice without understanding it and/or attending hospital births. As a doula, I've attended many of both. This doesn't make me an expert, but simply a witness.
Argue all you/we want about the ethics and style of birth, but let us get simple facts straight. Solid facts that cannot be argued with, such as training and equipment (because we all know data and numbers can be sliced, diced, and argued for either side).
Example comment:
"Do you believe that a homebirth midwife can evaluate a heart rate issue better with her stethoscope than a monitor that continually watches this?"
A midwife uses both a fetoscope and (most commonly in labor) a Doppler to listen to heart rates. She does this periodically throughout all stages of labor, just as the hospital monitors for about 20 minutes every hour (and NOT continually as it is often assumed). She also may perform cervical exams to ascertain position and descent of baby and stage of labor. There is much that can be done, if necessary, to manipulate a baby even within the womb. A midwife also performs vital checks on her client throughout labor, including taking of temperature, blood pressure, and pulse, just as it is done at a hospital by a nurse. Many things can be determined by these vitals, of course, including dehydration, signs of infection, etc.
Secondly, a midwife carries a plethora of life-saving and life-stabilizing equipment with her, which she has been trained to use, including: oxygen, bag and mask for neonatal resuscitation, laryngoscope for neonatal resuscitation, , basic anti-hemorrhagic medication, suturing supplies and instruments (suture and lidocaine), fetoscope and hand-held Doppler, Rescu-Vac and/or DeLee catheter for deep suction of the newborn if necessary (as in the case with passage of meconium), IV therapy equipment, urinary catheters, vitamin K for newborn blood clotting, and erythromycin ointment for newborn infection prophylaxis, blood pressure cuff/stethoscope, amnihooks, baby scale, sterile/non sterile gloves, betadine, gauze pads, bulb syringe, cord clamps, alcohol pads, perineal oil, ammonia amps. I suppose you could then argue that not all midwives use this equipment (or over use it), just as you could assume not all OB's use all of their equipment (or over use it).
Also, after the birth, midwives are trained to perform a throughout newborn exam and assessments, including APGAR scoring, drying, warming, stimulation, etc.
Third, many ARE indeed skilled enough to handle abnormal presentations such as breech, acyclitic, nuchal hands/fists, shoulder dystocia. A midwife would monitor the baby during labor and birth with these presentations and situations, as she would with any. If the situation warranted transfer to the hospital, she would call her back up OB and have them prepare to receive her client. A midwife would rely on the information on hand to make the BEST decision she can make in that moment. Just as an OB preparing for a C-section or Vac-assisted birth does.
I was a transport for my first Frank breech baby. She was safely born in a hospital, via C-section, over an hour after transport. It was a non-emergency situation once I arrived at the hospital and I had time to think about all of my options.
However, I birthed my second Frank breech baby at home without any health issues or concerns, with a professional support team in attendance, monitoring and caring for me. I was aware of all of my options prior, did my research, and made my decision based on my own set of values, ethics, and available information.
I respect OB's, midwives, and the women who choose the services of each. But please, if you want to truly, wholly, honestly, and compassionately speak on the safety of home birth OR hospital birth, attend births located in each place with professionals.
Until then, stick to your numbers, which speak to the outcomes: healthy and not. These are important, of course. But do not assume you know what level of care and skill occurred during those births (home or hospital) until you have witnessed some.
From Jen:
"just as the hospital monitors for about 20 minutes every hour (and NOT continually as it is often assumed). "
This is not true everywhere, but I assume it must be common practice wherever you are. The person whose comment you are responding to seems to have been referring to cEFM (since that is the one that has a "monitor that continually watches" the fetal HB. cEFM is called CONTINUOUS electronic fetal monitoring for a reason. The belts they put on you DO record the fetal HB continuously, printing out strips that show it. Some hospitals in the US (and all hospitals in the UK, from what I've heard) do not believe these are needed for low-risk women and do the intermintent monitoring (either with fetoscope, dopplar or using the EFM for small bouts of time) like you mentioned above. In the US, however, many (if not most)hospitals do the cEFM, and the trend has been going more and more in the direction of cEFM for all, mostly due to medmal suits for missed fetal distress.
From Emma B:
Secondly, a midwife carries a plethora of life-saving and life-stabilizing equipment with her, which she has been trained to use, including:
Midwives in homebirth-illegal or alegal states (such as mine) don't. Doesn't stop them from attending births anyway, which says something about their judgment.
From erin:
Dr Amy,
It's been just over 2 years since my daughter Birdie died...
After our attempted homebirth, and emergency transfer to hospital.
It has taken me a long time, but I just wanted to tell you that I agree with your views. I am now terrified of homebirth, and after the safe hospital delivery of my beautiful subsequent child, my son. I believe that birth can is safe and beautiful in a hospital setting. Most importantly though, it is ALL ABOUT the safety of the baby, not the experience.
From Anonymama:
Erin, I am so sorry for your loss.
From flim flam:
Erin you are extremely brave and i have nothing but admiration for the way you have tried to counter the "safe as life gets" propaganda in the face of fierce opposition from the true believers. Every time i look at your site with the photos of birdie my heart breaks for you and i am furious that you were so deceived and misled into choosing to homebirth. What do you think would have convinced you not to homebirth with birdie?. Was there anything that would have dissuaded you? or is the homebirth propoganda so convincing that everything else seems like scaremongering?.
Here in Australia history is repeating with another homebirth death.
"joyous Birth" ( and if you have a strong stomach i recommend having a look at the website for some terrifying reality free birth woo& equally terrifying photo"s, breech baby dangling from a vagina with the head still in the birth canal anyone?, oh, i forgot, breech is just a variation of normal, phew! for a minute there i though it might actually be dangerous for the baby! silly me!) convener Janet Fraser lost her baby after an unassisted ( by professionals) water birth. More details on NHS BLOG Doctor. Here in Oz we are currently experiencing quite an onslaught of evidence free homebirth propaganda. Given that the proportion of women in australia that choose homebirth hovers around 1%, and even in the alleged homebirth friendly paradise of NZ, where it is actively supported by the governmnet the percentage is a measley 2.5% the proponents certainly seem to have a big media presence.
I wonder how janet will process this avoidable tragedy? Come to her senses perhaps? or is she too far into the cult?. That she waited 5 days in active/stalled labour before seeking medical help defies belief.
When did an "experience" become mere important than the life of a baby?. Those who spout the homebirth/ freebirth lies are culpable in these preventable deaths. Birth is not as safe as life gets. Birthing at home& the idiocy of freebirthing are nothing but gambling with your babies life.
I am furious that another new life has been needlessly lost & a mothers heart pointlessly broken & for what? an ideal? A dream? a fantasy of how birth should be?. How many more?.
From Amy Tuteur, MD:
Dear Erin,
Thank you so much for taking the time to write. I followed your pregnancy and was thrilled at the birth of your son. I love the pictures that you post of him. I was deeply affected by your moving writing about Birdie, and I will never forget her or your story.
Sincerely,
Amy
From Leigh:
Flim Flam,
From your comment, I have to say you appear to be filled with just as much "propaganda" and "scaremongering" as the homebirthers you describe. Your comment is as tipped as far to the extreme as well. Your comment doesn't make me angry, it leaves me confused. I sense that Dr. Amy's blog is here to allow a place for safe discussion and understanding, not to solely change anyone's mind.
(Apologies in advance for a long comment...)
And this method of zealous, unbalanced, and uninformed thinking is EXACTLY why the culture of birth is where it's at, regardless of where you sit on the "childbirth" scale. It creates dissent, anger, and a cycle of distrust for women and their choices. I'm curious to ask how many home birthers you personally know. Have you sat and talked to them? Really listened and attempted to understand and ascertain their reasons for choosing homebirth? As part of the birth community (both home birthers and hosptial birthers) I've yet to encounter the typical "overzealous/hippy/uninformed" home birther that so many love to describe. And I have never, ever met someone who thought the "experience" was more important than the health of their baby. Rather, the reason most choose homebirth is because they deem it to be safer. And yes, there is a small sector of home birthers (and hospital birthers!) who would choose to not intervene in any way to save a baby's life. That is their religious/personal views that encompasses a whole other set of ethical and moral discussion. You must know going into the discussion of homebirth that many of us fundamentally and inherently view birth differently than the majority of popular culture. Sit with them (us), ruminate on the ideas, let thoughts swirl and settle before you go into any discussions with a homebirther (or any person). Seek to understand, even if you disagree. Unravel your notions of birth, life, death. This is how we sit eye to eye, shoulder to shoulder, even in contention.
I am a homebirther. One that had a" breech baby dangling from a vagina with the head still in the birth canal". (BTW, they have to come out that way, why wouldn't they be dandling in the birth canal?) One that was highly educated and knowledgeable on the facts, information, risks, benefits, and process for birthing a breech baby. One that had support, emotionally and physically. One that made my decision on my own, with no one breathing down my next either for or against. One that birthed a healthy baby, without a single moment of fear. One that had already accepted the small risk of her birth (or ANY birth, regardless of presentation), both spiritually and emotionally. I had done my homework on all levels, as I did with both pregnancies.
I have been following and supporting amazing Erin since the loss of her sweet Birdie. She has her own valid reasons for choosing homebirth with Birdie, as well as valid reasons for choosing a hospital birth with her son. Most important, she listened to her heart, something no one can ever see into, or judge.
You asked "What do you think would have convinced you not to homebirth?". Obviously, nothing or I wouldn't have birthed at home. Comments like yours would have only sealed the deal even more. I'd already done my research to be "convinced". Why do you arrogantly assume that once someone makes a decision based on their own conviction and research they can then be dissuaded? Rather, what would have convinced me to have a hospital birth? An instinct, pre-term labor, inability to find a midwife I felt confident in, or an emergency. That's just about it. My first baby was also breech and at 9cm (when it was discovered) I transported to a hospital. Why? Because I trusted my midwife. Had she felt my baby was descending well, I would have stayed home (I actually wanted to, but trust my midwife's decision). However, after going through that experience, I decided with my second baby that I would birth her at home with support.
Have you asked homebirthers what convinced them? Because I've yet to find a single one who has said "Well, I was determined and solidified in my decision to birth in a hospital, but then some homebirther swooped in an put me under their spell and made homebirth look so appealing and wonderful that I decided then and there to have a homebirth!". Actually, most answers look eerily the same: "Well, I've never been in a hospital and it just didn't seem right to birth a baby there. I never knew of anyone who birthed at home, so I did alot of research on my options, interviewed OB's and midwives, and came to the decision that I believed home would be the safest place for me and my baby." Some women have had traumatic abuse histories and are terrified to birth in a place with strangers coming and going, having to adhere to certain policies and timelines, and being poked and prodded (not that that doesn't happen sometimes at home). Their abuse issues are deep seated and they feel unsafe in a hospital setting. You tell me how selfish it is to want to feel safe during your birth experience?
Just for the record, there are many homebirthers who have had losses and or/traumatic births that still choose homebirth the next time(s). I've known women who lost babies in the hospital who went on to choose homebirth. I won't speak on their behalf, but they exist and I know of some personally. And until you sit with them through their grief process, and hold their space, and listen to them, and allow their words and beliefs and reasons to swell in you, you will never understand them. And I've done with same for women who have chosen to birth in a hospital after a loss. Do your research on birth trauma to better understand the factors and issues involved. Sit silently at a birth circle as women tell their stories in a setting where they feeling unjudged and loved. Attend births (I know, easier said than done). Visit babyloss communities online. Visit homebirth communities online. So until then, what we need to be is a safe haven for women, regardless of choice, setting, and manner of their birth. That is how you build community.
Homebirthers - knowledgeable of the benefits and risks - are not selfish, ignorant, deceived, misled, cult members, or any other the other choice terms people use. Just as I wouldn't dare say someone who births in a hospital - knowledgeable of the benefits and risks - are selfish, , ignorant, deceived, misled, cult members. Both trust their care providers, make informed decisions, and go with their heart. And that is all we can ask.
I hope, Flim Flam, you can find yourself able to channel your anger into positive change and love for all women and their choices (as you would with any woman-centered issue). As a homebirth advocate, of course at first I was passionate about the choice. But then, I began listening to women and noticing the support or lack of it that they have around them, and hearing their stories, and I began to understand that we only serve them by loving them. As a doula, that is my job. As a woman, that is my duty. As a human, that is my calling.
From Caryn:
"I never knew of anyone who birthed at home, so I did alot of research on my options, interviewed OB's and midwives, and came to the decision that I believed home would be the safest place for me and my baby."
This is the crux of the issue, though. Just because people believe something does not mean that it's true. Does having true beliefs matter?
You tell me how selfish it is to want to feel safe during your birth experience?
Is it more important to be safe than to feel safe?
I would argue that in many, many cases homebirth is trading the *actual safety* of the mother and baby for the *feeling* of safety.
Visit babyloss communities online. Visit homebirth communities online...
...visit preeclampsia communities online. Visit fistula communities online.
Pay attention to *all* the stories.
From flim flam:
you prove my point leigh, the experience is worth more than the babies life.
All this talk about empowerment, what a load of crap. there is nothing, nothing empowering or wonderful about the preventable death of a baby.
thanks for the drive by passive aggressive psychoanalysis by the way. i most definitely do not support women in making idiotic, dangerous choices based on fantasy and a gross misunderstanding of medical science and risk. i despair of a women who would choose another homebirth after losing a previous child in exactly the same circumstances.
birth has always been, throughout human history, the most dangerous event in a womens life. we are lucky to be living in a time where maternal and baby deaths are rare, this is not "natural" it is a direct result of childbirth being actively managed by professional doctors and midwives. Not crazed birth junkies who think it's perfectly safe to stand up while their breech baby is still hanging by their head from the vagina.
you bet i'm fucking angry!. angry that women keep falling for this naturalistic fantasy bullshit.
every single homebirth is a gamble, if it pays of, well bully for you! now you can youtube your spiritual birth. but where are the youtubes of babies dying? i notice there are no posts at all on joyous birth concerning the recent freebirthing death of one of its founders babies. why is that? why are the dangers so hidden? dont informed, educated women have a right to know the facts?. why so much censorship on homebirther sites?. musn't have any negative thinking upsetting the little ladies must we!. all the homebirth sites are so deeply anti feminist " oh little lady, you dont need to know about all the risks! just dream about rainbows and unicorns and do your hypnobabies and nothing bad will ever happen, dead babys only happen to other women, and they obviously weren't crunchy enough or did something wrong..oh, you had to have a caeser? poor you ( you failure!!) you must be so traumatised..healthy baby you say? but still how will you cope with not having a natural birth.. VBAC UC next time!"
If homebirthers dont want to be characterized as stupid hippy idiots, perhaps they should stop fucking acting like stupid hippy idiots.
And yes, in my previous life in a fairly new agey subculture( thankfully came to my senses)i have known homebirthers. one women i know had a homebirth in the country, miles away from hospital, candles and whale music. Beautiful, natural, lovely, until it wasnt, until it all turned bad and her son was born with hypoxic brain damage and now has severe CP. but the birth was lovely!.everything she could of dreamed of, apart from the damage to her son of course, but hey, that's the price you pay right? someone has to be the statistic!. guess she took one for the team.
I know women who have had preemies in hospital, womens who had PPH in hospital, babies needing resus in hospital, lots of complications but i dont know a single women who has had a baby die in hospital. i know of at least 4 homebirth deaths in new south wales just this year. they're were 2 in my state last year that i know of, one of which lead to not only the preventable death of the baby, but the mother needed a hysterectomy due to massive PPH. It was her first pregnancy, and last.
From Yehudit:
flim flam,
Do you have a view on the article just published in the BJOG?
A de Jonge et al, Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births
http://www3.interscience.wiley.c...323202/
abstract (access to the full text with Athens account)
From Li:
Conclusions: This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.
The latter part of that sentence is key. That's why you can't compare homebirth in the U.S. (and possibly Australia) with homebirth in the Netherlands or UK.
From Yehudit:
I wasn't comparing homebirth in the US with homebirth in the Netherlands.
I was asking flim flam (who writes, rather categorically every single homebirth is a gamble) whether she had read that new study. This site exist for the purpose of debating the safety of homebirth. Not homebirth in the US. Or homebirth with DEMs. Or unassisted homebirth. But homebirth, in all its varieties.
From Jessica:
Just wondering if you guys have any thoughts on a situation where a baby is being homebirthed and for some reason or another is not able to make its way completely out, and suffers some kind of asphyxia, maybe even resulting in CP. Couldn't this baby be helped more readily in a hospital setting? Just wondering...I have always supported homebirthing until I considered this scenario. Yes, maybe it's not statistically significant, but it's still the life of that individual child. I would like to come back to the side of supporting homebirthing, if someone can explain to me how this scenario does not put the baby at a higer risk in a homebirth. Thanks.
From Ellen:
flim flam, I also live in NSW and am also really pissed off at the natural birth movement. You have said everything I was thinking.
I'm thinking of starting some kind of antithesis to the Joyous Birth movement. I think I'll call it Safe Birth. Wanna join?
Here's my self-righteous little signature:
Mother to one lovely boy, born with the help of gas, pethidine, epidural, episitomy and an obstetrician who I will be forever grateful to for saving my son's life and my sanity. Slightly traumatised by being tricked by the natural birth movement into thinking I might have an orgasm.
From Caryn:
This site exist for the purpose of debating the safety of homebirth. Not homebirth in the US. Or homebirth with DEMs. Or unassisted homebirth. But homebirth, in all its varieties.
One of the first things that becomes obvious when you start doing that is that there's no such thing as the safety of homebirth, broadly construed.
(Which leads directly to the question: why are homebirth advocates in the USA so often asserting that a birth attended by a CPM is perfectly okay because look! they do it safely in the Netherlands! Do they not understand the difference? If they don't, who's at fault for conflating the two?)
From Yehudit:
It may be obvious to you, but it's not obvious to those who insist that homebirth per se is unsafe.
If one accepts that homebirth in certain countries/contexts is as safe as hospital birth, or at least safe enough to be a reasonable choice, it leads to different questions about the context for homebirth in the US. Such as, why is homebirth unsafe (or less safe than hospital) in the US? What is the role of referrals and transfers, interprofessional relationships, education and regulation of providers in that?
Whereas, if one believes that homebirth is always and everywhere unsafe, those questions are simply not interesting because there are no circumstances in which one would countenance homebirth.
From Caryn:
That's why I agreed with you that that debating the question was relevant to belief formation.
Beliefs are propositional attitudes. Take an example individual who believes that the proposition "Homebirth is safe" is true.
That belief can be either true or false or indeterminate. (In the latter case it needs to be broken down into multiple propositions which are themselves either true or false.) It can also be justified or unjustified. True justified beliefs are arguably knowledge.
So, *why* does she believe that the proposition "homebirth is safe" is true? What is her justification?
And once you start poking around justifications, the whole problem surfaces practically immediately.
People who believe homebirth is always more dangerous than hospital birth generally have reasons for holding that belief. People who believe homebirth is always safer than hospital birth generally have reasons for holding that belief. But *defending* those reasons is a different problem altogether, and one decent veritistic strategy is to set up public debate on the topic.
Which is likely why this blog gets the traffic it does, even if it's boring Dr. Tuteur.
From desiree:
the netherlands study had a transport rate of 30%. that's much higher than any US homebirth midwife i've ever heard of. i'll bet that has a lot to do with the success of homebirth in that study.
From Yehudit:
The most recent Netherlands study doesn't report the transport rate (outcomes are analysed by intended place of birth at labour onset), though I wouldn't be surprised if it were around 30%.
In a previous Netherlands study the "within hospital" transfer rate (from midwifery to obstetric care) was higher than the homebirth to hospital transfer rate.
From desiree:
the article i read said it did give the transport rate. do you have access to the full text of the study? is it free anywhere? i'd love to read it.
From Yehudit:
It's at the BJOG. http://www3.interscience.wiley.c...323202/
abstract
If you have an athens account you can get the full text for free.
From desiree:
i don't have an athens acct. can i get one for free?
From Yehudit:
I don't know, mine came with my library membership. Maybe ask at your library?
From julio:
I think a horror that midwives do not have the skills to avoid a death of a newborn but as the case may be inevitable.
From Melissa:
"Problems in this category include shoulder dystocia and breech with trapped head or nuchal arms. Most of these babies will simply die at home."
This is an unfair statement to make, especially without data to support it. In fact, Ina May Gaskin (a home birth midwife) developed the Gaskin Maneuver the first obstetrical maneuver to be named after a midwife because of it's success with shoulder dystocia.
From Anonymous:
Most times though a serious cord prolaps, massive abruption, or fetal bradycardia will end up with the same results whether it is in the hospital or at home.
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