From m:
I think that there *is* some responsibility taking going on in the homebirth community - it's just not useful. Psychologically, I see a lot of bargaining, and I can see how taking an active role in doing useless things could feel more satisfying and empowering than "submitting" to diagnosis and treatment. It happens on MDC all the time - where someone will post that they might want an ultrasound to rule out some problem - and then everyone will come to the rescue with a laundry list of tasks that purport to solve whatever problem might exist - so the "mama" can then set off with a schedule of yoga and chiropractor appointments and homeopathic remedies and a special diet... and no doubt this is a *kind* of "taking responsibility" - she'll feel more in control than she would if she "just" went to the doctor.
From Basiorana:
Part of me thinks that insurance companies should simply refuse coverage for anyone who knowingly endangers their life or health in a drastic way. So chain smokers, alcoholics, drug users, people who don't get vaccines and anyone who does not get proper preventative care, including seeing a doctor through a pregnancy and (barring accidents) giving birth in a facility that is equipped to deal with emergencies. Even if they cover most things, they shouldn't cover the direct results of a bad decision-- ie, a smoker getting emphysema or lung cancer, an unvaccinated person getting that illness, or a person who plans a birth in an unsafe environment without qualified assistance having to be rushed to the hospital and maintain their child on life support for several months.
Tell people that they will have to pay out of pocket for their own mistakes, and they'll take many more precautions. They'd still get treated, but they'd be paying for the care for the rest of their lives. All of a sudden homebirth wouldn't seem so safe.
From Ginny:
I find it interesting that simply trusting what the doctor says is considered being responsible. If the world were run that way, we would be in mighty big trouble. Most of these women that are giving birth in hospitals are in pain, under extreme stress, so when the doctor or a nurse comes in and says that you need x drug so that they can have their baby successfully, so they sign it believing that the doctor knows best. Unfortunately, doctor doesn't always know best. My husband is completing his PharmD Degree, that is, to be a pharmacist, and has realized that doctors most often have no idea what they are prescribing. They just know that everyone else uses it, not too many people have sued over, so yeah, fill her up with it! Yes, there are many modern medical advances in those rare cases that something goes wrong. But in my experience, all those times that something has gone wrong were because of something the "all-knowing" doctor gave to the mother. Taking responsibility for your own health care means finding out all the facts beforehand, and then making an informed decision as to how you want to do it. Personally, I think that if women have been successfully repopulating the world for thousands of years with little or no assistance, it is quite arrogant of us to say that only doctors know how to do it correctly.
From Vicky:
I posted this in the post below, but I meant to put it here...I am a technological idiot.
Interesting points here about accepting responsibility. I believe in a woman's absolute bodily autonomy and as a result, her right to give birth wherever she wishes. It's also her right about whether to hear all the risks or just pretend that doing finger shapes on the wall stops a PPH. But she has to take responsibility for what she believes and what she chooses as a result. It's my professional duty to try and give her all the risk benefit information about all her options, not just place of birth, but if she doesn't want to hear them, she doesn't want to hear them. I don't recommend it as a course of action, but it's her choice.
Interesting post today on another email list. A woman wants a VBAC at home attended by NHS midwives. Fair enough. We are compelled to attend her when summoned, wherever she may be. She went to see a consultant today and he explained that if her uterus ruptured and she wasn't at hospital then the likelihood of various outcomes was unknown, but it was thought probably that her baby and her would be more likely to die in that event than if she was in the hospital.
Now, I can't see the problem with saying that to someone. That is true. She isn't, we don't think, more likely to have a rupture at home (although there isn't any evidence either way) but IF SHE DOES then almost certainly she and/or baby is more likely to die or be brain damaged. Surely that is information she should want to have when making a choice? Surely, if she wants to take responsibility, she should know that and evaluate it and make whatever decision she wants to?
But no, her response was outraged disbelief at the doctor's "scaremongering" and obstructing her wish to have a homebirth, and various supportive commnets along the lines of "he's just scared of birth - don't listen to him!" followed. Now, to me, that is not taking responsibility. You have heard the truth and instead of weighing things up and factoring it in and making your decision, you flat out disbelieve what you're being told. How can that be taking true responsibility for anything?
It boggles the mind.
From Susanne:
m: "and then everyone will come to the rescue with a laundry list of tasks that purport to solve whatever problem might exist - so the "mama" can then set off with a schedule of yoga and chiropractor appointments and homeopathic remedies and a special diet"
Don't forget swimming when you suspect you have preeclampsia!
From Amy Tuteur, MD:
Ginny:
"I find it interesting that simply trusting what the doctor says is considered being responsible"
Trusting a person with advanced education and training in an area that requires years of study to become competent is certainly more responsible than pretending that simply having a uterus means that you "intuitively" know all you need to know. The first is practical, effective and realistic. The second is nothing more than naivite and wishful thinking.
It's not as though women who choose to "take responsibility" for their pregnancies and births have different or better outcomes than women who simply follow the doctor's advice. Their rate of complications is not less, their outcomes are not improved, and, indeed, the rate of neonatal death is higher. So how, exactly, does "taking responsibility" accomplish anything besides giving homebirth advocates an opportunity for self-congratulation?
From Susanne:
Ginny: "Personally, I think that if women have been successfully repopulating the world for thousands of years with little or no assistance, it is quite arrogant of us to say that only doctors know how to do it correctly."
A high natural level of wastage in birth is not inconsistent with the fact that we're able to reproduce ourselves as a species. It's a fallacious argument - "if birth were so dangerous, we would have died out years ago." Uh, no. There can be high levels of wastage AND we can still repopulate ourselves. I'll leave it to Emma to figure out the derivatives necessary to prove that point 
From Lori:
Ginny: "But in my experience, all those times that something has gone wrong were because of something the "all-knowing" doctor gave to the mother."
Are you being serious here? How many cases in your experience are you talking about? My doctor did nothing but take the utmost care of me, prolong my pregnancy to get more weight on my son, and ultimately save me from HELLP syndrome. My doctor gave me nothing to cause the pregnancy issues. It was a previously undiagnosed clotting problem wreaking havoc on my son's placenta. Were it not for my doctor's many correct courses of action (ordering a clotting panel, hospitalizing me for closer monitoring, and delivering me just before complete chaos took place) I wouldn't be here.
Things go wrong in otherwise healthy pregnant women. It happens...and the fact that is hardest for homebirthers to accept is that often times it is relatively unpredictable.
Lori
From sarahz:
If I had a nickel for every pregnant mother I know that smokes ciggarettes! LOL. But really I am weeping, because it is SO sad. And keep in mind that I generally try to limit my friends to those who practice Natural Health to some degree. So we are talking about mothers that otherwise accept Natural Health and STILL smoke!!! The smoking rate amongst the Dorito set is even higher. I don't suppose OBs know the 1/2 of it, because women typically lie on the intake forms. 
So you know, when they get all those Marlboro Mamas to quit somehow, then be my guest, come after homebirthers next, I suppose.
But the arm of the state is not that long or strong, I'm afraid. If they can't even get convenient stores to stop selling cancer sticks to women 8 months along, then, you know, whatever!
From Emma B:
There can be high levels of wastage AND we can still repopulate ourselves. I'll leave it to Emma to figure out the derivatives necessary to prove that point
In fact, if there weren't high levels of wastage, the population would be far higher.
If women have, on average, two children who survive to bear two children themselves, the population stays stable. If women have three children who survive to bear three children each, the population doubles every two generations. World population has never risen at anywhere even close to that rate, so clearly not that many children are surviving to adulthood.
The perinatal mortality rate in Afghanistan is 96%. That is, nearly 10% of babies die before or just after their birth. In statistical terms, that is a HUGE amount of wastage -- 106,000 dead babies a year, compared to about 930,000 babies who survive the neonatal period. Yet their population growth rate is 2.6% in 2007, indicating that their population is increasing despite the astronomical perinatal death rate.
Conditions in Afghanistan are a pretty reasonable approximation of those in the medieval area, and are certainly no worse than in the Stone Age. Birth is incredibly risky per the statistics, yet the population increases.
From Emma B:
I'm sorry, perinatal mortality rate is 9.6%. I should stop posting on Phenergan!
From Basiorana:
Ginny:
Of course you shouldn't blindly trust the doctor, it's important to get informed consent in all medical matters, and doctors are human, they sometimes make mistakes (for example, I've had doctors fail to notice that two medications I am on might overlap, especially if they didn't prescribe the other one themselves). I'm going into medicine, and I hope I can set up my laptop with a directory of medications to help with that problem, because it is a problem, but honestly, we can't expect a doctor to remember literally thousands of medications off the top of their heads. However, that means you should make sure they know your medical history and that you understand your chances of survival either way, not that you should instinctively distrust them.
Iatrogenic illnesses and conditions happen. That's why you need to know the risks. However, illnesses and conditions are every bit and more likely to be caused by a midwife in the home, where no real effort is made to preserve sterility at all, and there aren't as many double-checks and confirmations that everything is going well.
And personally I think it is quite arrogant of women to say that they intuitively know better than someone who has studied the inner workings of human bodies for years and witnessed/assisted in hundreds of deliveries. Also, even prehistoric women had older women assisting in their deliveries, who used the furthest extent of their medical knowledge from their training and experience. There is evidence that giving birth with "little or no assistance" was very rare since the earliest of human development; in most cultures women had a midwife, their older female relatives, etc around for the delivery to help them. And those midwives were replaced by doctors and certified nurse midwives, as we learned more about how delivery worked and how to help women survive and thus required more training to pass that knowledge on. Obstetricians are the modern version of midwives. DEMs are the modern versions of the old man in the oxcart who was transporting you to the midwife who maybe saw a baby get born once, so when you go into labor en route, he catches the baby.
Also, FYI, for a woman to successfully repopulate the earth she only has to have 2 or 3 children who survive to adulthood before she dies. Consider that most women before birth control gave birth every one and a half to two years of their life. A woman could lose 10 children, die in childbirth, and have 3 survivors and she would be successful at repopulating the earth.
From Caryn:
But in my experience, all those times that something has gone wrong were because of something the "all-knowing" doctor gave to the mother.
Your experience is quite limited.
I had to transfer care away from my homebirth midwife when I developed severe preeclampsia (PE) over the course of a week. On admission my blood pressure was 220/116 with a +4 dipstick.
In other words, I was in full-blown multiple organ failure, kidneys and liver shutting down, because I was pregnant. Not because of something my homebirth midwife had given me, and certainly not because of something administered by doctors. I didn't see a doctor until I crashed into my midwife's backup OB's office with full-blown PE.
Personally, I think that if women have been successfully repopulating the world for thousands of years with little or no assistance, it is quite arrogant of us to say that only doctors know how to do it correctly.
A high rate of death in birth is not at all incompatible with species survival, so long as enough women and babies survive the event. Not all of them need to live, particularly not when some women have more than two children.
From Antigonos:
anecdote time: my son-in-law's sister-in-law is 19, gravida 1, in her 36th week.
she smokes a pack a day. she has had two apparent episodes of SROM [high leak] which apparently have sealed over. weight gain during pregnancy has only been about 7 kilos [she's very proud of this]and the estimated weight of the baby by u/s is 2.2 kilo.
her OB wants her on bedrest, in hospital.
married only 4 months, she has refused, because she doesn't want to be separated from her husband.
risks have been explained. "but the baby moves all the time, so he's OK, right? and it's my choice, right?"
women like this, and there are a LOT of them, make me want to tear my hair out. it's like telling a 3 yr. old it's OK to play with matches as long as he doen't try to light them --and expect that he'll listen.
From Liz 1:
Sorry, but I am having a kind of conversation with myself here - because I am learning about something I find interesting. As I have said, I have hated NCB talk since it first took hold (in the UK, that was the 70s) My original objection was that they were lying to women, and making an airy fairy nonsense out of something that was too important. I particularly objected because they were comforting lies, easily swallowed but would lead to depression, disillusion, and feelings of inadequacy when they (inevitably) came up against reality. Coming here so many years later, I am cheered to find that the majority were never fooled. But the fantasies have become more complex, and much more dangerous, partly because of the grain of truth, or what sounds like truth, embedded there. So, ever willing to learn, can someone put me straight on the "just in case" CS? A CS at 37 -40+ weeks to avoid the possibility of disaster seems to me fair enough. Does it really lead to worse problems? Is it really so bad in the US? My only knowledge of this is a sample of one - the birth of my grandaughter. I felt - strongly but relatively silently (when my daughter was listening) that a CS was called for. The doctors were clearly not keen. I got the impression that VB was preferred whenever possible. Maybe that is because in England people generally don't sue, and there isn't much of a "compensation culture". So what is really going on, and are the relative merits being studied and worried over? I have detected a hint of impatience in Dr. Amy recently - that obstetrics is not the most pressing problem in the health field and does not merit all resources. Me, I think it is pretty important.
From Chris:
"My husband is completing his PharmD Degree, that is, to be a pharmacist, and has realized that doctors most often have no idea what they are prescribing. "
This is untrue of OB's . They know exactly what they prescribe for pregnant woman. Why? Because birth defects are forever. All the Ob's I know, know the exact mechanism of each drug they give a woman. Then again I live in Massachusetts and the reason I put up with the cold is the good medical community.
From Liz 1:
Heigh ho, still stuck in a groove. Yesterday, in my exchange with Lies, we discussed our relative acquaintance with disaster. I did a bit want to say that being the aunt of a disabled child isn't quite the same as being the parent but I think I want to say something else. I think we are all a bit gobsmacked - well I am - at how easily and philosophically some people deal with the idea of disaster - the baby that "wasn't meant" to make it. And in my daily life I get annoyed about labels - the disabled, as if they were all the same. To me, there is a huge difference between a child who was doomed from the start, and one who was intact and healthy one minute and gone or ruined the next. Is this a valid distinction? I can see that religious faith makes a difference, but I am curious about the myriad ways human beings accept the unacceptable.
From Vicky:
Liz, CS carries with it an increased risk of morbidity and mortality for mums and babies. Having said that, it is also a lifesaver when it is clean (obviously) and used judiciously. It's the job of an obstetric consultant or registrar to decide when the risks of a CS outweigh the risks of a VB and advise accordingly. I can list the risks of CS for you if you like, but I suspect you know them. The fact is there is a tipping point within the population where CSs begin to cause collective harm rather than collective good.
For instance, we know the risk of stillbirth in a subsequent pregnancy is significantly increased when a CS has been carried out previously. That's a risk probably everyone is willing to take when this baby or woman right here is in danger. But when they're not in emergent danger, have a CS for just in case reasons which may have been unnnecessary and then their next baby dies in utero at 38 weeks - well, we can tell that that particular CS WAS that bad.
Also, we live in a country with socialised medicine, and CS is hella expensive. The average CS costs the NHS £1123, with a VB costing the NHS an average of £363. Sectioning everyone in unsustainable and even if we had the money, we don't have the room - here we have two obstetric theatres and a section rate lower than the national average. I was personally involved in a case where a prolonged bradycardia (sign of fetal distress) was not acted upon for 45 minutes following onset (with no recovery to baseline in that time) because the theatres were occupied, one with an elective section and one with an emergency. That was a poor outcome for the baby. If you increase the seciton rate much more, women simply won't be able to access a theatre when they need one.
It's a bit like antibiotics. We know they save lives. We know they have been fab for healthcare. But we also know that if they are over used or over prescribed, problems result. It's hard to find the balance between doing sections judiciously and overdoing them. But we must be mindful of it, otherwise we will create further problems.
From Chris:
"Personally, I think that if women have been successfully repopulating the world for thousands of years with little or no assistance, it is quite arrogant of us to say that only doctors know how to do it correctly."
And there has been a high degree of morbidity and mortality before modern obstetrics. Remember the old show Wild Kingdom? How many baby seals, old lions, etc died in the natural order of things?
From Liz 1:
Vicky, you are very helpful. This is exactly what interests me.
1. I am aware - in England, how could you not be - of the cost. That is why I am so puzzled by the American model. Are doctors really going to do highly unnecessary CS?
2. I am interested too in this idea of a tipping point. Where is it? Does anyone know?
3. I didn't know that it increases the risk of stillbirth. Why? What is the biology of that, or is it a statistical risk? And how significant is significant? I think maybe I extrapolate too much from my own experience, but my second everything was so much easier - not straighforward, I don't think I can do straightforward, but pregnancy, CS, recovery were all better the second time. I think in a way your body does "learn" something. Maybe lugging a toddler about makes you fitter!
From Amy Tuteur, MD:
Liz 1:
"I think we are all a bit gobsmacked - well I am - at how easily and philosophically some people deal with the idea of disaster - the baby that "wasn't meant" to make it."
I wrote about fatalism about a year ago:
Fatalism is persistent and rather suprising theme in homebirth advocacy. Feelings of fatalism about health reflect the idea that "bad things are going to happen" regardless of measures we take, and often imply that it doesn't make sense to undertake certain healthcare measures because "if it's going to happen, it's going to happen". I'd like to make four specific points about fatalism toward childbirth that is often found in homebirth advocacy:
1. Fatalism is a religious and philosophical orientation. It is not a medical viewpoint.
2. Fatalism among healthcare providers can compromise the quality of care that patients receive.
3. Fatalism in homebirth advocacy is rather suprising considering the cult of personal responsibility that homebirth advocacy assumes and encourages.
4. Fatalism is an excuse designed to avoid responsibility for poor clinical decisions.
The fact that fatalism appears to be part of homebirth advocacy is suprising in some ways because homebirth advocacy aggressively promotes the notion that patients have much more control over health outcomes than they objectively do. Eating right, taking herbal supplements and avoiding childbirth interventions are emphasized as the keys to good childbirth outcomes. Therefore, at first glance, fatalism seems incompatible with homebirth advocacy. I believe that this apparent inconsistency serves an important psychological purpose. By invoking both personal responsiblity for health and fatalism, homebirth advocates are trying to have their cake and eat it, too. Essentially, they claim credit for good outcomes which they fervently believe are the result of homebirth advocacy, and they disavow bad outcomes which they fervently claim are beyond their control.
Simply put, fatalism is used in homebirth advocacy as an excuse. Homebirth advocates are quick to ascribe good outcomes to their choices and their actions, and bad outcomes to forces beyond their control. Homebirth midwives are quick to ascribe good outcomes to their own clinical skills (when it requires no skill at all to have a good outcome in an uncomplicated pregnancy and birth) and shed responsibility for bad outcomes by claiming that "it was meant to happen". Fatalism in homebirth advocacy serves a psychological function. It protects advocates from the psychologically difficult task of confronting and acknowledging the evidence that homebirth increases the risk of neonatal death.
From Vicky:
Where is the tipping point? Good question. A 2007 study showed that IP stillbirth rates decreased up to a seciton rate of 8%. So it's definitely got to be above 8%. However that doesn't take into account fetal or maternal morbidity. I don't think we can or ever will know, because some of the outcomes are so subjective. What's better? A 4th degree tear that heals well or a section wound that becomes infected and is a source of pain for a long time? And of course, if we do the section to prevent the tear we'd never know whether the tear would have occurred or if it had whether it would have been a good healer or not, and vice versa for the section wound.
Re: stillbirths. Thw 2007 BJOG study found that women with a previous section were more than twice as likely to suffer an antepartum stillbirth for explained reasons, 1.68 times more likely to have one for unexplained reasons. The jury is still out on why, although the current thought is that the scar causes improper placental implantation and subsequent function (which ties in with the fact that most of the excess explained stillbirths were as a result of a placental abruption). It'a being researched at the moment I believe
From Susanne:
am interested too in this idea of a tipping point. Where is it? Does anyone know?"
The real problem is that the mortalities / morbidities associated with a CS (either one completed, or one not done) don't have a common valuation.
For example, what's worse? (Examples made up)
10 women who are unable to have future children due to sequelae of a CS? Or one woman whose baby dies from not having a CS?
100 women who have rough recoveries while dealing with a newborn? Or one woman whose baby is brain-damaged for life?
If we all agreed on the "point value" of these different events - if a bad recovery is 5 points, not being able to have subsequent children is 10 points? If a brain damaged baby is 1000 points, is a dead baby is 2000 points? you could figure out a tipping point. But until there's uniform agreement as to that, people will have different tipping points.
Look at the women who feel that having a CS feels like they haven't given birth. Their feelings are real. I don't share them, so I give that 0 points. But for them, maybe that's 10 points, or 20 points, or 30 points, or 80 points. I didn't want a large family anyway, so any rise in infertility associated with a CS is 0 points for me. But for some other woman it might be huge. You simply can't calculate a tipping point unless you can assign commonly agreed on values to all of these events - and then you can play with every scenario ranging from "there are no CS ever" to "everyone is CS prophylactically at 38 weeks" and everywhere in between.
From Cordelia:
I hate it when people use cigarettes and smoking as the "obvious" example... and I don't even smoke! That argument is wrong in more ways than I can count. People expect medical help for that bad decision because the help is required-- the lawsuits have determined you can't refuse medical care to people because they make bad decisions.
On the flipside, the massive anti-smoking campaigns have so demonized tobacco that the establishment totally fails to recognize the benefits of nicotine as a mood regulator, and offers no better alternative (gum and patches are far too expensive for most people to use long-term, and have their own adverse consequences). I have known several people with OCD, schizophrenia, and severe adult ADHD who smoked (knowing the health consequences) because it actually improved their quality of life and they (and everyone around them) felt the trade-off was worth it.
When life-improving prescription medications have horrible side-effects, we hardly bat an eye. How is that different? Because it was prescribed by a guy with a white coat and a degree? Because it was expensive and dispensed by a pharmacy? Certainly we don't say "you idiot, you were warned about the side-effects before you took the medication, you don't deserve medical care now!"
Smokers are an easy target because the habit is distasteful to the rest of us. That's a cheap shot.
From Liz 1:
Susanne, your points are well made. I am biased in favour of "better safe than sorry" CS, but puzzled as to whether 30% is too high or not high enough. Certainly I would be unhappy with CS as first resort, understand the large families and simple regret at missing out on an experience, but cannot get this deep fear of complications. Childbirth is clearly not a talent of mine, but none of my problems were down to complications with CS, nor anyone else I know. Case by case seems sensible to me. I had an OB keen to avoid one, and look where that got me.
From Dianne:
Personally, I'd like to drop the whole concept of "responsibility" from medical care. It shades way too quickly into blaming the victim. Because you can always find something that someone did wrong that made them "responsible" for whatever illness occurred.
Yes, any smoker who hasn't been living under a rock for the last 100 years knows that smoking is dangerous. But what if a smoker tries to quit? They may gain weight, thus putting themselves at risk for heart disease, diabetes, osteoarthritis, etc. If they then develop one of those diseases should we say "tsk, you should never have quit smoking when you knew it would make you gain weight"? Or just blame them for not having the will power to quit smoking without gaining weight. Suppose a person quits smoking and starts an exercise program to prevent weight gain and give herself something to do when she craves nicotine. What if she is out biking and is hit by a car? Is she responsible for the damage to her body because she knew that cars were out there and were dangerous?
It's all too easy to judge people when they are ill. Often they did do something to contribute to the illness. But it's all really just playing the odds: nonsmokers can get lung cancer, hospital births can go wrong, people of ideal body weight, cholesterol, and blood pressure can get strokes. IMHO, it's not the place of medical personnel to judge whether a person has taken too high a risk or not. We can advise people on ways to reduce their risks, but we can't ever tell them that if you do this you will live forever. And no patient can say for sure that he or she is definitely doing the thing that will keep him/her healthy. So ultimately no one can or does really take full responsibility for their health. And no one is really to blame if something does go wrong.
From Amy Tuteur, MD:
Cordelia:
"Smokers are an easy target because the habit is distasteful to the rest of us."
That was the motive for choosing it as the example, but not for the reason that you think. I am not trying to claim that homebirth is distasteful; I am pointing out the fact that taking "responsibility" for one's health is not the same thing as making good decisions, or understanding the risks. Taking "responsibility" is perfectly compatible with denial, and an expectation that others will bear the bulk of the work and the expense involved in trying to fix the results of bad decisions.
Claiming that homebirth advocates take "responsibility" for their decisions is baloney.
From Amy Tuteur, MD:
Dianne:
"Personally, I'd like to drop the whole concept of "responsibility" from medical care. It shades way too quickly into blaming the victim."
That's part of its appeal. It is so much more comforting to blame those with bad outcomes for their problems than to acknowledge that the same thing can happen to anyone, and cannot be prevented by simplistic measures like good nutrition. It's just another way of pretending that bad things won't happen to those who "trust" birth.
From Susanne:
"Childbirth is clearly not a talent of mine, but none of my problems were down to complications with CS, nor anyone else I know."
While it's anecdotal, of course, I don't know of anyone who has had any complications with a CS either, other than recovery was harder than with a V. I, too, don't get the ZOMG-a-CS-is--a-burden-the-rest-of-your-life point of view.
From Lies_DamLies_and_stats:
I am not trying to claim that homebirth is distasteful; I am pointing out the fact that taking "responsibility" for one's health is not the same thing as making good decisions, or understanding the risks.
No, what you are trying to claim is that "responsibility" means every woman falling in line with _your_ views. You are not respecting that there are responsible, knowledgeable women who look at the same data that you do and make a different assessment for their situation. I do not know a single _responsible_ homebirther who would deny that there are risks, they merely accept them. By converse, I know a lot of hospital birthers who deny that there are risks inherent to a hospital birth - and even you hard-core obstetrics advocates have to agree with that, because your very premise in the obstetric model is that birth is inherently a disaster waiting to happen! Too many people think that if they turn every single little thing over to Teh Experts, they are absolved of any responsibility if anything goes wrong. Sadly, this is not true. You picked your birth place, you picked your care provider, and at the end of it all that care provider will leave that birth place and go home, you will leave that birth place and go home, and you alone will bear whatever aftermath there is. An informed, responsible woman giving birth will understand that responsibility and will make decisions that she can live with, whether that's the decision to find a care provider that she trusts (good or bad, right or wrong) and put all the decision making in their hands; the decision to retain the deciding power for all minutiae (not to mention the big decisions!) and actively decide in the moment; or - as is the case with most women - somewhere in between.
Susanne -
The real problem is that the mortalities / morbidities associated with a CS (either one completed, or one not done) don't have a common valuation.
Bravo!!! That is the crux of the issue. They don't have a common valuation - they're different to every woman, as your post so eloquently illustrated. This is precisely why some informed, responsible women will prefer to birth at home with the (possibly? slightly?) increased risk of perinatal mortality - pretty much the only stat of any importance on this blog, it seems - over the increased risk of mortality/morbidity that they see in their situation if they birth at the hospital. It's like saying (warning! fictional numbers to illustrate a point here) well, if the plane crashes, it's a 100% bad thing, but there's only a 1% chance of it happening, whereas if my car crashes, it's only a 50% bad thing, but there's a 5% chance of that happening. Add to that the fact that it would take me three days to travel by car vs. three hours by plane, and well, I'm buying that ticket on {airline}. Obviously the assessment in a birth situation is much more complex, and even in the one I made up above, I can tell you there are people to whom I am very close who would choose to drive rather than fly as I would! Again, I can't emphasize it enough, you're looking at a very diverse population. Yes, there are some darned irresponsible homebirthers out there who are doing it for the wrong reasons and who _definitely_ don't understand the risks. But I know a lot of women (IRL) who have given birth at home, and I don't know any (again, IRL) about whom I would say that.
On a side note, DA, the cigarette analogy was pretty bad. If you're going to compare a childbirth choice to smoking, perhaps you could make it something more apt, like... use of unnecessary drugs? 
From Susanne:
LDLAS: "You are not respecting that there are responsible, knowledgeable women who look at the same data that you do and make a different assessment for their situation. I do not know a single _responsible_ homebirther who would deny that there are risks, they merely accept them."
That's great for those women - seriously. I think what is galling online, however, is that those risks are not discussed online by many of the midwifery / homebirth sites. The choice is being portrayed as "homebirth is SAFER than hospital - and it's nicer, warmer, cuddlier, friendlier, too." How much more intellectually honest it would be to say that there are some greater risks to baby in a homebirth, both by dint of who the provider is and by dint of not being able to access emergency help / facility in a timely fashion in a crisis, but for some women those are offset by the comforts of home and the lack of annoyances of the hospital setting (having to conform to their rules, get the IV, etc.).
I just don't see a lot of that honesty. I see a lot of rationalizing. "Homebirth is safer than hospital birth! DEM's know more about birth than OB's! You don't have to even worry about shoulder dystocia because we have some fancy way of resolving them all that OB's don't know about! You don't lose any time in transport because not every hospital has an OR set up and waiting anyway! Your mental state has a lot to do with the outcome of your labor!"
It's the dishonesty which is the problem in my book, LDLAS. Not the actual choice of the homebirth. A woman who says she knows all this and accepts it? More power to her. Truly. Who was that woman (I don't recall her name) who was planning a UC and acknowledged what she was doing and the risks it took? I can respect that intellectual honesty more than I can the nonsense of pretending that hospitals are such dangerous places and interventions are such dangerous things that it's a miracle anyone walks out alive.
From Liz 1:
I can respect that intellectual honesty
I struggle to. In abstract terms, I can. But can you intellectualize a life time of caring for a damaged child/adult? It may sound horrible to say that I can see that you could come to terms with stillbirth intellectually. I don't believe you can "get over it" exactly, but I am obviously aware that many see it as "better dead than damaged". Try the micro-premmies boards, where this rages. I can intellectualise the value of my daughter's life. She can't. The risk you are taking is not just yours. Do you have the right to take it on the baby's behalf? When I read a comment on Birdie's site about how the baby would have enjoyed its passage down the birth canal before dying, I could see it as a clumsy attempt at comfort, but what a viewpoint!
From angela:
What interests me about "responsibility" in home birth advocacy is the denial. Again and again women claim they understand the risks. What they don't say is that, deep down, they don't actually think a bad outcome will happen to them.
To me, knowing that we can say one thing but feel (and live by) another is the height of self-awareness. People who lack this insight amaze me. Indeed, it seems natural birth advocates as a group lack some amount of insight: they truly don't understand how they are offensive in some ways, they actually don't appreciate how easily the mind can trick us (if B occurs after A, surely A caused B, right?), they are utterly unable to put themselves in a doctor's or nurse's shoes if for no other reason than to understand and communicate better with that person, and they really truly believe that a CS contributed to their depression or sadness rather than the pernicious societal expectations associated with vaginal birth.
I often puzzle about this lack of awareness, this inability to step out of the self and consider alternatives. Is it because they are young? Many natural birth advocates on this board sound young to me; indeed, we have confirmed that some of them are still in their 20s. People in their 20s lack experience and perspective yet; they may not have completed their educations or worked long enough in their fields; they can often still be guided by emotion; many of them are only recently out of the care of their parents, and look to their practitioners for that care and attention. Calm and problem solving are learned, and we are not the best at these in our 20s if I do say; it would be ridiculous to say I had more insight in my 20s than I do now. I think natural birth advocacy is dangerously appealing to impressionable women in their 20s, as appealing as having a model-thin body is to teenaged girls (and many 20-somethings as well). (Of course, natural birth is also appealing to first-world, mostly white, generally educated women with nothing better to worry about. It's a luxury we have.) It takes maturity to grow out of these "longings," to realize that other things in life are more important and that societal cues and pressures are a (dangerous) bunch of garbage.
Is it lack of intelligence, for some? Obnoxious question, I know. But surely one who has difficulty solving problems in work or academic life, has difficulty solving problems in her emotional life as well---or lacks insight. (It is not true that one who is smart in her professional life necessarily carries that over into her emotional life, but it is likely true that someone of average intelligence has a lower chance of being brilliant in other spheres. Yes?) It seems to take some degree of intelligence to realize that it's the expectations surrounding natural birth that cause upset, not the "interventions" themselves. It's a synaptic leap, an "A-ha!" moment. But I'm not sure. Warped psychology and a warped view of the world, I know, can certainly make people look dumb and ill-logical when they are really not being. It is hard to tell.
Certainly lack of education is a part. You can be smart and capable, but if you don't know the facts, you can think and say some pretty dumb things. Even education and learning can teach us how to deal with our feelings and our denial.
I think, too, that self-centeredness may play a part. There is no (seeming) dummy like the self-absorbed. As I said, there is this reluctance here among natural birth advocates to let go of the self, to say "Maybe I don't control this. Maybe external factors don't give a damn about me. Maybe I am fooled by bewildering inputs as to what caused what." It kind of goes along with the natural birth movement, as well---this focus on the self: my birth plan, my birth, what I want, hospital = bad infringer upon my self. When one is so neurotically focused on her self (breath, push the white coats away, trust my body, dim the lights, I want a pool, I want my nightshirt, I want to be alone, I want my hand held, I want, me, me, me), it is understandable that this person is completely unable to see the outside world: to understand the nurses are only trying to help, to consider options outside the natural birth script, to examine the world and see what tricks it is up to (to even see that "fetal" distress is more important than her own!). (Self-absorption is also an affliction of the young, but it can circumstantially affect the elders, too!)
Anyway, it is interesting to me, this inability to acknowledge that, sure, we can say we accept responsibility, but if we look inside ourselves, we have to admit we don't actually think the bad thing will happen to us (and, by extension, admit such denial may be dangerous); the near-moronic (or frightened?) refusal to see any point of view but one's own; a strange incapacity to see how one's actions---even feelings---often occur in a larger social context, which it would behoove one to examine.
From Susanne:
Angela, wow, what a powerful post.
A few things I particularly like: "I said, there is this reluctance here among natural birth advocates to let go of the self, to say "Maybe I don't control this. Maybe external factors don't give a damn about me. Maybe I am fooled by bewildering inputs as to what caused what."
"When one is so neurotically focused on her self (snip) ... to understand the nurses are only trying to help, to consider options outside the natural birth script, to examine the world and see what tricks it is up to (to even see that "fetal" distress is more important than her own!)."
Yes! Love the last line.
From angela:
It also amazes me to hear natural/home birth advocates say, "Well, if that happened to me, I would accept my responsibility" or "I wouldn't blame the doctor." What stunning narrow-sightedness! Sure, you can say such things, but wait until the bad thing happens to you; wait til you see what your feelings are, how you respond then. Again, it is life experience and maturity that teach us this. It is humbling to admit that you really don't know what you'd do in those circumstances; experience teaches us that we have been minor hypocrites in our lives. We try not to be, but things happen and change our points of view. (Note that the way we try not to be hypocrites is to not say such things as if we could predict them in the first place!) Such lack of realization of these things! It's life learning! How could you miss it??
From Liz 1:
Deeply interesting post, Angela. I would agree that lack of life experience may be a factor, and possibly a lack of experience of adverse events. If you have not had much experience of life's unfairness and arbitrariness, then you can "trust". But I am less sure about intelligence OR education. As we are reminded, there are many doctors who support and encourage home birth. Alternative medicine gurus are often highly educated. And then, many of the theories seem logical and convincing - at first sight. It seems to me that it is more a perversion of intelligence and education. Each our own expert. Visit a couple of web sites, read a book, and you are the equal of someone with years of experience and education. If "choice" is a modern good, then all choice must be good, even bad choices. And a focus on the present, the individual, so that the past is truly a foreign country. The role of religious faith has to be significant too - tho the saying that when people stop believing in something they will believe in anything seems appropriate. I try to teach my students to THINK. It is hard work!
From Lies_DamLies_and_stats:
How funny, because most of the "natural" birthers and homebirthers I know are older. Many are or were career women, and I can only think of one offhand without at least a four-year degree. Many of them have been "failed" by their bodies in at least one way, some by reproductive issues (e.g. inability to get pregnant or sustain a pregnancy without heroic measures, prior bad birth experience or outcome, etc). These are not rich white teens and twentysomethings who blithely "trust birth" and assume nothing bad will happen to them. (OK, many are white, though there are several A/PIs, Hispanics, and AAs in there too, and they range from well-off-living-in-million-dollar-houses to "medicaid mamas.") Most of the ones I know have parallel care with a CNM or OB. Many have "done it both ways" and know what their preference is - and it may be surprising to some that it is _not_ the medical model. Some of what I'm reading here really makes me think that you have to have some kind of horrible tragedy happen to you and earn a place on the pity train before you can be respected as having the "maturity" and "life experience" to be able to make your own decisions. I hate to be the voice of reality here, but there are people who have more "maturity" and "life experience" at 16 than many thirtysomethings I know! In addition, saying "I don't know what I'd do in that situation, I'd just do the best I could" or "yes, I accept that something bad could happen, and I stand by my decision as the best for me in this situation" is not necessarily stupidity, immaturity, or denial. It may just be a decision not to live in fear. The simple fact is that some people would rather regret having taken a risk and lost; others would rather regret not having taken a risk and having lost out on an ensuing benefit. Of course, in the end, it's a no-brainer that nobody really _wants_ to regret anything at all. No woman planning a hospital birth _wants_ iatrogenic complications or nosocomial infections any more than any woman planning a homebirth _wants_ to need a transfer, much less have a rare situation where transfer made the difference between a "good" outcome and a "bad" one (as if that's so black and white, predictable, and even able to be determined after the fact). The fact is that both situations happen, they're rare, but if they happen to you they're 100% of your experience. Understand that, and get the heck out of the mommy wars. Go do something to make a difference and make the decisions that have to be made better and easier for everybody.
From Liz 1:
A lesson I learned in my teens was the gap between theory and practice. We all have a theory or an idea of how we would react in different sets of circumstances, but when you find yourself faced with the reality, you may find yourself amazed at how little you knew, what you are capable of. I had lots of theories about how to bring up children - before I had children. I suppose some people like tight-rope walking, I like learning curves.!
From Liz 1:
Lies, I was reading your post with an open mind, until I came to the expression "pity train". Anyone who can hold that expression in their head without shame isn't worth a moment of my attention.
From Amy Tuteur, MD:
angela:
""Well, if that happened to me, I would accept my responsibility" or "I wouldn't blame the doctor." What stunning narrow-sightedness! Sure, you can say such things, but wait until the bad thing happens to you; wait til you see what your feelings are, how you respond then."
That goes along with your comments about denial. Homebirth advocates do not believe that anything can "naturally" go wrong. Therefore, if something does go wrong, they look around for someone to blame.
Just take a look around MDC where homebirth advocates routinely blame or consider blaming the midwife, the nurses, the doctor, just about anyone but themselves for unanticipated outcomes.
If homebirth advocates were really willing to take responsibility for their decisions, malpractice insurers would not rate homebirth as extraordinarily expensive to insure. Insurance companies only care about the bottom line. Their experience is that homebirth advocates do not take responsibility for their decisions; they sue.
From Amy Tuteur, MD:
LDLAS:
"Some of what I'm reading here really makes me think that you have to have some kind of horrible tragedy happen to you and earn a place on the pity train before you can be respected as having the "maturity" and "life experience" to be able to make your own decisions."
An inane comment like that is one sure way to demonstrate that you don't have either the maturity or life experience to understand what is at stake.
From Susanne:
"If "choice" is a modern good, then all choice must be good, even bad choices."
Apropos of this, I saw that there was a recent poll on CNN.com: Do you believe that vaccines cause autism? As Orac from Respectful Insolence might say, it's not as though we're going to rely on science to tell us the answer ... let our opinions and choices tell us the answer. If enough people say that they believe vaccines cause autism, does that make it so?
From Susanne:
I c&p'ed the wrong part of the post! I meant to C&P: "It seems to me that it is more a perversion of intelligence and education. Each our own expert. Visit a couple of web sites, read a book, and you are the equal of someone with years of experience and education." Not the sentence afterwards, about choice.
From Liz 1:
I do struggle to understand what it is Home birthers are seeking. Greater safety, greater convenience, a transcendent experience, to fulfil some inner need, avoid facing a greater fear? In my less charitable moments, I suspect that what they want is a drama in which they have a starring role. A kind of biblical epic struggle between Good and Evil, where the kudos accumulated from success allows them to preen for ever after. The more "strong" the pains, the struggle, the more they "overcome", the better the drama, the more enthralling the Birth Story, the bigger their star shines. The sneers about the "dead baby card", their contemp for people like me, where does that come from? Maybe they sense that my drama, Susanne's, Caryn's is a bit more elemental and didn't need to be manufactured. That we do NOT see ourselves as special is a permanent affront.
From Lies_DamLies_and_stats:
Lies, I was reading your post with an open mind, until I came to the expression "pity train". Anyone who can hold that expression in their head without shame isn't worth a moment of my attention.
An inane comment like that is one sure way to demonstrate that you don't have either the maturity or life experience to understand what is at stake.
Yep, my words were purposely harsh. And I stand by them. I've really gotten sick of the implied superiority of people who have had this or that situation, this or that outcome, that anyone who hasn't had the same or similar lacks "maturity" or "life experience." I could sit here as a rape survivor and castigate your comments about people "whining" about how they've been "violated" or have "suffered" because you haven't endured rape and thus don't have the maturity or life experience to say such things, but I don't. I could say that because you haven't suffered from (past primary and current secondary) infertility and/or the loss of a baby as I have that you don't have the maturity or life experience to value even the conception of a child, much less its birth, the way I do, but I don't. I could say that since you haven't had your in utero or ex utero baby in a car accident as I have, you don't have the maturity or life experience to judge the risks to you and your baby of driving in a car in huge urban area rush hour when all the insane people come crawling out from under their rocks to drive to work or home, but I don't. I could go on. After a while, it gets a little hypocritical to play the "I've lived this" card and think that what you say is thus inviolate and no one would dare attack you because of where you're coming from, all the while giving lip service to the fact that you're not to be pitied or called strong, and of course you're inevitably biased. We've all lived different things; of _course_ they're going to color our perception of risk and of what's best for us and our families. That's only one of the many reasons I choose and advocate homebirth FOR ME when it's appropriate, and I don't want my choice stomped on, and I don't want people to paint a certain picture of me based solely on the fact of where I chose to give birth to my children. I'm not telling you you should have given birth at home, or that you should do so in the future, whichever applies to you. Only you can make that assessment for yourself, both prospective and retrospective - and guess what? You bear the responsibility for it.
From Liz 1:
Harsh words? You think I am offended my your "truth telling"? Keep right on posting your self-congratulatory posts.
From Liz 1:
And postscript to the above: You do far more to prove the points of those you see as "stomping" on your precious choices than we ever could in sinking to your level.
From Sailorman:
Liz1,
Your post regarding theory reminds me of an saying in my old lab:
In theory, theory and practice are the same. in practice, this is rarely the case.
From Emma B:
I could say that because you haven't suffered from (past primary and current secondary) infertility and/or the loss of a baby as I have that you don't have the maturity or life experience to value even the conception of a child, much less its birth, the way I do, but I don't.
I have, as a matter of fact, walked in those particular shoes. My twins are the product of infertility treatment, although I was fortunate enough to conceive my current pregnancy on our last spontaneous cycle before beginning treatment again.
I have, as all infertile women do, had angry thoughts about women with unwanted pregnancies or who neglect the children I would have killed to have. However, I don't happen to think such thoughts are particularly mature -- they're the grown-up equivalent of "it's not faiiir!" It's not, and it's natural enough to sometimes feel resentful, but it's still immature and angry rather than mature.
What I do feel justified in wishing for is that other women have a little imagination and consideration for those of us who can't have what they have so easily. I do think part of becoming a mature and wise person is gaining the ability to exercise sympathy (as distinct from pity).
For me, infertility was one of two life experiences that really taught me that s@#% happens, and that everyone eventually acquires their own history of scars. It could have been some other kind of experience, but yes, I do think that many people don't until they have *something* unpleasant happen.
I know women who have led "charmed lives", where everything has always worked out just the way they wanted, and don't seem to know how to deal with adversity, theirs or others'. In contrast, the women I know who have dealt with slings and arrows approach other people's tragedies with empathy, even if the cause of the sadness is foreign.
I would not wish evil on anyone, but I do think that dealing with hardship tends to mature you. It takes away that certainty that "everything will turn out just fine", because you learned the hard way that sometimes it doesn't. I know I can't in good conscience say that to anyone -- I can say that I hope it will, but I know there are no certainties.
From Amy Tuteur, MD:
LDLAS:
"Yep, my words were purposely harsh."
Why? To express your displeasure that everyone is not agreeing with you? How does that strengthen your argument?
From Susanne:
Emma B: "What I do feel justified in wishing for is that other women have a little imagination and consideration for those of us who can't have what they have so easily. I do think part of becoming a mature and wise person is gaining the ability to exercise sympathy (as distinct from pity)."
I think part of becoming a mature and wise person is gaining perspective as well. From my POV, you had a healthy baby that you took home? Man, did you hit the jackpot. All the rest is detail.
Why do people sneer at bridezillas? Because they have no perspective. Because they aren't mature enough to discern that the happiness of a wedding comes because two people who love one another are pledging to share their lives, and while it's nice to have pretty flowers and a dozen bridesmaids and a reception at the Ritz, and those things can certainly be fun and enjoyable, in any kind of long run it doesn't matter at all. And I think a lot of these HBA/NBA don't have the long run thinking, and they really do think the details are of long term consequence.
From Nik:
um... WOW
The personality and psychological profiling going on here is not only extremely unscientific, it is just plain unfair.
I can't speak for people other than myself. I just want a home birth just because I do. Just because it makes sense to me. I'm not looking for any experience or any satisfaction or any protection from any hospitals. I understand the risk and I've accepted it, and this is just what I want to do. No psychological profiling necessary. On the flip side, if I need to go to a hospital so what? Big friggen deal!
Everything just seems so WAAAYY blown out of proportion! From BOTH sides of the argument.
p.s. The plane/car crash analogy was cute but it's not fair because it is generally accepted that planes are safer than long-distance car rides. It's the same way that the cigarette analogy was not fair, because cigarettes are generally accepted as unhealthy. I have YET to see an unbiased perspective. But, I suppose I shouldn't expect to see one.
You know, I
From Nik:
On the "issue" of responsibility.
The idea of medical responsibility doesn't make any sense and is therefore, to me, just not worth saying anything about.
The only reason that I know of that "HBA's" talk about "taking responsibility for your own health care" is because its part of accepting the known risks of home birth. I thought that it was purely legal garbage, and it was part of the agreement that I signed with my midwife. I saw it as the same thing as "taking responsibility for your own health care" when you sign an informed consent form for C/S.
From Nik:
Uh Oh!, my initial post got cut off...
I was saying..
You know, I
From Nik:
It did it again!!!!!!!
I think it's rejecting my little "heart" sign.
ONE MORE TIME
You know, I :heart: all of you. Maybe we should lay off the type-casting a little bit.
From Lori:
LDLAS:
It is really not about implied superiority. I do not view myself to be superior to other moms. I think that is one of the points of our arguments.
I have met many homebirthers who feel superior for having given birth at home.
It is not about riding a pity train. Trust me. I would much rather have NEVER experienced the things I did. I never thought I would. Things like that weren't going to happen to me. I was an extremely healthy woman with a planned pregnancy. What could go wrong?
Plenty can go wrong.
It is truly reprehensible to diminish the experiences of people like Caryn, Susanne, Liz, and myself by saying we are on a "pity train." Did you live what we lived?
We are living, breathing examples that your body doesn't always just "know what to do."
It is not that I even think that other women shouldn't have the right to homebirth. It isn't that at all. It is the idea being forwarded that homebirth is just as safe as hospital birth. Sometimes? Yep. Sometimes it is. I just want other young women who are going into pregnancy categorized as "low risk" as I was to understand everything that is on the table.
That they will likely have more intervention in a hospital birth. But they will also have more rapid access to life saving technology should something go wrong.
My experience is deserving of more respect than what you have given it.
Facing the death of yourself and your child in the same instant changes you forever.
Perhaps you will just never be able to understand it. I pray you don't.
From angela:
I hate to be the voice of reality here, but there are people who have more "maturity" and "life experience" at 16 than many thirtysomethings I know!
But this is an immature statement! Another natural birth advocate a while back, many many topics ago, said the exact same thing in response to the maturity argument. It's like you all have the same mind! No, there are not many 16-year olds who have more maturity, life experience, and perspective than 30-year olds. It is true, some 16-year olds have had a rough life and have been forced to become adults and let go of their childhoods long before their time; this is sad (and more complex than I can understand), but it is not the same as "maturity." Gees, if you were mature yourself, you would know that! I have met a couple of 27-year olds in my life who were certainly more mature and understanding than I was at 27 (but they still don't hold a match to me at 36!). And occasionally, of course, we meet a person of any age who is remarkably (ahem) uninformed by life by that point, but these exceptions don't prove any rule.
I've really gotten sick of the implied superiority of people who have had this or that situation, this or that outcome, that anyone who hasn't had the same or similar lacks "maturity" or "life experience."
First of all, you are glomming onto the people who have indeed learned from their bad situations. I did not emphasize that in my post. And personally I have had very few "bad" situations in my life (though this is to some degree a subjective estimation), including in my son's birth. Instead, I have learned from others' bad experiences, I have learned from and been humbled by my own, much smaller lessons (labor hurts more than they tell you; you love your baby more than anyone can tell you), and I can make the inference as to my lack of invincibility and the power of greater things than I. When do you see natural birth advocates doing this? I'm a prime example of someone who can hold some perspective (well, comparing myself to some people here is hardly a contest) without having had horrible experiences. Just being rear-ended by a jerk who drives off or becoming the victim of identity theft (a couple recent brushes for me) taught me to be careful and not assume I'm invincible. But these are minor assaults. Still, I can make broader inferences from them (look outward, with perspective), and humble myself (look inward and examine my feelings). How many natural birth advocates do you see doing this (besides Kneelingwoman)? If they did, they wouldn't absurdly blame their psychological difficulties on a CS itself, they wouldn't say "oh, I would never get a needle in my spine" and then honestly wonder why that's offensive in most contexts, they wouldn't say such simplistic and reductionist things such as "I would take sole responsibility if my baby died at homebirth!" or "I know plenty of 16-year olds who are more mature than 30-year olds!"
And I second Emma B's contribution: maturity also comes from being able to express sympathy or understanding without having had experienced that direct thing.
From Caryn:
We've all lived different things; of _course_ they're going to color our perception of risk and of what's best for us and our families.
Wouldn't you agree, though, that there's a difference between the perception of risk, and the actual risk? Or do you think that all of the risk one runs in childbirth is purely socially constructed? (I think it would be terribly difficult to sustain this claim.)
Me, I'm a realist. I post here mostly to discuss false claims about risk. There are plenty of them to be had.
From Nik:
"Wouldn't you agree, though, that there's a difference between the perception of risk, and the actual risk? Or do you think that all of the risk one runs in childbirth is purely socially constructed? (I think it would be terribly difficult to sustain this claim.)
Me, I'm a realist. I post here mostly to discuss false claims about risk. There are plenty of them to be had."
Any realist knows that to a certain degree (and in certain people) perception of risk imposes its own risks, which although imagined can manifest themselves as very real things.
Maybe someone is a little "crazy" and is afraid of a risk that isn't there. I believe that person is still entitled to care that makes them comfortable if there are no emergency circumstances. (Yes, men too, which do it more than women in my experience!).
I just don't think its fair to dismiss peoples fears (which are very real to them) as nonsense and then shove their fears in their face when its not absolutely necessary.
Reality is not black and white. Reality is not either "there is risk" or "there is not risk." In reality there are different kinds of risks, and some people are more inclined to take certain risks based on their perceptions than other people would based on their perceptions.
If you believe that a risk is there because there has been adequate research to represent that risk, and that risks do not exist if there is not adequate research to represent it, then that is your personal perception of risk. It does not matter if that perception is correct or not, it is still a perception. As human beings, that is all we can have.
From Nik:
I'm pretty sure I got myself in trouble with that last post.
Oh well.
From angela:
And yet I have learned something from the women here who have had bad (or should I say lucky, all considered?) experiences. It doesn't take much to listen to their stories and contemplate a thing or two.
I still don't think it could happen to me. I'm honest about that. Intellectually, I know that it could happen to me. But actually, I must confess, I don't that think it will.
And I'll bet they didn't either.
I mean, that's the whole point.
From LN:
I have to say that LDLAS has a point, though perhaps sharp words were not the right way to communicate it. There really is no need to beat people over the head with one's bad experience excessively, particularly when the only connection to the issue at hand is that birth is neither trustworthy nor predictable. I think even most HBA would have to concede that point. At least, I hope they would. That said, it is sad that people would ask LDLAS if she has lived what they have lived or accuse her of diminishing their experiences while they do the same for things that are clearly close to her heart. It is hardly immature to point out that neither life experience nor maturity is tied to chronological age. I think it is a point well taken - the loss of innocence happens in different ways at different times. I think what LDLAS was trying to say - if a bit clumsily - was that one loss of innocence does not necessarily trump another, but that they will impact people differently, and that those differences should be respected rather than used to put others' perspectives down.
From Liz 1:
Nik, If someone posts offensive nonsense in defence of homebirth, then they are likely to be criticised, not homebirth. I found nothing offensive in what you said. In fact, that you defend Lies because you don't like us psychologising is to your credit. I have two problems with homebirth - a fear, which I would say is objective and a little bit altruistic that SOME women might be seduced into it without truly understanding the risks. If people were to say "I know it is risky, but I don't care, it is what I want to do." then I am not sure I would argue. Angela is honest and perceptive when she says "I know it could happen,but I still believe it won't" That is human nature, and maybe a necessary form of blindndess if we are to cope with daily and unavoidable risks. I love my daughter, and believe fervently that her life has value and quality. But to find yourself in a reality where people like Lies believe they can patronise and sneer because of some imagined sense of superiority can, at times, be tiresome. In reality (and I'm afraid it is very black and white) no-one who knew me would dare offer pity, for fear of them needing the urgent attention of a dentist. But you do have to tolerate idiots. You do learn about some murky corners of human nature that you would rather not. My coded advice to people who think that "if it happens, it happens" is that if you have a problem coping with a nasty nurse, you do not want to find yourself in my shoes. I really do care. I am not denigrating your choice. I understand choice, and its importance. I work in a part of London where, increasingly, you need a flak jacket. It's a risk. Ho hum.
And then there is my other, less charitable view of some homebirthers. That they are childish and unpleasant people, who see themselves as a cross between Mother Courage and Mrs. Valiant-for-Truth. (I am not including you in this.) Unfortunately, they are obnoxious, and make me want to bite. A failing, I know, but I don't make any claim to perfection. These people don't just imply a sense of supeiority, they embody it. As for whether psychological profiling is necessary, I would disagree. For most thoughtful people human motivation and perception is interesting. We do wonder WHY people believe what they believe, and it is sometimes useful to discuss it.
Lastly "fair" and "unfair" are generally better left behind once one leaves the playground for the more complex adult world.
From Liz 1:
Musing as usual, I wondered whether perhaps a day spent in a school for older disabled children might be useful to help convince doubters that reality is very black and white. I know that I would definitely not want them around NICU. Their brand of patronising smugness would definitely not be welcome there. But it is a bit difficult to sneer at a stuggling child. I soon dismiss the idea though. After all, it could never happen to them! And the blinkers are too firmly in place.
From Liz 1:
I did stop reading Lies when I realised she had nothing to say that had any interest for me. There is a bit of a temptation to read anyway, out of amusement at how wide of the mark she could be, but really that is to sink to her level. To easy a target. So I am not clear whether she was saying that people like me are seeking pity (??!!) or that she is going to pity me whether I like it or not. (And it is decidely not) Either way of course, she embodies the less appealing personality traits of those attracted to homebirth. I think there might have been some sense in there with the nonsense, but who cares? The spite cancels it out. It is my very personal perception that the thing most pregnant women fear most is being me. Generally, I tell them it is not, in reality, quite as awful as they fear. Life and laughter do not stop. I tell them it will not happen to them, but they should take care of themselves, and not get carried away with the Supermum olympics. (Tactfully, I hope.) I don't waste my breath on those who preen. I do want to give people a bit of a glimpse into a world which I believe is ill understood. Should I?
From Liz 1:
Anecdote: Last year, when my grandaughter was born I came across a young women in tears because whe had just learned she had placenta praevia, and would require a CS. She was afrid she would not "bond" with her baby. I told her I didn't see my first for several days, and our bond could not be stronger. (It was slightly embarrassing that my younger daughter confirmed that my bond with her sister was indeed extraordinary). I realised that this young woman may have been thinking "What do you know?" but I was trying to make her feel better. What do women want from someone like me? That I should be invisible, silent? (Not much chance of that!) Do tell.
From Liz 1:
Apologies for typing errors. And compulsive posting!
From Nik:
"Lastly "fair" and "unfair" are generally better left behind once one leaves the playground for the more complex adult world."
I hate to pick this one statement out of your post but I'm not really sure how to take it.
Trying to psychologically examine an entire group of women who only have one very insignificant thing in common IS unfair. Would synonyms of "unfair" suit your more sophisticated vocabulary better.. unjust, prejudiced, unethical. Do any of those work for you?
I was not defending Lies, I was stating my opposition to both sides of the argument. They are both unfair.
Home/natural birth advocates blame and type-cast people who are opposed to them and it happens in the reverse just as often. It is a emotionally-driven mini-war. Both sides use lies and manipulations to make their points. The home birth side is crazy because their arguments seem to be based on imagination, but the hospital birth side is worse because they claim to have "research" and "scientific evidence" to support their prejudice. This is clearly ridiculous to me.
I really don't have a problem with it. I think it is normal and on some levels has to be beneficial for the parties involved. If it were offensive to me, I would not be here. I occasionally get great bits of information and those little gems keep me coming back. I also find these gems in midwife blogs.
There are is a great amount of people like me that are caught in the middle, trying to grasp at the good bits of information as they fly across the battlefield amidst all the nonsense. I suppose I am trying to defend that middle ground.
From Nik:
To your defense, Liz, I have not been in the "complex adult world" (whatever that is) for as long as most of the people here.
I would say that I was one of those 16 year olds that had such a "rough life" that they may have had more "life experience" than most 30 year olds. I can attest to the fact that this does not translate to maturity. In fact, it often has the opposite effect.
From Nik:
"For most thoughtful people human motivation and perception is interesting. We do wonder WHY people believe what they believe, and it is sometimes useful to discuss it."
You are implying that wanting a home birth embodies some kind of specific or universal belief. I don't think that this is true.
"I do want to give people a bit of a glimpse into a world which I believe is ill understood. Should I?"
Yes, and often, and with gusto. Even though I am often misunderstood, I believe that I have a unique perspective and I want to share it even at risk of criticism. Do it for yourself if not for the few that will learn something from you.
"Musing as usual, I wondered whether perhaps a day spent in a school for older disabled children might be useful to help convince doubters that reality is very black and white."
It's only black and white if you consider the only way to view the disabled is negatively. My best friend in elementary school had Down's. He died when he was 12 from lung problems. I was devastated but I never would have wanted him to not have Down's because it was part of who he was and I loved him. I have never viewed disability as negative. How black and white is it now?
From Liz 1:
Would synonyms of "unfair" suit your more sophisticated vocabulary better.. unjust, prejudiced, unethical. Do any of those work for you?
Yes. I am an English teacher, and I do react to particular words in a way that is probably unreasonable (I nearly wrote unfair!) In fact, I have changed my mind. Your use of this word may well have been fair enough in that context. I was getting muddled with "Life" being fair or unfair. What I wanted to say was that in being a bit disgusted with Lies, I was not rejecting her right to homebirth, or seeing her as representative of all who share her views. There does appear to be a strand of self-congratulation in some, but not all, that annoys non-believers. Communicating via the internet is odd; without body language, other clues, we may well all give the wrong impression and irritate each other without intending to. I am uneasily aware that I say things here I would not say in person - scary facts, that might worry or upset. (Though I am actually more virulent in face to face argument, when I think it is deserved. I do try to restrain myself here - I came late to the internet and don't always understand its conventions)
From Liz 1:
Nik, I like your style in these posts. I too had a rough early life. And I believe that though it might not make us mature early, it does teach you perspective from early on. Not so sure about a middle ground. I don't necessarily think people CAN agree on highly emotive and personal topics. What they can do is learn about each other and agree to disagree. Find *common ground in that we all care about our children, maybe about other women, but disagree on means and ends and attitudes.
As for viewing the disabled negatively, that isn't what I meant. There are some comforting illusions and platitudes about that would not survive contact with the reality. For instance, that Down's children are all lovable. I'm sure your friend was; and I am sure you learned some of the things I am talking about from having him as a friend. But try that one on a Down's parent. The point is that "the disabled" are people first, and disabled a long way after. Some are lovable, some are disagreeable. It diminishes them to stereotype. Which I think is where you and I reach common ground. You feel I am stereotyping people who choose homebirth, you object, and you are right. Lies made it easy. You see pointing to research as "prejudice", and both extremes as equally wrong. I don't. We are not going to agree, but we can have some respect for each other as struggling humans, doing our best. I sometimes read things on NCB blogs I agree with. But then they always launch out into fantasyland and lose me.
From Nik:
"You see pointing to research as "prejudice", and both extremes as equally wrong. I don't. "
For clarity's sake, I don't think that using research is prejudice. I think that it is unethical to claim that any "research" (in quotations on purpose) can support your prejudice. Both sides of the argument are, yes, equally guilty of doing this. The biggest problem I see is that those like Dr. Amy and others who are well educated scientists have the "rightness" of science (that is embedded in our culture) on their side. I believe this gives them an advantage that is warranted but not always used with proper discretion. If a doctor states "scientific facts," they are more apt to be assumed as correct even though they may be their own personal manipulations of data that have not been subject to peer review and therefore cannot be considered scientific.
Then, "scientific" people will often berate their criticizers by saying that they do not have the correct education and then adding subsequent demands for data which they are supposedly not qualified to produce. Also unfair.
On the flip side, there are those (HBA's) who are dreadfully under-qualified to be making the claims that they do. Unfortunately, they do this in the name of "science," continuously misquoting scientific papers or taking their elements out of context (the BMJ study is a good example of that one).
Both are lies and manipulations. Which is worse? I think they both stink.
"As for viewing the disabled negatively, that isn't what I meant. There are some comforting illusions and platitudes about that would not survive contact with the reality. For instance, that Down's children are all lovable. "
That was exactly my point, not all of them are one way or another and most of them are somewhere in between. It's just not anywhere close to being black and white.
"Not so sure about a middle ground. I don't necessarily think people CAN agree on highly emotive and personal topics."
No, but you can agree on certain aspects of both sides of the argument.
How do you feel about using something like science, which tries (so hard!) to remove emotive and personal aspects, to support a bias based on emotive and personal topics?
"I like your style in these posts."
That actually meant a lot more to me than you probably think it did. I've been working on my (infantile) writing career, and having an English teacher say that they like my style is great encouragement! I've been published before but only in scientific journals, so although my writing is technically adequate it's nice to feel like maybe I have some "style."
From Nik:
"I sometimes read things on NCB blogs I agree with. But then they always launch out into fantasyland and lose me."
I plan on having a long discussion with my midwife about fantasyland, as it is a place that I would not want to travel to, at my next prenatal visit (which is next Friday, and soon I'll have my 20 week ultrasound and I am so excited)!
The last thing I want to be bothered with in giving birth is fantasy, because the reality of it is going to be fantastical enough for me!
From Liz 1:
The last thing I want to be bothered with in giving birth is fantasy, because the reality of it is going to be fantastical enough for me!
And three cheers for that!
From Liz 1:
Nik, is this your first baby? Because first time mums are the ones who need to steer clear of fantasy most - but I'm not sure they need too much reality, either. I can't get my head round this one. When I went, as optimistically as I could, into my second CS I didn't know any of the things I know now. I had never really heard or though about uterine rupture, I certainly didn't know there was an increased liklihood of stillbirth or that implantation was a problem. I'm very glad I didn't know, because it wouldn't have helped a bit. As getting pre-ecl coincided with being incarcerated in hospital, I wasn't too well informed about that, either. I don't think you can have a baby without a high degree of optimism - which is generally quite warranted. It IS fantastic. My message is that it is birth, and the start of a new life that is fantastic, not the prefered method. I don't believe I was any less thrilled than more fortunate mums. My worry is, if you want hard information, who should you listen to? The realists or the idealists? You listen to your own heart first, then what? A lovely, kind midwife with an agenda, or a cold professional OB whose manner you don't care for, but who knows what he/she is doing?
From Liz 1:
Really loquacious today - nothing much to do. Just to say, I HATED my daughter's OB. I thought she was smug, arrogant and insensitive, not very responsive to my daughter's fears of following in my footsteps. I kind of got that we were not so special, just another panicking mother. My daughter didn't like her either. But my daughter has a lovely, healthy baby. Good care, or good luck? Who cares, now?
From Nik:
"My worry is, if you want hard information, who should you listen to? The realists or the idealists?"
I maintain (in my admitted naivete) that the truth is somewhere in the middle.
"You listen to your own heart first, then what? A lovely, kind midwife with an agenda, or a cold professional OB whose manner you don't care for, but who knows what he/she is doing?"
Well, what I did was I listened to my heart. Then, I broadened my perspective. I found a practitioner who I trusted and respected. If I had found a doctor, I'd have a doctor, I wasn't specifically looking for a midwife or a doctor or anyone. Just someone who I was 100% comfortable with. I like that my midwife will be there no matter what I decide to do. If I decided tomorrow that I wanted an elective caesarean, she'd be in the operating room. I've still got plenty of time to think it over. I needed that flexibility, because I'm still "lernin' about berthin'." A big plus for the midwife is that she was willing to educate me to the best of her ability, and doctors just thought I was crazy for asking so many questions.
I think I've had too much reality. I've had nightmares about embolism, and I've lost more hours of sleep to the thought of PPH than I can count. When I think about how lucky I've been up until this point, its hard for me to believe that everything will go smoothly. I conceived the first month that I tried, we heard the heartbeat at 6 weeks, I never lost my lunch and I felt the baby move early. It's just all been so splendid. I feel like Murphy's law is going to kick in at some point.
Sometimes you just need to suck it up and do it. A big part of me is still even in denial about the fact that I will give birth at all! I don't know if there's any amount of preparation that will prepare me for the actuality of it. I just need to let it happen. It might sound cheesy but regardless of how much I "trust" birth, I would really like to give it a chance.
From Susanne:
Angela:
"I still don't think it could happen to me. I'm honest about that. Intellectually, I know that it could happen to me. But actually, I must confess, I don't that think it will.
And I'll bet they didn't either.
I mean, that's the whole point."
That is absolutely 100% the whole point. Well said!
From Susanne:
Liz 1: "Anecdote: Last year, when my grandaughter was born I came across a young women in tears because whe had just learned she had placenta praevia, and would require a CS. She was afrid she would not "bond" with her baby. I told her I didn't see my first for several days, and our bond could not be stronger."
This is where I really get annoyed at the HBA/NBA of the world. Why did they even put such a silly idea in her head? She has a real medical issue to worry about, and now she has a pretend issue on top of that ("I won't bond!!") that they nicely added to her woes like a cherry on top.
Whatever for? When anyone with any common sense and life experience knows that it doesn't matter? That (gasp) sometimes women adopt children and they bond just fine too even if baby didn't emerge from their bodies?
From Amy Tuteur, MD:
Nik:
"perception of risk imposes its own risks"
Yes, it leads one to believe that he or she understands the actual risks, when they don't understand them at all.
From Nik:
"This is where I really get annoyed at the HBA/NBA of the world. Why did they even put such a silly idea in her head?"
I think that some women really have had trouble with that and they have perpetuated their nightmare to the point that now there are a lot of women who worry about it. I don't think it's any different from the few people who had horrible births perpetuating the idea that it's so unbearably painful that a lot of women think it's impossible for them to give birth without pain relief.
It is really very annoying. But, that woman that is worried will get over it when she finally meets her baby. I don't think it does all that much harm.
It's kind of curious to think that this woman's most worried about bonding when there are SO many other, much worse, things to worry about. Maybe its a coping mechanism.
From Nik:
"Yes, it leads one to believe that he or she understands the actual risks, when they don't understand them at all."
OMG I totally predicted this post!
You have succeeded to take a comment out of context yet again and respond to it in such a way that makes no sense relative to the point that I was trying to make.
It's almost like every time I start posting here, you take the first quotable thing I say, copy and paste it into the reply box and don't go back to read anything else that I posted.
It's like clockwork!
From Nik:
*ahem*
Sorry, I was so excited about my correct prediction that I really avoided addressing the comment.
"Yes, it leads one to believe that he or she understands the actual risks, when they don't understand them at all."
While it has nothing to do with what I was saying, if someone's imaginary risks REPLACE the real ones, then yes this is very, very true. I don't know how often that happens. I have imagined risk in ADDITION to acknowledging the real ones that I know about. I would think that most people are this way, but I could be wrong.
From Rooroo:
Dr Amy,
You might be interested in this feature on the UK's 'F word' - Contemporary UK Feminism.
A woman has written a piece on 'birth rape' at the end she ends the piece with homebirth being 'a perfectly safe option'
Car crash reading :o
http://www.thefword.org.uk/
featu...not_a_happy_bir
From Liz 1:
I think that some women really have had trouble with that and they have perpetuated their nightmare to the point that now there are a lot of women who worry about it.
Precisely. Though I think a vague worry about being a mother, and whether you can love this child is normal, myself. The constructed reality is the idea that "bonding" is some delicate process that can be disrupted if you do not have instant skin to skin contact. I was told that sometimes it can take time to fall in love with your child, and I think that is true for some. But the "bond" for most starts before birth, is biological in nature and not at all delicate.
I can remember getting upset when I was pregnant about the loss of leisurely Saturday mornings. Would I miss them? Was all this such a good idea? It was intense for a few minutes. In retrospect, it was laughably wide of the mark - but being a mother is such a full time job, and changes your life so much, it seemed daunting for those few minutes.
From Liz 1:
No means no, even in the delivery room
Groan. This is exactly the kind of article that drives me crazy. Take a real problem - insensitive treatment in hospital - dramatize it, give it an emotive name like "birth rape", mix it up with with a generous dollop of NCB rubbish and pretend you have identified not only a cause for concern, but its solution. I think women who think they have entered fairyland may well find birth traumatic. People are badly treated, you can feel violated. But feeling violated and being violated are not the same thing. I did once have a tooth drilled without an anaesthetic, because the dentist assured me it would be OK. I thought my head would explode! I staggered home feeling as if I had been mugged. It FELT like an assult, it wasn't. Birth involves strangers' hands where strangers hands don't often go, and most of us don't like it much. If people behave badly (and I came across one of those brutal idiots myself, so did my daughter) then complain, loudly and persistently. This attitude to women is all too common. But don't call it rape, because it isn't. Bit hard to have a baby with your legs crossed.
From Rooroo:
I agree Liz1. I don't think feministing about it helps either, if anything, aren't women harming other women more by the promise of a beautiful, empowering, fabulous birth experience - when that doesn't happen, it's the woman who normally feels like a failure. Then their little group of advocates suddenly are no help when they dish out helpful comments like, "You probably ended up with interventions because you didn't TRUST birth enough."
From Caryn:
Any realist knows that to a certain degree (and in certain people) perception of risk imposes its own risks, which although imagined can manifest themselves as very real things.
I would argue that this is precisely what happens when many women choose homebirth. They add very real risks to their births in exchange for avoiding small risks because they are socially constructing the risks of the hospital as greater.
But in many cases the level of risk women are running when they stay home is higher than it would be in the hospital. I know a woman who freebirthed after a C-section and was an accreta, for example. Not all women who schedule homebirths or actually have homebirths are *actually* low-risk; I suspect even if you think that low-risk women are equally safe at home you'd agree that high-risk women are not. There is an *actual* level of risk to birth which your beliefs do not affect; what changes is the venue and how equipped the attendants are to manage your risk.
In reality there are different kinds of risks, and some people are more inclined to take certain risks based on their perceptions than other people would based on their perceptions.
But the quantifiable risks do not change simply because they are willing to take them. They may *believe* that X is lower-risk, or magically lower-risk for them, but lots of people have false beliefs.
Science, as a way of knowing things about the world, is not only one of many "equally valid" ways of knowing. It's actually epistemologically privileged; it maps reality more accurately, on average, than the other ways of knowing things about the world. That doesn't mean that practicing scientists can't mess up -- that's what peer review is for -- but it does mean that in the long run, it works better than any other method we've found so far, including listening to your intuitions. (And if we found a method that worked better than science, we'd adopt it into the practices of science.)
Everyone uses the techniques that underpin science all the time in their everyday lives as a way to live in the world. Observation, induction, deduction -- they're how I find my car keys in the morning. I look around the house, I remember that in the past I've often left them on the kitchen table, and when they're not on the kitchen table I deduce that I must have left them somewhere else even if my intuition told me that I'd left them on the table.
From Susanne:
"They add very real risks to their births in exchange for avoiding small risks because they are socially constructing the risks of the hospital as greater."
Or because they are socially constructing downsides to things that don't have objective downsides, or have minor objective downsides.
From Erica:
I thought this was especially interesting from the above article: "her marriage nearly broke down because her husband couldn’t acknowledge that she was raped by the midwife and he had stood by while it happened. He begged her to stop calling it rape and to let it go, get on with her life."
From Liz 1:
And by the same token, if women are going to hysterically call an impersonal medical procedure rape, then they will continue to be dismissed as exaggerating or dramatising when they REALLY have cause to call it rape, to the great disservice of real victims of a horrible crime.
From angela:
Bravo!!! That is the crux of the issue. They don't have a common valuation - they're different to every woman
Some things do have a common valuation. Almost objectively a dead or compromised baby is worse than (worst-case scenario) not being able to use my uterus again. Now the occasional outlier(liar?) may at least claim otherwise (again, I wonder about the difference between what one says and what one feels or would actually do under the circumstances---so easy to hypothesize), but the vast majority of reasonable people would agree that the baby's death or injury is worse than almost anything else that could happen---certainly worse than surgical complications. So I think there are generally agreed-upon valuations in these things, and the exceptions---if they truly are exceptions and not just grand-standing---are rare.
In other words, someone who says that painful recovery from her CS is worse than even a reasonable chance of her baby dying or suffering via vaginal birth (of course, she would never put it that way, and that's part of the problem) is, in my opinion, making the wrong valuation. (That's right, Virginia, there are wrong answers!) She is not some gradation at the end of a long, mushy continuum that we should all respect, say no more, stop the discussion. (It's all good! It's all valid! You can go home, now!) There is some continuum, but not as much as you claim.
And really this argument is pure nihilism. If there is no one "right" answer or valuation, according to you, then there are no "wrong" answers, either; therefore, you are never wrong. It is a clever argumentative tactic and a perfect defense, but little more. It reminds of me of poetry classes in college where inevitably a vocal group of students (usually white, upper-middle class kids with more education and opportunity than I had had*) would insist that their highly personalized interpretation of a classic poem is as valid as any other. First of all, I disagree. Second, this line of argument ensures the students will never get a bad grade! How cleverly self-preserving!
Certainly there is a time and place in life for unique differences (valuations) to be respected, even within the home birth debate, but even the interpretation of a classic poem---and certainly the valuation of infant death compared to maternal injury---is just not one of those cases. Really, the "mushy" differences go only so far. And what I understood Emma to be saying is that there is more than just risk and chance of that risk---and HB advocates seem to gloss over this: there is also outcome. A tiny risk with a very bad outcome (death or injury at home birth) is reasonably weighed riskier than a bigger risk with a minor outcome (CS at hospital). At some point, it becomes a matter of reasonableness (as well as admitting you may just be mindlessly defending your argument or your ego!).
* What of this, by the way---the surety and "I'm worth it!" attitude of this social class? Is this attitude responsible, too, for the main demographic of the home/natural birth crowd?
From Caryn:
If there is no one "right" answer or valuation, according to you, then there are no "wrong" answers, either; therefore, you are never wrong.
It's even worse than that; it's fundamentally incoherent. If there is no one right answer, then the claim that there is no one right answer cannot be true.
From Nik:
"Science, as a way of knowing things about the world, is not only one of many "equally valid" ways of knowing. It's actually epistemologically privileged; it maps reality more accurately, on average, than the other ways of knowing things about the world. That doesn't mean that practicing scientists can't mess up -- that's what peer review is for -- but it does mean that in the long run, it works better than any other method we've found so far, including listening to your intuitions. (And if we found a method that worked better than science, we'd adopt it into the practices of science.)"
Science is a method for answering questions. There are many questions which are beyond the scope of science to answer, no matter how much you believe that science is some great savior of humanity from its own stupidity. Science has yet to answer the question "Is home birth safe?"
From Liz 1:
English teacher here again. Your analogy to the interpretation of poetry is interesting. There IS room for more than one interpretation of a poet’s “meaning”. Words are not fixed, and we do not always have control over the interpretation of what we say. For instance, there has been some dispute about Shakespeare’s Sonnets – Are these serious love poems, or a playful game? Addressed lustfully to a woman, or “shamefully” to a man? A poet is not necessarily in control of his words, may have hidden subconscious motives – so they are open to interpretation, and their meaning cannot be fixed, because we cannot see inside his head. So there is no one “right”, fixed interpretation – but you could not decide that he was writing about cars, or fishing, because that is what you “love”. When Lies tells us that she is going to share “harsh truths”, she means that she sees herself as brave and wise and eager to share for our own good. We interpret her words as presumptuous and self-deceiving, and her “truths” as paper thin, her insults the result of frustration at making a very poor argument. When homebirthers read that women die after CS, they see CS as the cause, and think no further. When I read bizarrely weird or obnoxious statements from (some) homebirthers, I conclude that homebirthers are weird and obnoxious. I tend to wonder what the connection is between acupuncture and PPH, and whether Hensbane or some other magic potion is really that effective against Pre-Eclampsia. So in poetry as in life, there is no one “right” answer. But some answers are wrong from almost any point of view. They WILL be argued over, because the student who believes that Shakespeare was writing about fishing may well be able to find “evidence” that supports his view, and stubbornly hold to it in the teeth of reason. Is there any point in trying to disabuse him? I think so, but it will be hard work. The sum of human knowledge is not increased by validating tripe.
From Liz 1:
Nik, Science HAS answered the question. It is safe most of the time IF nothing goes wrong. Big If.
It is safe (ish) under optimum conditions. It is safe (ish) but tends to be chosen by people on the basis of false beliefs. It is not much less safe than hospital birth - but that is not 100% safe either. Risks of disaster are much reduced in hospitals, but hospitals have other risks which are less of a problem.
From Nik:
"Nik, Science HAS answered the question."
No, that's YOU answering the question.
From Liz 1:
Just been doing a bit more musing on the Law of Unintended Consequences. If Dr. Amy is right (and I see no reason to doubt it) that Grantley Dick Reid originally formulated NCB as a way of getting "Superior" women to have more babies, it has misfired a bit. If one assumes that it is his target audience, priveleged white women, who are attracted to his thesis, he must be turning in his grave as they blithely accept the highest of the high risk strategies, thus risking the gene pool. (I don't accept for a minute that they are superior, but he seemed to think so.) And Kneelingwoman freely admits that she was instrumental in setting up a separatist strand of midwifery in her hippie days, only to realise now that it didn't work out quite as anticipated. What fascinates me is that NCB started out from false premises that lied to women for dubious motives (It doesn't hurt! Honest! It is safe - except when it isn't.) and has got ever more fanciful and ritualistic. Don't those women who admire the ancient midwifes realise that the purpose of ritual is symbolic, designed to ward of evil when you have no other form of defence available?
From Liz 1:
Nik, we will agree to differ.
From Amy Tuteur, MD:
Nik:
"There are many questions which are beyond the scope of science to answer, no matter how much you believe that science is some great savior of humanity from its own stupidity."
There is no better way to answer scientific questions. In every conflict over factual issues between science and any other "ways of knowing", science has always been correct and the other "ways of knowing" have always been wrong, always, every single time.
From Liz 1:
One of the fascinating things I have learned here is the number of people who want large families. Given that there is a bit of a crisis in most advanced countries over a falling birth rate, I was surprised. Large families are, I think, quite rare in England, especially among the more priveleged.(But maybe not. Here, the only people who can afford large families are the very rich and the very poor) I am also curious about women who decide to stop at one, either because they were traumatised or unimpressed by the whole thing. The stories of women who had a difficult first hospital birth and a more straightforward second at home interest me too - as homebirth gets the credit in a somewhat undeserved fashion, it seems to me, for the fact that second births are usually (anecdotally?) easier. Does anyone know what the detailed statistics on the US birth rate are? Not the average, but the distribution?
From Liz 1:
Oh Nik, I have only just read your post above about lying awake worrying. You really mustn't. I don't think Murphy's Law applies that much in childbirth. To me, it is hubris that is the danger. I think we all have to trust Life, that by and large, things turn out well, and anyway we will risk it. That is not the same as using a trust in birth to justify making unwise choices. You have chosen a good midwife, you have contingency plans, an open mind and a realistic assessment of the dangers - that is all any of us can do. A good pregnancy and a good birth go together more often than not. Fear of the unknown is natural, not shameful; most births are low risk, and most complications can turn out well so long as you are in the right place. Please sleep well, and have better dreams. If we didn't all "trust birth" to some extent, nobody would get born. No-one here wants to take away your trust, in birth, life or yourself. What is under attack is irrationality, not sensible choices. I trusted birth, or I would not have my second daughter. Thing is, that is the Life Force, the bravery of all women, not a select few who think they hold the secret of the universe. Things went badly for me. It was manageable. I am still here, and I would do it again.
From Liz 1:
"those differences should be respected rather than used to put others' perspectives down."
I've just read LD's post from way above, and I am frustrated. I am different from the majority. The majority start out as low risk, and stay low risk. A small number lose their low risk status, but all turns out well. I am the low risk mother who became high risk and it turned out badly. I belong to a statistically minute group. Should people worry about joining me? No, of course not. But they shouldn't pretend I am irrelevant to this discussion, either. The risk is tiny. You opt for homebirth, you increase it. I can see that maybe that is logical. But know what you are risking before you decide. Tiny risk, huge consequences. I am real, but very much absent from the fantasies. So I am not crazy about fantasies that leave me - and my daughter - out. If that is putting other people down - well, I fail to see it. I am in favour of safety, and against nonsense of the "which herb is best for PPD?" variety, or that the "experience" trumps the outcome. The most beautiful, intimate experience would not compensate for one lost brain cell in my book. If you feel differently, fine. If you defend your choice with rubbish arguments and weasel words, I will argue. I sometimes think that it is the fact that your story of a traumatic experience when the nurse left the door open pales into insignificance is what really pisses people off about my stance.
From Caryn:
There are many questions which are beyond the scope of science to answer, no matter how much you believe that science is some great savior of humanity from its own stupidity. Science has yet to answer the question "Is home birth safe?"
Given some definition of "safe", this is an *empirical* question. Those are the ones science answers.
I said nothing about science being a "savior of humanity". I said that science was, to date, the most accurate way to answer questions about how the world is. Facts about how risky birth is are facts about how the world is. They are not facts about how your personal values are are relevant to the question of which risks you are willing to accept.
From Lies_DamLies_and_stats:
Wow - so many thoughts, so little time between the current rigors of life to post. Globally, I must say the only "pointing and sneering" I see going on is being done by those accusing others of the same action. I've seen hints of lack of faith, non- or even perhaps anti-Christianity, but you might do well to pick up a copy of the Good Book and read Matthew 7:3-5. Seriously.
I do think I'm beginning to understand a little better, though - partly thanks to all this "self-congratulatory" nonsense. This is what happens when diversity amongst a group that is defined by one thing and one thing only - in this case, where they choose to give birth - is not accounted for and/or respected. It is clear that some people have painted a picture of me in their mind as someone who sees herself as some sort of Uterine Warrior, Birthing Goddess, or some such. Nonsense! I have nothing to congratulate myself on, unless it is the willingness to learn from the situations I was put in and the people who were put in my way to help me. And I don't really consider that some grand accomplishment, though from reading some posts around here it might be more than I give it credit for. In my birthing situations, I was BLESSED (some people might say charmed, some lucky, pick your vocabulary, I've chosen mine). BLESSED that I was able to even have children. BLESSED that my hospital experiences went well. BLESSED that I escaped unnecessary cesarean for my first two children by not a whole lot - and to me, an unnecessary cesarean _is_ a bad outcome. Not nearly so bad as harm to the baby, certainly, but I do account harm to the mother as a bad outcome (and I'm surprised that a lot of pro-choice people don't). In addition, the increased risk of future miscarriage with cesarean is a huge deal to me, not only because we already have difficulties to begin with but also because I believe life begins at conception - so for me the mortality risk to my children with a cesarean is much higher than the medical journals would ever want to address. I know that many people don't feel that way, and that's fine for them, but I do. Would I have a cesarean if it were necessary to save the child currently in my womb or my living children's mother? Absolutely, and I would be upset but have no regrets. It is interesting that the more I learned, the more experience I gained, the more I was pushed away from the obstetric model of care, and also from the hospital because that model ruled there. At any rate, I don't think it's anything out of the ordinary to do what any decent mother should do - the best I can for my children and myself (because if I don't care for me, how can I care for them?). I truly cannot see where you think I'm somehow "congratulating" myself for doing that. Do I think that, for example, Susanne should have chosen homebirth, or even the care of a midwife, or declined intervention? No - quite the opposite; that would not have been being a uterine warrior, that would have been stupid. In the end, she did exactly the same thing I did. That is, what she needed to do for the sake of herself and her children in light of the situation she was in at the time. The situations many of us find ourselves in make us no more worthy of congratulations than anyone else, unless it is for being unselfish enough to bring new life into the world into the first place. What greater gift can we give than that, letting a baby take over our body for many months, totally dependent on everything we do and the nourishment we provide for the both of us, let alone nurturing them once they're physically separate from us? No matter what setting we choose to birth them in, no matter who we choose to be our care provider, that is what is amazing, and that is what we all share (or so I believe - outside of any non-mothers/men posting on here 
).
From Caryn:
They are not facts about how your personal values are are relevant to the question of which risks you are willing to accept.
Should read: They are not facts about how your personal values are, even if your personal values are relevant to the question of which risks you are willing to accept.
From Lies_DamLies_and_stats:
Darn! Tangent! Oh well. Back on track...
There really is no need to beat people over the head with one's bad experience excessively, particularly when the only connection to the issue at hand is that birth is neither trustworthy nor predictable.
LN, you hit the nail right on the head. Excessively bringing up your experience in every little point of conversation begins at some point to seem an emotional attempt to bolster your argument. Especially when you then make a huge issue against pity (and there's a reason that word has such a horrible connotation - there's generally understood to be an element of looking down, or contempt, in pity. That's why, if anything, I prefer sympathy. Think about the root words). I truly believe - having been there and done that with awful situations in my own life and having served as a peer counselor for many years - that the only thing more manipulative than playing the pity card is to show it in your hand without laying it down; first, because it contains within it that play, and second, because it sends mixed messages and really puts people off that want to have a healthy relationship. It is what some psychs call "emotionally obnoxious" behavior.
That said, it is sad that people would ask LDLAS if she has lived what they have lived or accuse her of diminishing their experiences while they do the same for things that are clearly close to her heart.
Precisely! Right after accusing me of minimizing a situation, people turn right around and do what they think I am doing (but wasn't) and deem so reprehensible. In my (rather extensive) experience with rape survivors, we tend to be able to pick one another out. Sometimes it's instantly obvious; other times it's a slow realization, but when we figure it out it suddenly becomes clear why we felt so connected on a deep level. According to my uncle, combat veterans share a similar connection. It's like we've been to the same dark place. I remember very clearly one night watching The Color Purple with a girlfriend, and we both had quite an emotional reaction to a particular scene (those of you who have seen the movie probably know which one). Having recently realized that I was identifying more and more people with whom I had that in common, I looked at her and said, "were you a rape victim?" She replied, "No." As I tried to process my embarrassment and steel myself for the inevitable questions, she said, "I am a rape survivor." Even though I thought I was further along in my journey and had stopped seeing myself as a victim, I can now look back and realize that that was a huge turning point for me. In any case, survivors know each other. Survivors often connect. I have met women who have experienced "birth rape" - what you sneer at as crying wolf - and I will tell you that I have had that same sense of connection. In fact, the woman who first taught me the term "birth rape" was a woman whom I'd originally thought was a rape survivor, but it turned out she wasn't - at least not in the conventional sense. When she told me of her experience, it made perfect sense to me. Because rape isn't about love, and it isn't about sex - it's about power, and the abuse of that power. A doctor or midwife who performs an "impersonal procedure" isn't necessarily committing birth rape; perhaps s/he merely acts with clinical detachment. It may be upsetting, but it's not nearly the same thing. A doctor or midwife who cuts an episiotomy as a woman is screaming, "I do not consent to an episiotomy!"; who continues to pick at a pushing woman's vagina even though she screams that s/he is hurting her and is crawling backwards up the bed to get away; who injects powerful medication into a woman's IV even though she has explicitly refused it; those doctors are committing birth rape. They are abusing their power and violating a woman's body and self-determination when she is in a vulnerable state. I do believe that there are women out there who abuse the term "birth rape," who cry "birth rape" when the nurse comes in and turns on the lights to check a monitor strip or asks for the second time if the mother wants an epidural, or other such things that are not truly a violation, just an annoyance. That truly disgusts me. It is wrong, though, to let those situations cause a discount of a very real problem, and a horrible crime. In many states, practitioners in the situations I described as "birth rape" above would be considered guilty of technical battery or assault, but I do believe we should call it what it is. Sometimes harsh words are needed to wake people up to a serious problem that they are letting slide.
I should clarify - I did not experience "birth rape," but rather rape _well_ before I ever gave birth. My hospital experiences were not horrible (though also not wonderful - they did make a huge contribution to the decision for homebirth the last time around). I would definitely go back to the hospital in a heartbeat if it were necessary.
From Lies_DamLies_and_stats:
Some things do have a common valuation. Almost objectively a dead or compromised baby is worse than (worst-case scenario) not being able to use my uterus again. Now the occasional outlier(liar?) may at least claim otherwise (again, I wonder about the difference between what one says and what one feels or would actually do under the circumstances---so easy to hypothesize), but the vast majority of reasonable people would agree that the baby's death or injury is worse than almost anything else that could happen---certainly worse than surgical complications. So I think there are generally agreed-upon valuations in these things, and the exceptions---if they truly are exceptions and not just grand-standing---are rare.
But you're only talking about a limited view of relative valuations here. Of course the baby's death or injury is worse than almost anything else that could happen - except perhaps the death or severe injury to the mother (I'm talking permanent neurological disorder, surgical/nosocomial complications that result in amputation/physical disability/etc), which would then leave the baby and any older siblings without the mother able to care for them fully or at all. However, a full view of all risks for each option, weighted with probability of occurrence and severity of impact, along with any benefits that do not correspond to a risk of the opposite per se, is much more complex. There also exist differences in the severity of impact assigned to certain risks, as both Susanne (I think?) and I implied upthread. For example, future children are extremely important to me, but not to her; therefore, we would place vastly different valuations on risks regarding impacts to future conceptions, pregnancies, and births. When it comes to birth, it appears that a lot of the obstetric advocates on here are single-issue voters. Yes, it is (almost) the most important issue, but not nearly the only one, and it is not enough to reduce other issues to negligible status. Could you imagine how that might play out in our presidential election? "OK, the most important thing to me is the candidate's position on Iraq. Forget the fact that they favor policies that have a high probability of our breadwinner's job getting cut, and thus our family will be struggling, but at least our troops will come home! Or go back to Bosnia." ?!?
From Liz 1:
Lies, still skimming your posts, so will not take on your substantive points (can't be bothered) but I see you launch into linguistics in the early part, and that interests me. Etymology of sympathy and pity. Pity, from pietas, family feeling, obligation. So, definitely not appropriate from strangers with no right to have any feeling. Sympathy: Prefix sym = with and pathy = sensation. In other words, appropriate if you have had identical experiences. Otherwise, kindly refrain from offering either.
From Lies_DamLies_and_stats:
Sympathy: Prefix sym = with and pathy = sensation. In other words, appropriate if you have had identical experiences. Otherwise, kindly refrain from offering either.
As to sympathy - I don't think "identical" is truly an element, or the word would be basically meaningless. Two people could be in a tiny, cramped foxhole together during a firefight and not have an "identical experience." It simply means exactly what you have denotated: to feel with someone. Hallmark apparently thinks it's appropriate. Ever see the whole rack of "with deepest sympathies" cards? Generally the people giving them didn't have an identical relationship with the lost loved one. Is it only appropriate to give one of those cards if you've had an "identical experience?"
More importantly, I don't see where I have offered or asked for either one, to you or anyone else. I think you simply saw a four-letter word you didn't like and had a knee-jerk reaction without even considering the context. I'm not incredibly impressed. I know a lot of four-letter words that offend people. I also know situations in which I would use them.
From Caryn:
Yes, it is (almost) the most important issue, but not nearly the only one, and it is not enough to reduce other issues to negligible status.
I am certainly not arguing that risk of death is the *only* risk to assess. I am simply claiming that the empirical questions about the risks one runs in birth in different venues are, in fact, empirical, and not affected by one's beliefs about how much risk one is running.
For example, there are plenty of lay homebirth advocates posting to LiveJournal etc. who claim that the Brewer diet prevents preeclampsia. They believe this claim is true. There is plenty of empirical evidence that it is false; that they *believe* it and follow the Brewer diet during their pregnancies does not, in fact, affect their risk of developing preeclampsia.
Certainly people are going to assess their personal values *as well as* their risk levels. It may be a fact, for example, that a woman with three previous C-sections would prefer a homebirth. That fact, the fact that she would prefer one, does not change her risk of rupture, and so of course the different response times available to her in different venues is also relevant to her decision-making.
I haven't seen anyone posting here who wants to tell other women which choice to make. The argument is that the risk of death or permanent disability is lower in the hospital and that this fact affects, or should affect, things like professional certification or medmal insurance requirements.
From Liz 1:
Lies, I will declare a truce. We are different, I do not like your perpective or your choice of words, and you do not care for mine. If we were to met in real life, we would recognise that we could not like each other. So I will not read your posts, and you don't read mine. I did not take them as any kind of personal attack, I just cannot share your viewpoint on any part of this discussion.
From Lies_DamLies_and_stats:
The argument is that the risk of death or permanent disability is lower in the hospital and that this fact affects, or should affect, things like professional certification or medmal insurance requirements.
I believe someone also argued that health insurance shouldn't cover... what was it? Complications of poor choices? My paraphrase, but I think it gets the idea across. Of course, this all brings up an interesting thought... Obstetric advocates get all up in arms when NBA/HBA say that elective interventions (such as pain meds, elective induction, elective cesarean, etc) should not be covered by insurance. Yet, if someone plans a homebirth - and I'll assume a competently attended, prepared homebirth for this example - and has the good sense to transfer due to a complication, they should not only be treated with disrespect (this already happens), but should also not be covered by insurance? This seems a bit ludicrous. That's kind of like saying if you choose to go to your GP with a possible heart problem and he refers you out to a heart surgeon, you shouldn't be covered because heart problems can be life threatening, you could suffer from a completely unexpected heart attack at any moment, and going straight to the heart surgeon would have been much safer, because your GP doesn't have the training to handle your problem. (?!?) But, if you really want to go that route, then perhaps a cesarean due to a failed social induction shouldn't be covered. Perhaps the care for a permanent neurological disorder due to an elective epidural shouldn't be covered. Perhaps the surgery to repair damaged organs or adhesions after an elective cesarean shouldn't be covered. And so on.
From Lies_DamLies_and_stats:
Lies, I will declare a truce. We are different, I do not like your perpective or your choice of words, and you do not care for mine. If we were to met in real life, we would recognise that we could not like each other. So I will not read your posts, and you don't read mine. I did not take them as any kind of personal attack, I just cannot share your viewpoint on any part of this discussion.
I'm not asking you to share my viewpoint. I'm asking you to understand that everyone who doesn't share your viewpoint is not some kind of earthy naked women dancing under the light of the moon chanting vedic texts while trusting birth in the face of pre-e rich white twenty-something whining charmed-life-living innocent sprite.
While I have chosen to not read the posts of certain personalities in the past, I did find that it sometimes made me miss whole chunks of a conversation, so in the name of good communication I chose to read them to make sense of what others were saying, even though they sometimes raise my blood pressure. Occasionally I'll even find a gem in what they're saying, even if it's only a slight increase in understanding of an opposing viewpoint. Just warning you that skipping over posts based on who wrote them can be difficult. Of course, you can always feel free not to respond to a particular post. There are many that I simply don't respond to with anything other than an IRL eyeroll, and there's nothing wrong with that.
From Nik:
"There is no better way to answer scientific questions. In every conflict over factual issues between science and any other "ways of knowing", science has always been correct and the other "ways of knowing" have always been wrong, always, every single time."
Well, no kidding. However true that is, it does not change the fact that there are some questions that science cannot answer. Apparently, there are things beyond human understanding in this world. I don't think that should come as a surprise to anyone.
"Given some definition of "safe", this is an *empirical* question... Facts about how risky birth is are facts about how the world is. They are not facts about how your personal values are are relevant to the question of which risks you are willing to accept."
Who will define safe? Maybe we need to define a sliding scale of safety definitions so maybe these questions could be answered more accurately.
As far as knowing if home birth is safe or not...
There have been answers that are pieces to the puzzle. Most those pieces to the puzzle are valuable answers about how often certain events occur in certain populations, and so on. But certain pieces of the puzzle we haven't found yet, and I think that everyone here can agree to some piece of that puzzle which they just cannot locate.
So, on both sides of the argument we've got people relying on incomplete pictures, filling in the blanks with their own personal experience and corrupting the value of the information that we DO have in order to make their own pictures complete. One very dangerous thing about "HBA's" is that they tend to fill the blanks with nonsense and lies that are based on nothing but their own biases. At least here those blanks are filled with anecdotal experience, which has some value.
I am fine, however, with the idea that we just don't know enough yet to say whether or not home birth is "safe." Maybe it's because I don't have enough personal experience to fill in those blanks on my own.
Liz, thank you for your encouraging words.
From Caryn:
Who will define safe? Maybe we need to define a sliding scale of safety definitions so maybe these questions could be answered more accurately.
It's safe to say that the most important questions here are "What is the survival rate of the mother? What is the survival rate of her singleton offspring? What is the survival rate if she's carrying multiples?" We can follow that up with questions about major morbidity rates. We'd follow that up with questions about minor morbidity rates.
These are empirical questions about rates in populations with known answers.
We know that unattended birth in Afghanistan has a lifetime maternal mortality rate of 1:8. We know the historical MMRs in Western countries quite well. We know the current obstetric MMRs.
I think that everyone here can agree to some piece of that puzzle which they just cannot locate.
Such as? We have excellent population rates for these sorts of questions; what additional questions do you think we need to answer?
From Caryn:
if someone plans a homebirth - and I'll assume a competently attended, prepared homebirth for this example - and has the good sense to transfer due to a complication, they should not only be treated with disrespect (this already happens), but should also not be covered by insurance?
I hadn't seen this comment made, but it doesn't seem unreasonable to me to have a discussion about what the role of an insurance company actually is here. My old health insurance company, under which I had my homebirth transfer of my son, covered neither organ transplants nor prescriptions. I think it would be difficult to have requirements about how a birth would be covered as many are precipitious, but it doesn't seem wholly unreasonable to suggest that planning a birth unattended by the insurance company's definition of "competent provider" might sometimes result in the insurance company's bearing more of the costs of a damaged baby.
Is that a risk the insurance company is willing to take? and Is that a risk the parents are willing to take? are different questions.
From Caryn:
We have excellent population rates for these sorts of questions; what additional questions do you think we need to answer?
(Should note: and we'd have even better ones if MANA would release their data.)
From Liz 1:
The role of insurance companies in America is fascinating to me. They are not my favourite people, as they seem to guard profit above all else - and the "wallet biopsies" we see on TV and the thought of people in desperate straights for want of insurance is horrifying to most Europeans. But logic dictates that if you bring disaster on yourself, they are entitled to object.
From Caryn:
They are not my favourite people, as they seem to guard profit above all else - and the "wallet biopsies" we see on TV and the thought of people in desperate straights for want of insurance is horrifying to most Europeans. But logic dictates that if you bring disaster on yourself, they are entitled to object.
It is possible for states to pass laws mandating certain forms of coverage in that state, so any given state could (and some have) mandate coverage of homebirths. This might raise objections from other citizens if the cost they bore out-of-pocket increased in response to the mandate (I am thinking of objections to mandatory car-insurance laws here.) Whether or not the cost would *actually* go up, I don't know.
From Amy Tuteur, MD:
LDLAS:
"Obstetric advocates get all up in arms when NBA/HBA say that elective interventions (such as pain meds, elective induction, elective cesarean, etc) should not be covered by insurance. Yet, if someone plans a homebirth - and I'll assume a competently attended, prepared homebirth for this example - and has the good sense to transfer due to a complication, they should not only be treated with disrespect (this already happens), but should also not be covered by insurance?"
That's because the risk of homebirth is orders of magnitude higher than the "risks" of the interventions. It always comes back to the ignorance of homebirth advocates about the facts. Of course the difference in attitude makes no sense to you. You do not know what any of the risks are.
From Amy Tuteur, MD:
Nik:
"However true that is, it does not change the fact that there are some questions that science cannot answer."
Even if that were true, it is irrelevant. The safety of homebirth is an empirical issue, which means that science is the only appropriate method for elucidating the answer.
From Emma B:
I believe someone also argued that health insurance shouldn't cover... what was it? Complications of poor choices? My paraphrase, but I think it gets the idea across.
I'd like to point out that this was the suggestion of one person, and it is a suggestion with which I personally disagree. Unusually enough , I find myself in complete agreement with LDLAS that assigning blame for medical complications leads down a disastrous road. I'd like to see some modifications to the US insurance system, but that is not one of them.
Admittedly, this is probably colored by two health situations of my own: a complicated twin pregnancy subsequent to infertility treatment, and three knee surgeries (and probably an eventual replacement) stemming from a long-ago skiing accident. However, assignation of blame is a bureaucratic nightmare for the insurance companies, and I think we're unlikely to see it happen.
From Emma B:
That's because the risk of homebirth is orders of magnitude higher than the "risks" of the interventions.
I will point out that this same argument applies to post-infertility pregnancies. I got pregnant after gonadotropins + IUI, and my risk of triplets was 10% and of twins 25%. Almost all triplets are born preterm and need at least some NICU time, and 60% of twins are born prior to term (although not all of those need NICU time). That's significantly higher, by one to two orders of magnitude, than the rate of serious post-homebirth complications.
Personally, I did have twins (and we think I lost a triplet before my first U/S at five weeks). My pregnancy wasn't as expensive as many -- I went near-term and my babies required no NICU time -- but it still ran close to $100K. Had I had triplets, it would have been several times higher.
Your logic here, that higher risks justify insurance denial, applies to me just as well as to an HBA. Do you also favor insurance denial of coverage for post-infertility pregnancies?
From Lies_DamLies_and_stats:
Excellent question, Emma B! It extends into other areas of health as well - and I doubt there'd be any special interest group that wouldn't be affected by a blanket policy that elective increase of risk would result in denial of coverage. As DA now hopefully sees, the "well that may be risky, but this is riskier!" argument doesn't work, even in an extremely narrow scope.
I would also like to see mods to the health insurance system, some of which do protect people with lower risk from paying too much for people with higher risk in the interest of fairness, but assignation of fault for a particular incident and subsequent denial of coverage just strikes me as a bad idea for all involved - the person involved in the incident, the care providers, the insurance company, and the other consumers. The whole move toward policies that are only useful if you never have any health problems is a bit disturbing, too - at that point, why bother with insurance? The people for whom it works don't need it, and it doesn't work for the people who do need it.
From Caryn:
The whole move toward policies that are only useful if you never have any health problems is a bit disturbing, too - at that point, why bother with insurance? The people for whom it works don't need it, and it doesn't work for the people who do need it.
Right. This is the whole problem with turning insurance into a for-profit instead of a mutual-aid phenomenon, and is one of the drivers behind laws like the ones requiring every driver to carry vehicle collision insurance.
But since we do already have insurance companies that do not cover transplants or prescriptions (my old company didn't cover infertility treatment, either), we already have to deal with the consequences of having some medical conditions covered simply because they're judged too expensive to cover, by the insurance company.
I have seen many people make posts around the 'net saying that their insurance companies do not cover homebirth; does anyone know in which states that is illegal and in which states it is legal?
From Nik:
Apparently, nobody shares my perspective. I am ok with that.
Some cute, but relevant, comics:
ttp://xkcd.com/55/
ttp://xkcd.com/106/
From Caryn:
Nik, you seem to be saying that you are choosing a homebirth because you personally value a homebirth even though it isn't, statistically speaking, as safe. That's fine; as I've said, people take their personal values into account here. Some people even value a homebirth over a greatly elevated risk of death for mother or baby, and that's their call.
I am simply disagreeing with the claim that liking something better than the alternatives will change how risky (or not risky) they are. (IIRC you've even acknowledged that homebirth is only as safe for low-risk women, which means you accept the idea that there's some sort of external measure of risk that makes some women lower risk than others and some women higher risk than others regardless of their personal preferences.)
From Liz 1:
Do you also favor insurance denial of coverage for post-infertility pregnancies?
No, and I never meant to imply anything like that. As I said at the beginning of that post (or implied) I don't really understand a healthcare system paid for that way. I wasn't thinking, and kind of mixing it up in my head with car insurance (where fault is relevant) and private, extra, medical insurance in England, where some companies do refuse cover for some things, and compensation for bad outcomes. In fact, I am relieved, now I have turned my brains back on, that it doesn't work that way.
From Liz 1:
I think I should really apologise further for the unintended implications of my idiot views on insurance, based entirely on ignorance. I have absolutely no understanding of the financial implications of normal or high risk pregnancies - I can't even figure out whether homebirth is an expensive luxury, or a money saving exercise, or neither.
From England, America is regarded as a country with superb and advanced facilities, compared with our ramshackle NHS - people save up to go to you for treatments not available here. But we also read stories of people being financially ruined by ill health. I don't understand medicaid or any other aspect. But I certainly didn't mean that the might of the insurance companies should influence anyone's choices, just that as a profession, they were a bit good at finding reasons for not paying up.
From Caryn:
Liz, very few people on this side of the pond understand insurance either. Some even argue that it's designed that way.
As a data point: my health insurance company didn't cover prescriptions, which means they didn't cover birth control, but they would have covered another of my pregnancies even though it wouldn't have been in their financial best interest to do so, but they had a lifetime cap on how much money they'd pay out, and regardess of whether or not I went with a DEM or an OB I was going to be paying about $2000 out of pocket because of the cost of my deductibles and my copays.
Some insurance policies make very little sense, to anyone.
From Nik:
"I am simply disagreeing with the claim that liking something better than the alternatives will change how risky (or not risky) they are."
Well, that just doesn't make any sense! Who said that?
From Katie:
Caryn,
RE: legality of home birth. As my husband is fond of pointing out, everything is legal until someone comes along and specifically declares it illegal. However, the trick comes into what about home birth is illegal. Is it illegal for a mother-to-be to give birth at home on purpose, with punishments such as the baby being taken away or being imprisoned? Is it illegal for someone to declare themselves a midwife and attend home birth in the capacity of a caregiver? Usually it's the later. According to my midwife, it was illegal for her to attend home births in Washington, so she moved to Oregon, where it is legal (she's a CPM). She did not want to go to prison in the event her client (patient?) needed to go to the hospital, nor did she want to put the client in the position of having to conceal her status as a midwife.
I think this is one of the biggest stumbling blocks when it comes down to creating a national standard for what a DEM is. As each state makes it's own rulings, it means one state may have more stringent or weaker guidelines than the one next to it.
Insurance becomes an even more complicated picture. I had to pick between two types of insurance, and the option health savings account. One covered "out of network" care, one didn't, and the HSA could go towards any medical care. I went for the cheapest option (1/4 of my paycheck instead of 1/3 - oh that pisses me off!) and went for the one the didn't cover OON care, and no HSA. I hid my pregnancy officially until I got my hands on the policy which specifically stated pregnancy didn't count as a preexisting condition (this used to be normal) and was covered for new applicants. It covered various aspects of my care, but a hospital birth would've cost, after my insurance, AT LEAST $1000. And this assumed that I didn't even have an aspirin. My home birth cost $3300 all together. If I'd had the foresight I would've put the money into an HSA ($3K max), applied it towards my home birth, and spent $300. If I'd gone with the more expensive insurance, it may very well have covered my home birth, since my midwife is certified and licensed to practice in the state.
It makes for a hell of a headache trying to figure out, financially, what the options are. I think my insurance would cover large chunks of any emergency care resulting from child birth, but there's not guarantee. They actively look for ways to deny you care. But this is the nature of a for-profit business. In the same time you have people coming here for treatment, you have people going on medical vacations to go to other countries to receive care specifically because it is cheaper (why does a hip replacement cost 10X more here than in other countries, for example?). There's something fundamentally flawed with the system as is, which somehow believes that everyone is loaded with cash, even with hospitals closing for lack of funds and people going bankrupt.
If I took the $6K I spent on health insurance last year and invested it, and paid for everything out of pocket, I would come out ahead, but because a broken arm could cost me a ridiculous amount of money, I pay into a system I hope (but do not feel sure of) will care for me when I get sick.
Rant over.
From Elizabeth:
Random thoughts...
1. I agree with Nik, LDLAS et al's earlier sentiments.....the "homebirthers are twisted freakz!!!11!!" meme on this blog has gone entirely too far.
2. Accordingly, my perception of other posters' "likeability" has almost nothing to do with whether they agree with my own view that HB is a really bad idea. If I want a self-congratulatory circle jerk of contempt for the hated other, I can always log on to MDC.
3. My insurance covered my HB transfer because hospital birth was one of the promised benefits, full stop. DEMs can do so little, good or bad (other than encourage/discourage transfer) that there is virtually no meaningful difference between a UC transfer, a DEM transfer, and a woman who simply gets to the hospital late. This is the reason why DEMs are so poor - their rates are held down by the fact that parents must hedge their chances of having to also pay somebody else who can actually assist the birth. I believe this also plays into DEMs' reluctance to recommend transfer; the higher the transfer rate, the greater the parents' risk of a double bill, and the less they'll be willing to pay the MW.
4. Nik (I think it was): segregating persons of high risk from persons of low risk is not "in the interests of fairness" - the whole point of insurance (which has been largely lost sight of) is to pool risks across populations whose individual risk factors vary considerably. Low risk people can segregate themselves by paying less for insurance that covers less of the things that they think won't happen to them. But since low risk isn't no risk, that means there will be no one to share their burden in the unlikely event. I believe fairness means moving back towards more diverse risk pools (perhaps all the way to universal), not less.
From Nik:
Nik (I think it was)
For clarity, it was not me. I didn't say anything about insurance (and nor will I, because I have no knowledge or interest in it).
From Susanne:
"Is it illegal for a mother-to-be to give birth at home on purpose, with punishments such as the baby being taken away or being imprisoned? Is it illegal for someone to declare themselves a midwife and attend home birth in the capacity of a caregiver?"
It's the latter, because the state (appropriately IMO) has a vested interest in establishing the competency and requirements of someone who provides medical care.
Else, why couldn't you have direct-entry surgeons just like you have direct-entry midwives and let the buyer beware?
From Nik:
"I agree with Nik, LDLAS et al's earlier sentiments.....the "homebirthers are twisted freakz!!!11!!" meme on this blog has gone entirely too far."
In the interest of fairness, the "doctors and nurses and those who defend them are twisted freakz!!!11!!" has also gone too far.
From Amy Tuteur, MD:
I don't think anyone has really addressed the central issue:
How are homebirth advocates "taking responsibility" for their decisions when they fully intend to call on doctors and hospitals to fix any problems that occur whether they could have been prevented in the hospital or whether they were caused by the decision to have a homebirth. They fully intend for their insurance company to pay for any screw ups. They fully intend to sue any doctor, hospital, paramedic involved in a bad outcome, even if the bad outcome is directly related to the decision to have a homebirth. They fully intend to take state aid, Medicaid, SSI, etc. if their child becomes disabled because of hypoxic brain damage.
That does not sound to me like taking reponsibility for bad outcomes. It sounds like making everyone else take responsibility for bad outcomes.
From jh:
"Tell people that they will have to pay out of pocket for their own mistakes, and they'll take many more precautions. They'd still get treated, but they'd be paying for the care for the rest of their lives. All of a sudden homebirth wouldn't seem so safe"
Wow, shouldn't the hospitals follow this same concept? The HOSPITAL should pay for the care of a patient who gets MRSA or another infection...or an unnecessary intervention or sugery.
And homebirthers associated with smokers? What a horrible analogy. Y'all are just pissed that homebirthers question your practices, your fancy diplomas, your big heads.
I have yet to see on this blog you guys get down to the REAL point. If YOU just make it better for a woman to have a natural birth in a hospital with minimal interventios if she wishes, than we will birth there. End of story. Until you do that, women will continue to birth at home.
Gosh y'all get so stuck on crazy details.
From Amy Tuteur, MD:
jh:
"If YOU just make it better for a woman to have a natural birth in a hospital with minimal interventios if she wishes, than we will birth there."
You've just missed the point. The hospital does not exist to create "better" birth experiences. The hospital exists to save lives and it does. Homebirth increases the risk of preventable neonatal death. Is a good "experience" worth risking a baby's life?
From Emma B:
I have been thinking all afternoon about the correlation between the deliberate risk assumption of infertility treatment and the deliberate risk assumption of homebirth. If nobody minds, I'd like to explore this a little more.
I chose to go through infertility treatment, knowing that there was a 1 in 3 chance I'd wind up with multiples. The particular procedure I had is the one that is associated with almost all high-order multiples (these rarely come from IVF proper, since it's easier to limit the number of embryos transferred back in IVF than to limit the number of follicles in IUI). I knew that going in, and I knew the statistics about multiples and prematurity, and I had long talks with my mother (who is my RE's nurse) and my RE. I researched the pros and cons of selective reduction, so that I would be well-informed in advance, and I read books on high-risk pregnancies and prematurity. I think my consent was as informed as it could possibly be, short of having done a residency in reproductive endocrinology.
Fast-forward thirty weeks to when I'm hospitalized in preterm labor, hooked up to the mag sulfate and staring the reality of preemies right in its ugly face. I knew intellectually what I was getting myself into, but I had no idea how terrifying it would truly be. I was lucky, and my labor was stopped, and my babies were born healthy four weeks later -- but I didn't forget the feeling that I hadn't REALLY understood what I was signing up for.
I took a *tremendous* risk getting pregnant in the manner that I did. In retrospect, it was quite possibly larger than that of most of the homebirthing mothers here. I do not know, off the top of my head, the perinatal mortality rate of twin births, but I would not be surprised to find out that it is higher than 2.7/1000, or that the maternal mortality rate exceeds that of homebirth as well.
I had good reason to take that risk, when faced with potential childlessness or with the tremendous difficulty and expense of adoption. I would have done it again -- in fact, I was preparing to begin Clomid in my next cycle, with a 10% risk of twins, only it turned out that I was pregnant instead. Subjectively, I think that my desire for a child is a "better" reason for assuming such risk than a desire for a natural birth, but that is an opinion and a value judgement.
I also took that risk counting on modern medicine, and on the US social security system, to be able to help me out. I expected my insurance to cover my very expensive prenatal care, and to pay for any NICU coverage my babies would need. I expected my doctors to provide me and my babies with the highest quality care available, although I would not have blamed them for a poor outcome. In the event that my children had been disabled, I would have taken advantage of any government benefits we might qualify for. I pay taxes and insurance premiums to provide these services, but if we'd needed them, it would have been because we lost the bet that I chose to make on their behalf.
Do you consider that failing to take responsibility for bad outcomes, Amy? If not, how do you feel that what I did is materially different from the choice to homebirth?
From Caryn:
Nik, this is just one of my pet peeves. I'll try to explain why I went off on this particular tangent; you said: If you believe that a risk is there because there has been adequate research to represent that risk, and that risks do not exist if there is not adequate research to represent it, then that is your personal perception of risk. It does not matter if that perception is correct or not, it is still a perception.
But some perceptions more accurately map reality than others. Even if you believe that X is safer than Y, there can be empirical evidence supporting the claim that Y is safer -- and this is *epistemically privilged* in the way that claims backed by scientific evidence tend to be.
I've seen plenty of HBAs deriding the "allopathic model of care" as if a model derived from something *other* than scientific method was likely to predict reality just as well. I'll also grant that it is probably true that no observation, no matter how safe, is completely paradigm independent. So maybe there is some paradigm such that people in the grips of that paradigm perceive flying rocks. But it is extremely rare for people to hold such paradigms, and the best explanation of this is that such paradigms build up anomalies very rapidly and would consequently be abandoned almost immediately if anyone ever actually accepted them in the first place. For example, the "flying rock" paradigm is going to have trouble dealing with the fact that when you drop a rock above your foot, whether you see it flying or not, your foot hurts.
No doubt there is some possible paradigm that would prevent you from seeing the rock fall AND from feeling the pain in your foot, but it will be even more tenuous.
In the case of science, of course, paradigm dependence does play a significant role and many observations are correspondingly threatened. But at the lowest levels, science really is trying to explain the sorts of everyday observations that are like the behavior of rocks.
A scientist's theory of electromagnetism certainly would predispose her or him to make certain observations more than others, but how likely is it that commitment to such a theory is all that is responsible for her or his observation that magnets attract when oriented one way and repel at the opposite orientation?
Those observations were, after all, the ones that got people to develop a theory of magnetism in the first place, and it is ultimately those relatively paradigm-independent observations that science is trying to explain.
And pregnant women and fetuses really do die. An awful lot of the time. And they really are saved from that fate by interventions that cause problems that most people would rank as "not as bad as death". It doesn't matter which model of care you've adopted; there really is an external reality.
Back to your regularly scheduled debate programming.
From Nik:
Caryn, I think you took my comment on perception waaaaaaay out of the range of what it was trying to accomplish!
From Caryn:
Caryn, I think you took my comment on perception waaaaaaay out of the range of what it was trying to accomplish!
But what *was* it trying to accomplish?
It *matters* if some perceptions are better grounded in reality than others!
From Katie:
Amy,
I retiled my roof last year; if I'd fallen off the roof and needed to go to the hospital, should I have been denied care because I hadn't hired a professional to do it? My mom pierced my ears with a needle when I was six. If they had gotten infected, should I have been denied care because my mom did it (instead of someone with a piercing gun)? I broke up a dog fight. If I had been bitten, should I have been denied care? The answer is no, I should not be denied care. It's not how something happens, it's if something happens, that medical professionals are required to provide care. It would be a terrifying world indeed if care was only provided to those who followed all the "rules" and were still hurt.
You miss another point. You say that I (since I had a home birth) don't want to pay for my mistake, and expect health insurance/Medicaid to do it. Damn right I expect health insurance/Medicaid to pay up. I pay a bunch of money every month for health insurance. I pay for Medicaid every month too. And, what with deductibles and copays, I would still have to shell out money for my care! Like I said, if I'd had a hospital birth, the MINIMUM I would've paid is $1000, assuming NOTHING went wrong, and I didn't need stitches or an aspirin or a chat with the lactation consultant. Show up, shove out baby, take a nap, leave = $1000 on top of my insurance premiums. If I weren't paying into the system, then no I wouldn't expect the system to pay for my care, but since I do, it should, regardless of where or how the injury occurred.
And, in terms of lawsuits, do you know (like a study you could link to) what proportion of injured home birth (at least intended) families sue vs. hospital birth? Do HBs sue on the same rates as hospital birthers? If the shit had hit the fan, and my baby was injured, I wouldn't have sued (unless there was apparent gross negligence or mismanagement on the part of the midwife, or EMTs, or doctor, or whoever). But I would expect the system I pay into to pay out to us for the baby's care.
From Nik:
"It *matters* if some perceptions are better grounded in reality than others!"
My point is that it is still a perception. I didn't mean anything beyond what I said. I said it because at the time in the conversation people were throwing around the word "perceived" like it meant something bad.
As far as it mattering, I see that it matters to you and I can understand that. It does not matter to everyone. (Obviously).
From Amy Tuteur, MD:
Emma B:
"Do you consider that failing to take responsibility for bad outcomes, Amy?"
No, I don't. I think that situation differs from choosing homebirth in a variety of ways.
First, you were not ignoring the advice of a medical professional who told you it was too dangerous for him or her to recommend.
Second, you were not pretending that the medical evidence showed something different than what it really showed.
Third, the complications were not out of the realm of your known experience, so you were not pretending that they could not occur. Everyone knows someone who had multiples due to infertility treatment. Everyone knows someone who had complications of a multiple pregnancy.
Fourth, you never made the claim that you intended to "take responsibility" for bad outcomes.
I am not suggesting that individuals should be forced to accept complete personal and financial responsibility for their choices. The issue is that homebirth advocates claim that they ARE taking full personal and financial responsibility for ignoring medical advice, but they are actually doing nothing of the kind.
From Amy Tuteur, MD:
Nik:
"My point is that it is still a perception."
No, you were trying to suggest or claim that all perceptions are equal; they're not. Perceptions about empirical issues that are not based on science are not based on reality.
Science is the ONLY way to understand empirical issues. No other way has ever been shown to be accurate. Indeed, all other ways have been shown to be wrong.
From Liz 1:
Wow! If this becomes a discussion about the true nature of personal responsibility, than that is a real can of worms. I carelessly commented on it yesterday, and now realise again how useful it is to turn your brain on before you open your mouth.
Emma B has put into simple words what I have been struggling to say. That an abstract risk is very different than coming face to face with the consequences when it goes wrong. It is human nature to take risks, and anyway they are unavoidable. We can all be carelessly irresponsible. It seems to me that Katie’s roof mending exploits are typical of all of us. Maybe some of the time, we quite like living dangerously, taking a gamble. Does that justify homebirth? It might, under certain circumstances. To me there are two counter arguments: Denial of risk, by believing in nonsense. (Gravity doesn’t apply to me, the alternative is worse) and there is another human life involved that has no choice. I know, and knew, that my choice to have a second child was risky to the point of irresponsibility. And I could not claim I did not understand the risks. I understood them only too well. I knew from experience that this child was not safe until it was born and breathing, and I knew it was high risk. I feared my own death or disability (dodgy kidneys not fully recovered from the first) I knew, because I had been told, that the doctors would not try too hard to save this one. I feared my husband’s despair, if we had to raise two disabled children. I feared society’s disaproval, if I incurred the expense of their care. Don’t tell me fear is a weakness. If I had gone into this pregnancy trusting birth then I believe that would have been criminally irresponsible. Why did I do it? I’m not sure I know. I WAS ambivalent – scared to death, in fact, and happy and hopeful. I had what I wanted – a child to love and raise, and I did not care that she did not measure up to society’s definitions. I can remember feeling sad that my husband would miss the pleasure of a child who developed normally, but I had two nieces who were like my own, and would have been happy to adopt or foster. So what is the difference between the huge risk me and Emma took and homebirth? We didn’t have a choice – unless you count childlessness as a choice. We knew very well what we were doing. It was calculating the odds, not denying them.
So that is “risk” what about responsibility? What Dr. Amy says is shocking. In one way, it is difficult to argue or debate this, because this is not a matter of opinion or facts against fantasy, it is a philosophical question of the nature of society. I am answering her points off the top of my head, again without much thought – though I am sure that like Emma I will go on thinking about it and maybe come to different conclusions. What comes into my mind is Hobbes Leviathan, a treatise on the nature of civil society (His view of Nature was “red in tooth and claw”) He said that human life was nasty, brutish and short – unless people got together and ordered a social world of collective responsibility. The hardest part of having a disabled child is, sometimes, having to rely on the state. Your life and how you live it becomes public property. “The taxpayer” feels entitled to have a view on whether my daughter should live or die. That is hard to take – until I remember that I am a taxpayer, too, and support your child’s education, and your hospital care. “Individual responsibility” is a chimera; it doesn’t exist in real terms.
And that is as far as I can get, for now.
From Amy Tuteur, MD:
Katie:
"I retiled my roof last year; if I'd fallen off the roof and needed to go to the hospital, should I have been denied care because I hadn't hired a professional to do it?"
I am not claiming that individuals should be required to take full personal and financial responsibility for medical choices. However, if you had claimed when being warned of the dangers of going up on your roof that you were planning to "take responsibility" for that decision, you would have been a hypocrite in the same way that homebirth advocates are hypocrites. They have no more intention of taking responsibility for their mistake then the person who falls of their own roof.
"do you know (like a study you could link to) what proportion of injured home birth (at least intended) families sue vs. hospital birth?"
I am not aware of any evidence that shows that homebirth advocates with bad outcomes are less likely to sue than anyone else with a bad outcome, and homebirth advocates are more likely to have bad outcomes than comparable women who give birth in the hospital.
Insurance companies, which care only about the bottom line, set high premiums, or refuse to write policies that cover homebirth because they consider it medically indefensible, and because their experience shows a high rate of financial judgments.
From Susanne:
"And, in terms of lawsuits, do you know (like a study you could link to) what proportion of injured home birth (at least intended) families sue vs. hospital birth? Do HBs sue on the same rates as hospital birthers? "
This is a straw man argument - if homebirth were to expand, it would attract more women with greater diversity vs the type it does now, and the rate of suing would go up.
From Caryn:
It does not matter if that perception is correct or not, it is still a perception.
and
As far as it mattering, I see that it matters to you and I can understand that. It does not matter to everyone.
are both wrong.
It *does* matter, and it does matter to *everyone*, if one of the perceptions is more accurate than all of the other perceptions. This is the sort of empirically-derived evidence that *everyone uses preferentially all of the time*.
Or else we couldn't find our car keys in the morning.
From Liz 1:
Further thoughts on responsibility. So the question then become is it responsible to take on a known risk? I think the answer has to be no, it is not, but it is acceptable IF YOU DO NOT DENY THE RISK. I don’t think I would ever attack the DECISION to have a homebirth. I would criticise the reasons, if they rest on an indefensible belief that it is as safe, or safer than hospital in all cases. I will argue against it if I think the reasons are based on false information, to challenge the false beliefs, not the decision. Do I have a right to an opinion? Not really, but when did that ever stop anyone having one?
From Susanne:
Further thoughts on responsibility. So the question then become is it responsible to take on a known risk?"
Well, sure it is, Liz. Otherwise we'd never ride bikes, or go skiing, or fly in airplanes. My peeve is more with the lies that are told about how homebirth is just as safer or safer.
From Lies_DamLies_and_stats:
I am not aware of any evidence that shows that homebirth advocates with bad outcomes are less likely to sue than anyone else with a bad outcome, and homebirth advocates are more likely to have bad outcomes than comparable women who give birth in the hospital.
In other words, you can't quantify it, you don't know, your "science" has failed you. It really is OK - not everything in the world has had an RCT done on it. Not everything can, whether practically or ethically. This is why it's not the only standard by which people choose to live their lives.
Wow! If this becomes a discussion about the true nature of personal responsibility, than that is a real can of worms.
True - I don't think we have a good definition of "responsibility" that we're all working with here. For example, I contend that if you have a planned homebirth with a competent midwife (let's make her a CNM so we don't have to debate her competence), and a complication is developing that necessitates transfer to the hospital and OB care, it is _taking responsibility_ to make that call, transfer to the hospital, and ensure the best outcome for your baby, yourself, and your ability to care for your other children (perhaps my perspective is colored here by the fact that I already had other children when I had my first homebirth). DA seems to be contending that in that case no, you are not taking any responsibility at all, but somehow sloughing it onto the "good people of the world" (i.e. doctors, nurses, possibly taxpayers depending on the situation - and never mind that you're probably a taxpayer yourself). Is DA's definition of "responsibility," then, to clean up one's own mess by providing one's own healthcare? How, then, is that different from Emma's scenario of fertility treatments resulting in a riskier pregnancy situation, or for that matter getting pregnant in the first place (if you're blessed to be able to do it the natural way), and expecting a medical care provider to care for your pregnancy and birth at all? Before you can have a discussion on responsibility, you need to have a common definition what responsibility is. There are many different connotations for responsibility; I think that we are working with different ones (and that some people are twisting them altogether).
From Lies_DamLies_and_stats:
From Merriam-Webster:
Main Entry:
re·spon·si·ble Listen to the pronunciation of responsible
Pronunciation:
ri-ˈspän(t)-sə-bəl
Function:
adjective
Etymology:
Anglo-French responsable, from respuns
Date:
1643
1 a: liable to be called on to answer b (1): liable to be called to account as the primary cause, motive, or agent (2): being the cause or explanation c: liable to legal review or in case of fault to penalties
2 a: able to answer for one's conduct and obligations : trustworthy b: able to choose for oneself between right and wrong
3: marked by or involving responsibility or accountability
4: politically answerable; especially : required to submit to the electorate if defeated by the legislature —used especially of the British cabinet
— re·spon·si·ble·ness noun
— re·spon·si·bly Listen to the pronunciation of responsibly -blē adverb
synonyms: responsible, answerable, accountable, amenable, liable mean subject to being held to account. responsible implies holding a specific office, duty, or trust . answerable suggests a relation between one having a moral or legal obligation and a court or other authority charged with oversight of its observance . accountable suggests imminence of retribution for unfulfilled trust or violated obligation . amenable and liable stress the fact of subjection to review, censure, or control by a designated authority under certain conditions .
Clearly, some of this does not apply. I guess when I'm talking about "responsibility" I'm falling more in line with items 2 and 3. The fact is, you're ultimately accountable no matter what your birth place or care provider is (as I have stated I don't know how many times). It's just much more transparent in a homebirth, partly due to the fact that you have much less recourse.
On the other end of the spectrum, it's much more transparent in a high-risk pregnancy, too. High-risk pregnancies - which better be taken care of by a person with the appropriate specialized medical training - are also a situation of increased responsibility. Not because you have a smaller team caring for you (in fact, it's larger), but because you need to be as active in your care in other ways.
From Another Amy:
I believe this also plays into DEMs' reluctance to recommend transfer; the higher the transfer rate, the greater the parents' risk of a double bill, and the less they'll be willing to pay the MW.
Happened to a friend of mine. There's a CPM in my state who's well-known for being TERRIBLE. She's the backup of our local "celebrity midwife" (no names mentioned, but I'm in Massachusetts and since there's about two celebrity midwives in the US and the other one's in Tennessee, it doesn't take a genius to figure out whom I'm talking about) and she's FAMOUS for dumping clients and trying to get them to sign statements swearing things they never said.
In my friend's case, she wanted to transfer when intuition told her something was going wrong, and the midwife refused to accompany her, insisted on full payment, and a few weeks later wanted her to sign a statement saying the midwife had been the one to recommended transferring.
I'm honestly surprised she still gets clients since even on MDC she's got a terrible reputation.
From Susanne:
"In other words, you can't quantify it, you don't know, your "science" has failed you. It really is OK - not everything in the world has had an RCT done on it."
No, she's simply saying that she's not aware of any evidence suggesting that HBers with bad outcomes are less likely to sue compared to mainstream birthers with bad outcomes. Not that "science" has failed, but she isn't aware of data to prove or disprove any such hypothesis.
Nonetheless, it may very well be that HBers with bad outcomes are less likely sue compared to mainstream birthers with bad outcomes. Part of this may be due to the pockets issue - there aren't any deep pockets with a lay midwife who isn't carrying med mal insurance, so someone might want to sue, but practically speaking, what's the point (and what lawyer will be interested). Part of this may be due to a philosophical issue - these are women who are just more accepting of bad outcomes and not looking for recourse.
Assuming that HB-ing grows, however, the profile of women choosing it will be more diverse than the current profile and I would see no reason that it wouldn't get to the same equilibrium in terms of % of bad-outcomers-suing.
From Susanne:
LDLAS: I agree that your hypothetical situation (planned HB with a competent midwife, you then transfer) is taking responsibility - after all, the alternative is to stay at home and let baby die, and I for one don't think that's terribly responsible. However, by the same token, if I go use an OB (or MFM), how am I not equally taking responsibility? Those of us on the mainstream side are constantly being told that we're not taking responsibility because we've engaged those health prof'ls. For the life of me, I don't see the difference.
Back to responsibility, I'm glad you made your hypothetical a CNM. Because the CNM herself has shown responsibility in the level of training she's getting and (presumably) her collegial / backup relationships with OB's / hospital staff so when she transfers, it ensures near-seamless care.
I simply don't think DEM's, for all their talk about assuming responsibility, are assuming responsibility because all they can do is show up at the hospital door and say I've got a woman here in trouble but they bear no coordinated responsibility for her care (other than a moral one). In the Cryns case in my state, the midwife showed NO responsibility - she said "I'm leaving, don't tell the paramedics I was here."
Now some DEM's will claim that the "problem" is that the OB's / hospitals don't think of them as anything other than lay people, and won't listen to their explanations or give them coordinated backup or admitting privileges. However, the reason they don't is because the DEM's haven't taken the responsibility to get the education / training that it takes to BE "worthy" of the OB / hospital giving them the time of day. I contend that they are the true irresponsible ones.
And I think a transfer plan of "we'll just go to the OR unannounced, because they HAVE to see you" is irresponsible.
From Lies_DamLies_and_stats:
OK, I'm sure that definition must have gotten messed up somehow... so, in the interests of accuracy, here's a link:
http://www.merriam-webster.com/d...ary/
responsible
Silly inadvertent tags.
From Caryn:
The fact is, you're ultimately accountable no matter what your birth place or care provider is
This is vague. Can you be responsible for how your birth goes? (Can you deliberately only grow babies who fit out?)
Which things *are* people responsible for? I would say it's entirely possible that we're responsible for some components, and not others.
Should various laws be arranged in a way that forces people to take a particular degree of responsibility here? One of the things in the environment that we weigh when we're weighing risks and benefits is whether or not homebirth transfers are covered; we evaluate the risk to ourselves and our children given the environment we find ourselves in. Do we want a situation in which people can control their risks in this way, or do we think that it's unfair because these people are engaging in a behavior that for some reason shouldn't be covered by insurance?
Which brings us back to that earlier point about whether or not there are imprudent risks that shouldn't be covered. Do we, as a community, cover injuries incurred from basejumping?
As things stand, whether or not anyone who engages in any kind of behavior is covered depends on whether or not the insurance company finds that it is *in their interest* to cover them. As a matter of fact, some things are not covered *now*, as in the case of my insurance company that didn't cover prescriptions, organ transplants, or infertility treatments. If an insurance company denies a liver transplant to a person with alcohol-caused cirrhosis, are they doing that because the alcoholic is responsible for his condition, or are they doing it because they're cheap, or are they doing it because he's less likely to live as long on his new liver than another transplant candidate because he's got a proven track-record of destroying livers?
Also, it's not as if it's an all-or-nothing game here. Smokers have health insurance, but often have to pay an inflated premium.
From Lies_DamLies_and_stats:
No, she's simply saying that she's not aware of any evidence suggesting that HBers with bad outcomes are less likely to sue compared to mainstream birthers with bad outcomes. Not that "science" has failed, but she isn't aware of data to prove or disprove any such hypothesis.
I understand what she's _saying_, but there's an inherent hypocrisy in that whenever there's no extant data (or at least, not that any one's _aware_ of on either side) to address a specific issue when DA asks someone who disagrees with her for an RCT, then the contention is that no, they are simply horribly ignorant and therefore anything they say is wrong. I am simply calling out a double standard here. If anything, a medical professional - or one who chooses to bolster their arguments with a medical background - should be held to a _higher_ standard since they ought to be keeping up with the research as an inherent part of their profession (not to mention that they tend to have easy institutional accesses and don't have to drag three children to a research library to get the full text of a study that someone has made them aware of). However, where birth is concerned I shouldn't be surprised, considering the number of OBs out there who are not current with research (some even still believe some myths that were debunked over a generation ago), and who don't go with ACOG's own guidelines when ACOG has theoretically done and digested the research for them! I loved one OB that I worked with in the past - he was excellent about staying current on research, practiced evidence-based medicine, and we had some fantastic conversations about studies that had come out, what they might mean for areas that had not yet been really researched, etc. He worked with CNMs who were constantly saying he was so great, he could be a midwife (). Interestingly enough, he was highly recommended for homebirth and birth center risk-outs... and he had a VBAC rate approaching 80%, coupled with a low cesarean rate (don't remember the exact number). Sorry for the tangent, great memories. Anyway, there's not research on everything. There never will be. When the research doesn't touch something, you've got to fill in. What you use to fill in? Your experience. Common sense. Your values. Anecdotal evidence. Whatever works. Sometimes you just have to take your best guess. New evidence arises all the time, too - you just can't be offended when it doesn't match your pretty picture of the world. You can choose to discard it, or you can choose to work it in. As a medical professional, you have an obligation to be current with research, to inform your patients and provide references if they want to (dare I say?) take responsibility and have an active role in their own health care, and to let them know when the research stops and how you are reaching what, truly, is your best guess. As a patient, it is your responsibility to get as informed as you need to be and to make the decision as to whether to agree with that doctor's best guess, because you are the one who has to live with that decision.
Getting incoherent due to distraction, so I'll try to circle back later...
From Susanne:
"However, where birth is concerned I shouldn't be surprised, considering the number of OBs out there who are not current with research (some even still believe some myths that were debunked over a generation ago), and who don't go with ACOG's own guidelines when ACOG has theoretically done and digested the research for them!"
I'm not defending an OB not being current AT ALL, but DEM's don't even have a culture of research to be current or not-current about in the first place! At least with science-based reasoning, you can say ... here are the journals you need to keep up with, here are the position papers, stay tuned, as further information comes, we will revise as appropriate. The DEM culture is one of simply saying that birth is to be trusted and the body always knows what to do and if you just step back and honor it, all will be well in maternityland. There's nothing to "keep up with" in that philosophy, since that philosophy doesn't lend itself to learning and new data inputs.
From Li:
LDLS, I agree. I switched OB's halfway through my pregnancy because I was so frustrated with my first OB's unwillingness/inability to explain why he wanted me to undergo certain tests and procedures.
When I developed cramping at 25 weeks he ordered me on bedrest, but when I did some research on it there was no evidence that it works. I asked him, "Does bedrest even work?" and his reply was "Oh, absolutely!" Because this didn't jibe with the research I went to another OB. She told me that there was no evidence that bedrest works but because there aren't any good treatments for premature labor, bedrest is an appropriate intervention. Well, that was good enough for me. Why couldn't the first OB have explained it to me that way instead of representing bedrest as a proven treatment? He destroyed any trust I had in him and I couldn't continue to use him as my healthcare provider.
From Amy Tuteur, MD:
LDLAS:
"I am simply calling out a double standard here."
No, you are simply misunderstanding, yet again. Someone was implying that homebirth advocates take responsibility by refraining from lawsuits in the case of bad outcomes. However, if there is no evidence to support the claim, there is no reason to believe the claim.
From Vicky:
But what consitutes evidence and if we can't believe a claim because there is no evidence to support it, can we disbelieve a claim with no evidence against it?
From Susanne:
LDLAS: "I am simply calling out a double standard here. If anything, a medical professional - or one who chooses to bolster their arguments with a medical background - should be held to a _higher_ standard since they ought to be keeping up with the research as an inherent part of their profession."
But this isn't a MEDICAL claim. It's an EMPIRICAL legal claim. It's observational in scope -- over X amount of time, what % of (planned) homebirthers with a bad outcome sued vs what % of hospital birthers with a bad outcome sued. There's no RCT or double-blind or trial playing into this at all. Apparently it hasn't been collected.
From Amy Tuteur, MD:
Vicky:
"if we can't believe a claim because there is no evidence to support it, can we disbelieve a claim with no evidence against it?"
No. This is logic 101. There is no need or obligation to prove a negative, only a positive.
From Katie:
Well, since there isn't proof either way, I am going to assume that HBers do NOT sue as often as hospital birthers (that's a negative, so I don't have to prove it).
Bah! Playing at logic games on this board is insane. Since the sun doesn't shine at night, it doesn't exist! Another negative I don't have to prove! Bull. If you are going to make a statement about some tangible aspect of reality (that HBers expect someone else to be financially responsible for their "mistakes") and expect everyone else to give oodles of evidence, you do to. Since you can't, then the only answer is that YOU DON'T KNOW how much financial responsibility HBers are going to take, or how often they sue, or if they don't sue WHY they don't sue. You are making assumptions you can't back up! It's okay you know, to be wrong or to be ignorant about something. Happens to everyone.
And LDLAS is absolutely correct that we seem to work off a different definition (I would say application) of responsibility. If a person picks a course of action, and then address the possible complications of said action, and uses all the tools available to them to either avoid problems or react to them, I think they are being responsible. Does it really matter if they are base jumping, or having a home birth, or electing a non-medically indicated C/S?
From Amy Tuteur, MD:
Katie:
"since there isn't proof either way, I am going to assume that HBers do NOT sue as often as hospital birthers. I am going to assume that HBers do NOT sue as often as hospital birthers (that's a negative, so I don't have to prove it)."
Sigh. That is not a negative. It is a positive. The meaning of " a negative" in logic is not the same as the colloquial meaning of negative. You need to do some reading and learning about basic logic. You clearly don't have a clue.
According to the principles of basic logic, you cannot claim that there is a difference between the rate at which homebirthers sue compared to women who give birth in the hospital. We are required to assume that they are the same unless someone shows us that they are different.
From Caryn:
Well, since there isn't proof either way, I am going to assume that HBers do NOT sue as often as hospital birthers (that's a negative, so I don't have to prove it).
First of all, the adage that "you can't prove a negative" is not good news for someone relying on a negative, as you're assuming it unreasonably. Secondly, you *can* prove a negative; what you can't prove is a negative universal claim of infinite scope, because it would require an infinite number of observations. Since your claim ranges over the finite set of individuals who've filed a lawsuit up to this point in time, it's possible to compare the two numbers and see which one is bigger than the other one.
That said, you can of course prove logically necessary negatives via contradiction.
The person making the claim is responsible for supporting it. If you want to claim that HBers do not sue as often as hospital birthers, you need to support that claim. Or you can backtrack and say that we don't know which population sues more often, or if it is even the case that there is a difference between the two. Incidentally, this is what Dr. Tuteur said. (I am not aware of any evidence that shows that homebirth advocates with bad outcomes are less likely to sue than anyone else with a bad outcome...)
If a person picks a course of action, and then address the possible complications of said action, and uses all the tools available to them to either avoid problems or react to them, I think they are being responsible. Does it really matter if they are base jumping, or having a home birth, or electing a non-medically indicated C/S?
At some point, the people who get to make the laws can decide whether or not some behavior is responsible. That's their job. Sometimes they're not very good at it, either -- there are plenty of crazy laws -- but there we are.
When it comes to birthing issues explicitly, there's a huge amount of grey here. Take a UCer as an example: there's this tool available to a UCer called a hospital which she is choosing not to use. There's this other tool called a birth attendant. At what point does her failure to use those tools to avoid problems indicate a lack of responsibility? Is there such a point?
From Katie:
Damn, I lost an entire post!
A UCer has (initially) greatly restricted their tool bag. However, this does not mean they can not access those tools at a later time. Just because they don't intend to use a hospital, does not mean they can not use a hospital (nor as Amy seems to think should they be denied use of a hospital). Even if they do not use a hospital, and end up with a damaged baby, they still have the right to use (or not use) the tools of medical care. Whether or not anyone else bears responsibility for the outcome depends entirely on their involvement. If a UCer shows up at an ER in distress, requesting aid, and it is denied care or care is delayed because the doctor on hand disregards her request and does not care for her appropriately, and this results in a damaged baby, the doctor does bear some responsibility for the outcome (as opposed to seeing her in distress and reacting in an appropriate manner). What exactly that would be depends on the situation, of course. But I don't think this is any different from someone showing up to a hospital and being denied care, or care being unreasonably delayed, for any emergency (like, say, putting someone with a broken arm ahead of the person with the gunshot wound to the abdomin). Those with experience and knowledge should make these decisions (who is more important in terms of needing timely care), and if they can't make these decisions without bias (like not treating the gunshot victim because he's black) they should not be in that position.
An individual is generally responsible for the actions they make. When they turn to professionals, and those professionals take on some part of the decision-making process, those professionals take on some of the responsibility as well. If they don't want the responsibility, they shouldn't take it on. The devil is in the details, and how much responsibility each party should bear will vary, often enough dramatically, and needs to be decided on a case by case basis. Is a UCer or HBer being irresponsible? Depends. Amy thinks so in all cases.
I think there is also a difference in acting irresponsibly and taking responsibility for one's actions after the fact. I think the phrase is "owning up to one's mistakes." I think this is the other problem (besides definition) with a discussion of responsibility. Is it the action or the response that we are considering responsibility for?
From Liz 1:
I haven't a clue whether the perspective of a non-scientist (who was a lab technician for years,) is relevant in this discussion, but in the language field, you learn to beware of either/or. Homebirthers, mainstream, is it so clear cut? We are women, mothers, would-be mothers, not two clear cut camps. My position is that I hate gobbledy gook, because I think it is dangerously misleading, and, besides, it is wincingly irritating, tending to be wrapped up in smug certainty. But I can listen with respect to people who think differently to me - so long as they do not expect me to convert. I will accept it as a personal quirk - a failing if you like - that I have trouble believing that oil of geranium is as effective as an epidural, or that a plastic paddling pool is a better venue than a hospital room. The trouble is, that on here, that is taken as an attack on homebirthers per se, and an attack on personal freedom and choice. It isn't. I can understand the appeal of homebirth, the desire for something that appears "natural" (while not seeing natural as a synonym for safe). I absolutely reject the idea that one form of birth is superior to another - I don't believe that your euphoria was any better than mine - in fact, the opposite. Sometimes, I think SOME people are trying to turn birth into Performance Art, and would like an Oscar, or to be crowned Queen of the Birthing Pool. That particular sub-set make me very irritable indeed. I often don't understand the appeal for civility here, for middle ground. This is a debate, an argument, not a support group, and I think vehemence is inevitable. I respect all mothers, regardless of how different, regardles of choices. Mamas are a different thing altogether.
What has this got to do with this thread? I'm getting to that! I am deeply interested in this question of suing - another strange corner of human nature, another area where myths abound, another area where there seems to be a huge difference between our two countries. Who would homebirthers sue? For what? In England, suing for a dead mother, a dead baby hardly ever happens. They aren't considered to be worth much. There will be an enquiry for a mother, censure for the hospital, but not often a civil case. It is the damaged baby that hits the jackpot. And how distasteful that idea is. I didn't sue, because money wouldn't fix my daughter. Because it is a horrible and uncertain process, having nothing to do with justice and a lot to do with people covering their backs, manipulating and distorting.(On both sides) In England, you can prove negligence, but unless you can pin it to causation, you will lose. No juries here. And I don't like drama, had no desire to play the Suffering Mother, put my daughter forward as a Tragic Case. So who would homebirthers sue? They are going to be disadvantaged from the start, by their initial choices. I would love to get closer to the truth of these particular myths, so - anyone have any facts to go with their intuitions?
From Amy Tuteur, MD:
Katie:
"as Amy seems to think should they be denied use of a hospital"
Please read what I wrote, instead of making up what you think I said.
At no point did I ever say that anyone should be denied the use of a hospital. What I said was that homebirth advocates don't plan on taking responsibility for a homebirth gone wrong; they plan on dumping it on the doctors and nurses at the local hospital, often without event the benefit of medical records, or a call ahead to let the staff know that an emergency is coming in.
From Liz 1:
An individual is generally responsible for the actions they make.
BEING responsible for consequences is not the same as TAKING responsibility for outcomes. If you fall of the roof, then you have some responsibility for a broken leg. But if you had foreseen that as a consequence, you wouldn't have gone up there in the first place. You allow it in the back of your mind as a possibility, but gamble on it not happening. So there is a difference. Does that make sense?
From Liz 1:
And when it comes to suing, as I am belatedly realising, when it comes to a damaged baby, it is not the mother's feelings that matter. The loss and the consequences are for the child. We get stories here about infants suing mothers - for fetal alcohol syndrome, for instance. Don't know if that really happens, and it seems a very slippery slope to me. But puts a slightly different slant on questions of responsibility?
From Liz 1:
Unless it is even more different in America than I thought, you don't get to sue for damage, you get to sue for negligence causing damage. And that is only the start. If the delay is caused by the need to be transported, who on earth are you going to sue? And this isn't a question that can be answered by medical research, but only by lawyers. There is a lawyer's blog, Eric Turkowitz, which had a very interesting section on how "clients" are selected. Nothing to do with outcomes, simply - what can be proved? People who have been egregiously injured cannot do a thing about it. There was even a story about doctors charging twice for chopping off the wrong leg.
From Susanne:
"If a person picks a course of action, and then address the possible complications of said action, and uses all the tools available to them to either avoid problems or react to them, I think they are being responsible."
So, the midwife in my state, who practiced in defiance of a cease-and-desist-order, who attempted to deliver a known breech and then then told the family to call 911 and told them to hide her things and not tell the paramedics / hospital that she was there, was she choosing responsibly? After all, she DID use the tool available to her -- an ER / paramedics who were ethically bound to render the aid they could to a mother and baby in distress.
Indeed, by your definition, NO ONE could be irresponsible -- because they can always rely on the tool of the ER who will clean up the mess.
That sounds suspiciously like saying that I can leave the doors to my house open with a sign saying "my valuables are this way" but I can rely on the tool of the police to react when my valuables are stolen.
Which gets to a broader issue. Nothing prevented this midwife from becoming a CNM and then she could have delivered babies legally to her little heart's content. But their vision of assisting women isn't about assisting women in the venues where women may want or need to be. It's about assisting women in one venue -- at home. Because it fulfills *their emotional needs and desires. And that's not the definition of a professional. An OB doesn't deliver women in the hospital because he has a deep psychological craving to be in a hospital. He does so because he wants to deliver women, and the hospital is the best venue for that in his professional judgment. See the difference?
From Susanne:
"An individual is generally responsible for the actions they make. When they turn to professionals, and those professionals take on some part of the decision-making process, those professionals take on some of the responsibility as well. If they don't want the responsibility, they shouldn't take it on."
Paramedics, ER personnel, and the OB's / nurses who react to a woman being brought into the hospital in distress DON'T HAVE THE OPTION of not taking on that responsibility. It feels to me like you're not understanding that piece of the equation. They have to clean up someone else's mess. How is that "responsible" to turf your mess at someone else and walk away?
From Susanne:
"Unless it is even more different in America than I thought, you don't get to sue for damage, you get to sue for negligence causing damage. And that is only the start. If the delay is caused by the need to be transported, who on earth are you going to sue?"
You can sue for damage, and for negligence causing damage, and for pain and suffering above and beyond the costs of the damage (damage being, for example, the cost of lifelong care for a disabled child).
It would be interesting to know that if, theoretically, a med mal insurer were to write a quote for a DEM, what the cost would be.
If I'm a med mal insurer and I'm looking at an average ob-gyn, I can see he's board-certified, has attained the necessary competency in the field of ob-gyn, is required to have continuing education, has attended real universities / medical schools, and I know he has the necessary training to be able to handle any obstetrical emergency including surgery, has privileges at hospitals, and I *still have to charge him $100,000 for $2 million worth of coverage.
Now just THINK how much I'd have to charge a DEM who has attended a MEAC school with aromatherapy and homeopathy, has little training other than apprenticing, can't handle any obstetric emergencies because she doesn't have the ability, deliberately practices in a place that doesn't have that personnel / facilities on hand, and doesn't have any back-up agreements or options other than dumping on the grounds of the ER! Who in their right mind would insure such a person? How come the DEM's haven't gotten together and self-insured?
From Caryn:
Katie, I note that you are now broadly in agreement with Dr. Tuteur's original post.
She asks,
What does it mean to "take responsibility" for one's health?
,then illustrates a scenario in which someone says she is taking responsibility for her health because she has made a knowledgeable decision and is aware of the potential consequences. She will suffer the harms if she's on the wrong side of the statistics, but she's also not taking the risks as seriously as the numbers indicate, and she intends to get medical treatment for complications, and she intends for the community to pay for the costs of her choices via higher insurance premiums.
She never suggests that this individual should be *denied care* or that the care provided to this individual should be biased. She does ask if the community should be paying higher premiums because this person is making poor decisions, or if this individual should bear more of the costs of her choices because she is making poor choices. She does not provide an answer to this question.
People who've incurred bodily injury while committing a crime are always provided with medical care. It's just that they are often also prosecuted.
I note that we often charge additional life insurance premiums to cover BASEjumpers, where they are covered at all, because they are engaging in an activity substantially more risky than the rest of the population. Smokers also pay higher insurance premiums. Should women planning a homebirth pay higher premiums? And in which circumstances?
You ask essentially the same questions she does. Is a UCer or HBer being irresponsible? Depends... I think there is also a difference in acting irresponsibly and taking responsibility for one's acts... Is it the action or the response that we are considering responsibility for?
What counts as responsibility? Is expecting the rest of the community to pay for a bad outcome when she deliberately ran a much larger risk via failure to use available tools taking responsibility for her outcomes in any meaningful way?
No one's really tried to answer this question. But both you and Dr. Tuteur have asked it. It's a *complicated* question that is going to be sensitive to lots of different factors. There may still be a right answer nonetheless.
Not every homebirth is equally risky. Some precipitous births occur outside the hospital. There are conscious choices -- intent -- and there are known risks. Homebirths to a low-risk woman with one previous spontaneous vaginal attended by a CNM taking place across the street from a Level III NICU are a different sort of problem from unassisted HBAC 40 miles from town.
(I don't want to be taken as endorsing any particular birth scenario here as a responsible one, btw. They are just illustrations.)
From Nik:
"what you can't prove is a negative universal claim of infinite scope, because it would require an infinite number of observations."
ALL claims require an infinite number of observations to be proven by definition.
Someone really made a good point when they said "What constitutes evidence?" Dr. Amy picks and chooses her evidence, will regard her own personal analysis as fact and disregards the analyses of those who she deems "unfit for making analysis." (She is somehow fit to make that decision based on... ?)
Dr. Amy, Oh Great Statistician, you should know that outliers do not become outliers until all the data has been collected. Therefore, ALL kinds of evidence should be included in your analysis even if they do not support your own biases. That's one mark of a good scientist and you should know that. You should have known that from the first time you weighed pennies in chemistry lab.
From Nik:
By the way, good research reports its outliers. The best research does subsequent experiments to explain the presence of an outlier. No valid research will dismiss an outlier as "invalid" and move on with their point. Its scientifically unethical.
From Caryn:
"what you can't prove is a negative universal claim of infinite scope, because it would require an infinite number of observations."
ALL claims require an infinite number of observations to be proven by definition.
Some statements are necessarily true. All bachelors are unmarried, even though we haven't asked every single bachelor about his marital status.
When it comes to scientific claims about reality, even though no universal general statement can be known with absolute certainty to be true for the reason you mention, it doesn't follow that every such claim is equally well-supported.
It's more rational to believe theories that are confirmed by a significant set of finite coherent results than to believe theories that aren't similarly well-confirmed.
Apples might start to rise when we drop them tomorrow. But we have no observations that would make that theory credible enough to adopt, and a veritable boatload of observations to the contrary.
From Nik:
Caryn, captain obvious, whatever, you completely missed my point.
My point was that the point you were making was not reasonable for the exact reasons you just described to me in your last post.
From Caryn:
My point was that the point you were making was not reasonable for the exact reasons you just described to me in your last post.
My point was
Secondly, you *can* prove a negative; what you can't prove is a negative universal claim of infinite scope, because it would require an infinite number of observations. Since your claim ranges over the finite set of individuals who've filed a lawsuit up to this point in time, it's possible to compare the two numbers and see which one is bigger than the other one.
I stand by this. It is possible to count the number of homebirthers who have sued following a bad outcome, and the number of hospital birthers who have sued following a bad outcome, and *compare the two*. The number of lawsuits that have been filed is finite and observable.
From Nik:
Well then I guess I missed your point, too.
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