Monday, April 17, 2006

Home

The baby was full-term but he needed a ventilator to breathe. He had been deprived of oxygen during the birth process and suffered perinatal asphxia. He suffered it bad. His kidneys didn't work, his heart wasn't so good either, he had seizures until he became comatose, and eventually his brain got so bad that there were barely any brain waves. After discussing it with his parents, we removed the baby from the ventilator and he died.

This baby was the result of an attempted home delivery. An uncertified midwife kept the mother at home far too long, having mother push and push, trying to keep her from having to go to a hospital with it's too technical and "unnatural" approach to birth, where, heaven forbid, they might actually try to monitor the baby's condition during labor and intervene if it were necessary. By the time she did finally go to a hospital and deliver, the baby was a goner. He was a fine baby. If it hadn't been a screwed up delivery, he'd probably be playing ball with his dad now.

I knew that sooner or later I would write about home deliveries. I do it now because a commenter on a recent post of mine (CDMR) said that after she had a caesarean section she had her next two deliveries at home. In a nutshell, I hate home deliveries.

I think that most people who have a home delivery do it because they want a better "childbirth experience". I ask such people, why are you having a baby? What is the purpose of this pregnancy? If it's to have a good experience, skip the pregnancy and go out for dinner and a movie instead. But if it's to have a helathy child, go to a hospital and take advantage of the modern world. It wasn't that long ago that many women and babies died in childbirth. A lot can go wrong. Ten per cent of babies need some type of resuscitation at birth. A good childbirth experience won't make up for the loss of a child. (By the way, this is not a rant against midwives. I have nothing against them, as long as they are certified and deliver babies in the hospital.)

The baby I write about here is not, unfortunately, the only baby I have seen die because of a home delivery. Pregnant and in labor? Go to a hospital.

228 Comments:

Anonymous Anonymous said...

Amen!

There are a lot of woes in the world that western medicine cannot cure and there are still no guarrentees that you will have a perfect baby by going to hospital. However, the odds of having an adverse event at home (particularly with your first child) are so much higher than they are in a hospital in which antibiotics and c-section are at least available, with a competent health care provider present at delivery (note I did not say it had to be a doctor in attendance) as to be a no brainer. And that's what happen's when a home delivery goes bad - the baby becomes a "no brainer" in those precious 10 extra minutes it takes to get it out because it has no access to oxygen.

I can't even pretend to be objective about this. Some things are just too costly in human potential. This is not like teenage pregnancy (where life choices are made that subtly alter life potential but do not completely abrogate all chance of life quality). Home deliveries seem fine when every thing turns out alright (which is 90% of the time). They are a parent's worst nightmare and the scourge of neonatology the rest of the time. "No Mam, I'm sorry, I don't think your child will ever walk, or talk, or be able to sit up if we keep up the life support. Yes Mam, I'm pretty sure that I know how the damage occurred..." I hate that talk! Parents are never the same afterwards. Never! It ruins their lives, it ruins the lives of existing siblings because of the guilt (because they survived and their little sister didn't). It is absolute hell and those families can't go back and change their minds once its too late. And I'm not talking about the ones that survive... I'm sure you can imagine what a life time of giving care to a child in persistent vegative state will do to your family dynamic.

Don't do it! Its probably the most important advice I can give to prospective parents. I know hospital aren't perfect. I know its not natural. I know... but in this one case we're talking about the single most dangerous event of life (giving birth). Don't do it!

Well, you did it NeoDoc. You finally managed to push one of my buttons. This was the one with the warhead underneath. Thanks for performing an important public service. I'm going to go take my blood pressure medicine now.

Cherubsinthelandoflucifer.com

10:49 AM  
Anonymous Anonymous said...

I attempted to have an out of hospital (birthing center) birth with my baby, and we ended up having an emergency C-section (prolapsed cord). The _second_ for my midwife in her 20+ years of delivering babies out of the hospital. But one of the main reasons we chose her was that she was professional and knew when she couldn't continue with the plan. She monitored regurally with a doppler, and when baby's heart tones dropped, she said we were going to the hospital.

You may have your view on home births because the only babies you see are ones that have problems- I'm sure there are many more that come into this world just fine, with the aid of an experienced midwife (or not, as some women prefer).

It is my belief that if a woman is low-risk, she should have the opportunity to give birth to her child in the way that she feels most comfortable. Interestingly, I know two nurses (one a NICU nurse) who both gave birth at home with a midwife.

Personally, my next child will be born in a hospital, though I would like to try VBAC, I will feel more comfortable being where help is immediately available. I will use a midwife still, though, because I prefer their philosiphy of care (sorry about the spelling).

-JS

11:38 AM  
Blogger Amie said...

I respectfully disagree about homebirth. This is a tragic situation to be sure, but definately the exception not the rule.

I also think you are downplaying the importance of the birth experience to a woman.

Doctors against homebirths...almost as surprising as teachers against homeschooling.

1:22 PM  
Anonymous Anonymous said...

Boy, I would hate for my baby to be the 10% exception to the rule. Actually, I think 10% accounts for more than an exception.

After assisting at many deliveries that the baby required at least a little oxygen (>30), there is no question in my mind what is safe and what is not.

In addition, a little help at birth can avoid a longer stay in the NICU or even well baby nursery...isn't it "unnatural" for the baby to have to be in the hospital after birth?

And pediatricians aren't against home births because it takes away our business...in all reality and unfortunately, we have more patients to take care of in the NICU because of home births.

2:09 PM  
Anonymous Anonymous said...

The Doc said that complications were an exception and not the rule. Delivering at home is like throwing caution to the wind, and I believe it is one of the most selfish acts that a mother can commit. I personally would not be able to live with myself if my healthy baby died or was brain damaged because of a home birth complication that could have been quickly remedied or prevented in the hospital -- all in the name of a "good birth experience". I would gladly trade the absolute worst birth experience in the world (which would at most be 48rhs of my entire life) to be able to take home and raise a happy, healthy baby.

I also know two neonatal nurses who delivered at home, but it was only because their labor went so quickly, that they didn't make it to the hospital. I have never spoken to a neonatal nurse (or any nurse for that matter) who thought a home birth was a good idea. Not knocking certified nurse midwives who deliver in the hospital--I think they are a good alternative for women who want a natural birth with minimal interventions.

2:20 PM  
Blogger Amie said...

Where is data to back up 10% of homebirths will end badly?

3:26 PM  
Blogger Dream Mom said...

There may be no guarantees when you go to a hospital but gosh, your odds are a lot better. This whole conversation reminds me about life insurance-you don't pay for life insurance for the times when you beat the odds, you pay for life insurance for the times you don't. Ditto for health insurance, car insurance, homeowner's insurance and the like. Having a baby at a hospital is like having some insurance-you have a back up plan in case you get into trouble.

To me, it's just plain crazy to think of having a home birth when you know what can go wrong. If it's a better birthing experience that women would like, then I can think of nothing better than taking home a normal heathly baby without any disabilitites. If women want to take the risks, then they may have to plan for the worst case scenario-a lifetime of disabilities or planning a funeral. Somehow, the hospital birthing experience has got to rate higher than either of those.

As for those arguing over what percentage, let me just say this. It doesn't matter if the statistics show it's 10% or 5% or 1%; when it's your baby, it's one too many.

3:49 PM  
Anonymous Anonymous said...

Amie,

"ending badly" is subjective, I'll grant you that they don't all end up dead or vegtables. 12.1% end up being transported to the hospital with 3.4% being transported emergently (read lights and sirens because the baby is in distress). This is the biggest study to date: Outcomes of planned home births with certified professional midwives: large prospective study in North America.BMJ. 2005 Jun 18;330(7505):1416. and I would stress two things: 1) the authors have clear bias in that they're measuring what they want to measure (maternal deaths and of course there weren't any because our EMS system is quite good), 2)the study doesn't measure what really counts - neurodevelopment of the infants at 18-24 months of age. In fact, they don't actually measure infant morbidity in their study at all, instead they do a meta-analysis of previous studies comparing in hospital births (where some of the studies are 35 years old) to more recently performed group of at home studies. It was a stupid comparison and its one of the reasons why the study makes me angry. There was no significant difference but if you knock out the studies before 1990 (16 years ago) there would have been and it would have been in strong favor of hospital birth. This study should not be taken as anything other than propaganda for home births, but the data on the percent of women who end up at the hospital anyway should give mothers cause for pause, since these are the professionals who are advocating for home deliveries.

This is the best study looking at home birth and infant death: Outcomes of planned home births in Washington State: 1989-1996.Obstet Gynecol. 2002 Aug;100(2):253-9. Basically your term baby is twice as likely to die if you deliver it at home if you live in Washington State (and they have a very progressive mid-wife community).

Neither of these studies addresses what happens to surviving infants with regard to IQ. I consider any adverse affect on neurologic outcome as a birth experience that ended badly.

Cherubsinthelandoflucifer.com

4:29 PM  
Blogger clara said...

Neonatal Doc, I only ask that you try and be gentle with these parents, many homebirthers don`t do it for a "good birth experience" for the mom. The safety of out of hospital birth has been shown repeatedly to be on par with hospital birth, chances of getting an infection are lower and the same is true of episiotomies.

My husband and I chose homebirth for the baby`s sake, believe it or not. We knew he would not be separated from us, would breastfeed easier and would have a gentler start at home. Its not easy being at home and completely drug free, but that `s also in the best interest of the baby. If performing a section on myself without drugs would guarantee the best outcome, I would do that too, it was never about me.

With my first homebirth, we transferred after 60 hrs of labor, baby boy was born vaginally in hospital with help of a little extra pitocin.

My second son died from lack of oxygen, we had transferred and nobody in the hospital could deliver him from severe shoulder dystocia. Because we had started out at home, we were treated horribly by neonatalogy & it added to the worst possible experience to feel accused of causing our son`s death. Our mw did everything right & we transferred with enough time, (2 minutes from the hospital), yet he still wasn`t delivered in time. Shoulder dystocia is still completely unpredictable, especially since I had none of the known risk factors.
Also, many practitioners tend to panic, ours didn`t and still nothing worked in time.

My next son was an elective section and I`m due to have another one in August, I am OK with the fact that birth doesn`t work for me, the baby is all that matters.

Horrible things happen in obstetrics, we don`t blame anyone, including ourselves for our worst nightmare. The OB that finally got him out told me right away that had we been in the hospital the entire time, it would have been the same outcome. I can see your point about homebirth, neonatal doc, but each case is different and most parents really are thinking about their baby first, at least we were. It was only after seeing us holding and caring for our baby all day and much of the night (as we did for 7 weeks) that the staff apologized to us.

My husband and I attended a support group where out of 20 + couples, we were the only ones not to have been in a hospital the whole time. If you went to that meeting, hospital birth would have sounded like the scariest way to give birth because so many of the deaths were preventable and some were glaring medical errors.

This is very tough for me to discuss and I am sure I`ve gone on too long, but thanks for writing about this and please be kind to these families, even if they made a terrible mistake in choice of midwife or being at home, there are no guarantees and when their child is dying, they can`t feel any worse.

4:51 PM  
Blogger Fat Doctor said...

Some people tell me that having a baby at home is reasonable because that's the way it was done for generations before modern medicine. In response, I point out that we used to remove appendices on the dining room table using shots of whiskey for anesthesia.

5:06 PM  
Anonymous DawnCNM said...

Neonataldoc--I love your blog and usually agree with you, but here we must agree to disagree.
I have seen babies die in the hospital, and have known about ones that died at home. In some cases, the baby may or may not have died BUT....what is the difference between my home, 5 minutes from a level 3 hospital, where I can get a stat c/section in less than 10 minutes, and delivering at the tiny, level 1 facility I worked at in Virginia--no OR staff at night and only 2 L&D nurses so only 1 was available for the OR--if we started a c-section in 30 minutes, which is how long it took to get a scrub nurse in, that was good Usually it was longer than that by the time you got the OB in, the scrub nurse, the pediatrician, woke the anesthesiologist.....No, we didn't have any of those people in house.

What is the benefit of having a woman lie in bed on a monitor for hours instead of being up walking around, having gravity assist in her labor? No other athlete is expected to run marathons while fasting, but we always expect pregnant women to do so (I always equate labor with running a marathon...but think labor takes much more energy).

Yes, hospitals have their place . I had pre-eclampsia with both of my pregnancies, severely the second time around, and needed a hospital for my health and safetly. I worked in birth centers, both freestanding and attached to a hospital. I think those are the best of both worlds. I wouldn't personally have a home birth, but won't condemn those who do PROVIDED that they utilize a competent health care provider who knows when to say "we need to go to the hospital". As a CNM, I regret being lumped with those who have no education but learned to "birth babies" from other uneducated people.

Anon--I have to disagree with you about the odds of having an adverse event at home. I saw more adverse events in the hospital then either at home (no, I didn't do home births, except during my midwifery training) or in the birth center (and not including the high risk mothers--only comparing low risk to low risk). Yes, a level 3 hospital may have saved those babies...so now will we only allow births in those facilities?

I am not objective. Childbirth can go bad at any time. My first maternal/fetal death I saw occurred in a tertiary care center when the woman went into laryngospasm when they tried to intubate her for a nonemergent failure to progress c/section. Would she have lived if she'd been allowed to labor longer? Probably. Would the baby have lived? Who knows? The baby was in no distress but the mother had been ruptured for 12 hours without labor, no fever, no elevated WBC's BUT the OB was going out of town....

Please don't condemn home births for everyone. Providers with attitudes like this are the reason we have to fight with our clients to go to the hospital when the need is there. Our clients usually know that this is the attitude they will be facing and they delay going to the hospital to avoid it.

I apologize for getting on my soap box. I'll get off now.

7:40 PM  
Blogger clara said...

"Our clients usually know that this is the attitude they will be facing and they delay going to the hospital to avoid it." Dawncnm

This is an excellent point, it didn`t matter to me, I learned to put the ignorant comments out of my mind, but it can be a very harsh atmosphere for a homebirther in the hospital.

8:23 PM  
Blogger Jamie said...

The August 2002 study praised above as the best available is problematic for several reasons. Thirty-four-weekers aren't good homebirth candidates, for one thing. More importantly, whenever a study contradicts a substantial existing body of research, we need to ask why.

Homebirth safety has been extensively studied. For low-risk women at full term, planned attended homebirth (assuming a nearby hospital and maternal willingness to transfer if deemed necessary) is no riskier than hospital birth. It's a counterintuitive conclusion in this technophilic culture, but that doesn't make it false.

I am an allied health professional; I worked happily in a hospital before I became a full-time mother. I am not naive about the risks of childbirth, having had a baby with an initial APGAR of one. He was my first son, born in a hospital with every intervention short of a C-section. My second son was born in a hospital with very little intervention - it was lovely. But my third and fourth sons were born at home, one with a family practitioner attending and one with a certified nurse-midwife, and it was a completely different realm of experience. It was astounding.

If you've never been involved in a homebirth, I don't think you can appreciate how different it is. We are telling women in this country that they are foolish and selfish for considering homebirth instead of going to hospitals rife with MRSA, short on nursing staff, and quick to intervene even when the recommended interventions are associated with high rates of iatrogenic complications. But the data just don't support the conclusion that planned attended homebirth is unsafe. If your own preference is to be in a hospital, go for it. Across-the-board opposition to homebirth isn't evidence-based, though.

If you disagree with the Cochrane Review folks, or the many other peer-reviewed studies in support of planned attended homebirth, I'm willing to listen to why. But given a low-risk pregnancy, a vertex baby, and an experienced attendant, I'd choose home over hospital in a heartbeat.

9:31 PM  
Blogger Catherine said...

I agree very much with your opinion. The strong movement for 'natural' birth has developed only now, when birth is no longer considered a life-threatening event. What was the maternal and child death rate of our foremothers with natural childbirths, I wonder?
The newly safe birth process, and the hospital-savings driven normalisation of birth (does it really only rate 2 days of rest in hospital before assuming a 24h job of caring for an infant, often alone?) has created a culture of assuming that it is a natural, therefore safe process. A bit of information to the contrary would be useful, even if it'd frighten some prospective mothers.

However, I'd like your opinion on the relative safety of certified-midwife attended home birth within short distance of a hospital vs one in a hospital. As I remember, my birth was midwife-attended until things started to go wrong, and it took 1h to organise a ceasarian section for fetal distress (which was rather impressive as neither anesthesiologist, paediatrician nor obstetirician were in the hospital at the time). An ambulance trip from home to a bigger hospital 30 min away might have meant the same or shorter lead time to surgery.

11:55 PM  
Anonymous Anonymous said...

In my area, out-of-hospital midwives are licensed professionals and certainly carry oxygen and can and do perform neonatal resusitation when indicated. They also carry pitocin and miso for hemhorrage.
They regularly monitor the fetal heart rate in labor and monitor almost continuously in second stage.
If events leave their defined scope of practice, they transfer to one of many hospitals in this urban area. These midwives operate with conjunction with their physician consults and have pretty good relationships with lots of professionals in the system.
I would have to say that is a far different situation than that described in the original post. That's just bad practice, period, and one I am not familiar with in our area.

1:25 AM  
Blogger Flea said...

At the risk of being tangential, I wonder how many homebirthing midwives have been sued for bad outcomes? I'm guessing few, but the numbers have been small.

Also, feeling lazy and overworked today, can someone pull the refs supporting homebirth safety, so that we can get away from the anectdotes and empirical experiences here?

best,

Flea

5:54 AM  
Blogger clara said...

http://bmj.bmjjournals.com/cgi/content/full/330/7505/1416?ehom

9:59 AM  
Blogger clara said...

A birth center that also does homebirths in the DC area, they keep good records & link to other studies. This group has at least 25 births a month in 2006.

http://www.birthcare.org/safety.html

10:07 AM  
Blogger neon88 said...

It is interesting that the topic just a few days ago was C-sections on demand... I believe that the data suggests that the properly chosen pregnancy in the hands of a skilled and experienced certified MF can be accomplished safely. I would not recommend it to anyone, however. We have midwives that practice at our hospital under the supervision of OB's and I get called STAT to their deliveries to resuscitate depressed babies as often as any deliveries. I have taken care of terribly asphyxiated infants born at home. The American Acadamy of Pediatrics recommends that both the mother and the baby each have someone to care for them. I also have to say that some of our sickest babies come from small hospitals without Neonatologists or 24hr in house anesthesia. So it seems that if you are very selective about who delivers at home it may be better that at some hospitals. After all some of these small hospitals aren't any better able to handle an emergency and they deliver women who a midwife would not. A ruptured uterus in a hospital that can't do a C-section because the anesthesiologist is at home isn't much better than a delivery at home. The first 5 minutes of your babies life may be the most critical and you should want the most skilled person available.
The answer to all of this is to improve how we do things in the hospital. We have mom's that bring in long lists of how they want things done. They bring in doulas. We have to stop rolling our eyes when these kind of people come in. Our DR's can be more like your home but we don't make house calls amymore.
neon88

1:53 PM  
Anonymous Anonymous said...

Isn't it convenient that over the years certified mid wives as a discipline have progressively backed off. At first they thought they could deliver anything down to 34 weeks gestation, then the 2002 study from Washington came out now its only term infants of mothers who are vertex and who have already had at least one successful vaginal delivery that are the best candidates for a home delivery. Well sure! These are the mothers at least risk for complication anywhere, in any setting. Even when you reduce the over all risk by selecting the best patient population, you don't change the fact that home deliveries re-introduce the same elements of danger and uncertainty to birth that we've spent centuries trying to erradicate. If your baby gets stuck or has a cord prolapse during a home birth (no matter how favorable your risk category), you will wish you were in an appropriate hospital. I want to just add that I have no problem with birthing centers that are stationed in close proximity to hospitals. I really think these are an ideal solution to this cultural conflict.

2:48 PM  
Blogger Jamie said...

Cochrane Review is here. You can find some lists of references here and here. Ina May Gaskin reports her stats here.

Certainly, some families who choose homebirth do so in a way that endangers their babies. Some homebirth providers are scary. But in my experience they are a small minority, and it is unjust and unwise to tar us all with the same brush.

I have written at length about this on my own blog: my first homebirth story is here, my second homebirth story is in two parts, and this is a post on why I think the homebirth option is important.

One commenter mentioned the need to assess neurodevelopment of home-born babies -- as a population, they may well fare better than their hospital-born counterparts. Breastfeeding initiation/duration rates among homebirthing women are far higher than those in the general population, and breastfeeding is associated with improved neuromotor development.

I would offer a reference for that assertion, but my one-year-old just used his sophisticated neuromotor skills to snag a bottle of salad dressing from the pantry and empty it down his front. Clean-up time. ;-)

4:44 PM  
Anonymous armchair ethicist said...

A friend of mine had no choice but to homebirth. Her husband lost his job early in pregnancy and they lost their insurance b/c they could not pay COBRA.

That said, I have always opted for hospital birth, all 4 times. 2 babies with moderate shoulder distocia, another prenatally diagnosed with a life-threatening set of defects. Nope, to the hospital I go. Few things are worse than visiting your baby's grave, I'm sure, especially when it was a preventable death.

4:50 PM  
Blogger clara said...

All deaths are preventable at some point. A child killed in a horrific accident, their death would have been preventable too if they hadn`t been in the wrong car at the wrong time.

There was a baby in a hospital in Hawaii who was severely brain damaged because neonatal put him under CO2 instead of oxygen. That is the most preventable type of injury. Something that could have been handled equally in the hospital or at home falls into a different category.

5:00 PM  
Blogger neonataldoc said...

Wow. So many excellent comments, so little time. Thank you all.
The Cochrane review of this subject basically says that there is not enough evidence to make a recommendation as to which is better, home versus hospital delivery, so perhaps we should study it rather than argue about it.

In our area there is a hospital with a birthing center that accommodates people who want a better birthing experience and facilitates things like breast feeding and early discharge to home. It is physically connected to a hospital with an NICU and in-hospital OB's and anesthesiologists, so if a mother or baby has a problem it's just a short trip down a tunnel or hallway to an area with comprehensive help. Until we have better data to support home versus hospital delivery or vice versa, maybe a birth center like that is the best solution.

5:19 PM  
Blogger Clark Bartram said...

Neonatal Doc,

This would be a great submission for the pediatric blog carnival I'm tryinig to put together. Mind if I include it?

7:44 PM  
Anonymous Anonymous said...

I am the commenter you slammed. I am the reckless woman who dared to give birth at home, for the convenience of "having an experience". I dared to not want to have another major abdominal surgery for convenience sake. Shame on me.
I was surprised that it wasn't my reply on another "medical" blog that sparked your commentaries.
My last birth (six months ago) saw the arrival of my daughter with poor tone, no respiratory effort and 100 bpm... She had absolutely no indication of what was wrong until she was out. Her heart beat was monitored during the pushing stage, which was all of seven minutes.
She was resussed. She was pink and crying and fine within the four minutes it took the emt's to arrive. Here is the frightening fact!
THE MEDICALLY TRAINED PERSONNEL DID NOT:
have an infant mask,
proper cords to attach the extra one my midwives had
training in infant intebation
NOT ONE OF THEM WAS TRAINED IN INTEBATION!
The second midwife handed ALL the equipment needed to one of the six emts (yes six) and marched out to the ambulance with my daughter.
Two hours later a Neo Natal Neurologist sent her home. Where she belonged with her family. If you would like a copy of the letter she sent me just recently thanking me for giving her a good start to life let me know!
My daughter grew with a cord around her neck. It was flat. FLAT around her neck curly from belly and to placenta. She could have died at any point.
We were lucky she came out quickly, because I was unmedicated, not flat on my back and I was in control of my body. IF I'd been in a hospital all of those things could have hampered her decent. And caused her death. So where exactly does the doctor who insists on their patients delivering on their backs with an epidural take responsibility here?
I guess I'm just stupid for not wanting to have another scar. I guess I'm stupid for not going to the hospital where all those interventions could have killed her huh? Midwives in Canada (except Alberta, and it is getting better there too) have full hospital rights. I chose to give birth at home.
Think I'll just curl up and die now... give the Darwin Awards another candidate?
K

8:27 PM  
Blogger Jamie said...

Oops -- there's more info at this Cochrane link.

8:50 PM  
Blogger Amy Tuteur, MD said...

Women did everyone a favor when they challenged the traditional methods of hospital delivery. When they insisted on fathers at delivery, no shave, no enema, etc., doctors initially refused. After a while, though, they began to ask themselves why they were refusing. There was no scientific evidence for traditional practice and it was dropped.

Of course in any movement, there are always radicals and the natural childbirth movement is no exception. Personally, I think that if you want to have your baby at home and risk having its death or brain damage on your conscience, that should be up to you, since you will have to live with the consequences. Unfortunately, most women who opt to deliver at home do not understand the risks and above all, do not believe it could even happen to them.

Childbirth is inherently risky. In fact, women are at greater risk during pregnancy and delivery than at any other time in their lives except old age. We can minimize the risk, but we cannot remove it. Then the question becomes: who will bear the risk, the mother or the baby?

When a mother opts to have a C-section in a questionable case of fetal distress, she is saying in essence: put the risk on me, not on my baby. In fact, when a mother chooses to deliver in a hospital, she is accepting an increased risk that she may have a medical intervention, necessary or unnecessary, performed on her. When a woman chooses to deliver at home, she is saying in essence that the baby should bear the additional risk. She'd rather protect herself from interventions, and let the baby carry the risk of death or brain damage.

There is precisely zero evidence that home birth is in any way good for babies. It may not carry a large increased risk, but it does carry an increased risk. There are absolutely no evidence that homebirth improves breast feeding, bonding or anything else you might think of.

So the bottom line is this: do you want to risk your baby's life and health for the sake of your experience? If you think it isn't a risk, just read the posts above. At least one baby actually died among just the 27 women who posted here. That's a pretty high death rate. Death at home birth can and does happen. No woman should ever think it can't happen to her.

9:54 PM  
Anonymous Anonymous said...

Wow, much discussion here. I agree that home birth is a somewhat selfish act.
But hey, I'm just the one that will be taking care of your child in the NICU.
I'm the one seeing your child in clinic, fighting with insurance to get community services for your child that can't walk or talk, or even communicate, with their only daily action being the frequent seizure.
I'm the one admitting him to the hospital every three months for aspiration pneumonia or UTI.

I love your child, too, and I don't understand why you wouldn't do everything possible to protect him from birth. After all, even though my job is to protect your child, so is yours.

11:28 PM  
Blogger Flea said...

Fascinating discussion.

Amy Tutuer has it about right. I couldn't have said it better.

best,

Flea

5:21 AM  
Blogger Amie said...

Perhaps its selfish of moms to attempt vaginal deliveries at all. Maybe we should just all have c-sections every single time, because that carries the least risk to the infant and if we love our babies we would want the smallest risk possible for them, isn't that what your saying?

8:43 AM  
Blogger Jamie said...

Despite your assertions to the contrary, Dr. Amy, Johnson & Daviss did find that homebirth increased a mother's likelihood of breastfeeding. Kroeger and Smith's thoroughly referenced book provides extensive information on the deleterious effects of medicalized birth on breastfeeding. Can you offer some references to back up your point of view?

There are certainly benefits of planned, attended homebirth to babies. Off the top of my head-- risk of nosocomial infection is, by definition, zero. Risk of depressed respiratory function secondary to intrauterine opiate
exposure: zero.* Risk of sabotage to early breastfeeding relationship by overloaded hospital staff: zero. Continuity of care and patient/caregiver ratio are typically excellent.

(*Of course some home-born babies have impaired respiratory function. I'm talking here about iatrogenic problems arising from labor analgesia.)

I've been certified as a breastfeeding counselor since 1998, and I've been an
IBCLC since 2004. I have assisted hundreds of breastfeeding mothers. I can tell you that some home-born babies have latch problems, and an epidural doesn't automatically spell trouble for breastfeeding. But if you're a betting woman trying to guess which breastfeeding relationship will proceed more smoothly, put your money on the undrugged baby.

I am puzzled by the inconsistencies in your post, Dr. Amy. You're saying it was good for women to object to unnecessary obstetric interventions 40 years ago, but these days women should submit to unnecessary (and sometimes harmful) obstetric interventions for the sake of their babies? A woman who consents to a questionable C-section is taking a risk that somehow ennobles her? Would her baby be ennobled by proxy if he developed TTN as a result?

I disagree. I disagree, furthermore, with your contention that homebirth increases risk to babies. I'd be happy to read your references, though as I mentioned above I think there are methodological problems with that August
2002 study.

No one here is disputing that homebirths and homebirth transfers sometimes end with sick or dead babies. What some participants in this discussion seem reluctant to acknowledge is that approximately as many intrapartum complications arise in hospitals as are resolved in hospitals. As improbable as it may seem, hospital birth doesn't improve outcomes for low-risk women or their full-term babies.

If you disagree, please do so with references at hand.

9:20 AM  
Blogger That Girl said...

I agree with Amy Tueter also. As Ive said before, so many stories from the people in my support group start "I had the baby at home..." and the homebirth of these undiagnosed babies led to death or additional organ failure (CHD is the most common birth problem and less than 50% diagnosed in-utero).

Fact is, most people dont think bad things will happen to them until they happen. Regret will not bring your baby back, or help them recover from a stroke.

On the flip side, having spent many, many hours in the hospital with my child I know that one of the worst things in the world is constantly having nurses judging your parenting and making calls that are more about style than function, and having to get permission to do things with your own child from a stranger.

Surely there has to be middle ground.

9:39 AM  
Anonymous Anonymous said...

I have to respond to "K" the anonymous poster...

I would think that your birth experience would tell you something. What if your daughter hadn't come around? I'm assuming the midwife did the resusscitation...what if you were bleeding out from your placenta? Who would she choose to help? I'm not suprised the EMTs didn't have the correct equipment...in any hospital it would have been within feet of your daughter and a trained nurse (or pediatrician) would be there too! Scary situation to be in, one that I wouldn't think you'd want to be in again.

As far as breastfeeding & homebirth...I would be astounded if there wasn't a higher association. Mothers who choose to deliver at home wouldn't dare use formula would they? Comparing homebirth to hospital birth here is comparing apples to oranges.

A very interesting conversation none the less...I'll be waiting for the one about back-to-sleep & pacifiers for SIDS next!

10:04 AM  
Blogger Amy Tuteur, MD said...

I can offer a list of references as long as my arm, if that's what you'd like, but first I want to address the fundamental misunderstanding that motivates the home birth crowd (please correct me if I am misrepresenting you):

The fundamental error, which renders all subsequent judgments suspect, is that childbirth is inherently safe because it is natural. The fact is that human reproduction is a remarkably wasteful process and that childbirth itself is subject to competing evolutionary pressures that render it inherently dangerous.

For example, every woman is born with millions of ova she will never use and every man produces billions of sperm that will never fertilize an egg. When conception occurs, many newly fertilized eggs fail to divide. Of the ones that divide, many fail to implant in the uterus. Of the ones that implant, many are washed out with the next period (chemical pregnancy). Of the ones that are not washed out (probably less than 50% of the original fertilized eggs) more than one fifth of those will miscarry in the next 3 months. I could go on and on, but I think you get the idea. Fetal death and neonatal death are natural and expected consequences of pregnancy. This is born out by the appallingly high intrapartum death rates before contemporary obstetrics and or in places where contemporary obstetrics is not practiced.

So fetal and neonatal death is fundamental to the process of human birth.

Second, the process of human birth represents a compromise between competing evolutionary pressures. On the one hand, a more neurologically mature newborn is more likely to survive, so there is an advantage for a baby to be born more with a bigger head so it will be neurologically more mature. On the other hand, there is a limit to the size of the woman's pelvis. That's because a larger pelvis renders walking more difficult and if the pelvis is large enough, walking upright is impossible.

Therefore, there is tremendous evolutionary pressure to increase the size of the neonatal head and equally large evolutionary pressure to limit the size of the maternal pelvis. I'm sure you can see where this is going:

There is naturally and inevitably a significant amount of incompatibility between the size of the baby's head and the size of the mother's pelvis. This is built into the system. In other words, a significant amount of maternal and fetal death is built into the system and is unavoidable. This doesn't even begin to take into account all sorts of other complications like breech or pre-eclampsia or premature labor. Those add significantly to the death rate.

You can imagine that starting from the premise that neonatal and maternal deaths are inevitable is going to lead to different conclusions than the erroneous assumption that childbirth is inherently safe.

Of course, you don't have to take my word for it. There have been quite a few neonatal deaths at homebirths that were assumed to be inherently safe.

Now, switching gears entirely to breastfeeding. Correlation does not equal causation. So, while it is true that women who opt for home birth are more likely to breastfeed (whether they deliver at home OR in the hospital), that hardly means that the act of delivering at home makes breastfeeding easier or more likely. I'm sure you know as well as I that breastfeeding is correlated quite closely to other factors such as maternal age, education level and income level. In other words, women who aren't likely to breastfeed are hardly likely to want an unmedicated home birth. So the rate of breastfeeding among women who choose homebirth tells us precisely nothing about the effect of homebirth itself on breastfeeding success.

"Off the top of my head-- risk of nosocomial infection is, by definition, zero."

Well, sure, risk of hospital acquired infection is zero if you are not in hospital. Of course that's a far cry from saying that risk of infection is zero. For example, the risk of neonatal infection rises with the number of hours after rupture of membranes. Therefore, women who rupture at home and are not in labor (and of course will not be induced) are at much greater risk for peripartum infections like group B strep.

"You're saying it was good for women to object to unnecessary obstetric interventions 40 years ago, but these days women should submit to unnecessary (and sometimes harmful) obstetric interventions for the sake of their babies?"

No, I am saying that it was good for women to object to interventions that did not improve outcomes, but it is bad to object to interventions that are known to improve outcomes simply for the sake of your experience.

"A woman who consents to a questionable C-section is taking a risk that somehow ennobles her?"

Yes, I do believe that.

"No one here is disputing that homebirths and homebirth transfers sometimes end with sick or dead babies. What some participants in this discussion seem reluctant to acknowledge is that approximately as many intrapartum complications arise in hospitals as are resolved in hospitals. As improbable as it may seem, hospital birth doesn't improve outcomes for low-risk women or their full-term babies."

Here's the problem. According to the tenets of the home birth movement, there shouldn't be any sick or dead babies, right? Even in carefully screened populations of women who have no risk factors for any problems, some babies will die. That's the bottom line. Now if you are willing to accept that your baby might die during a homebirth, go right ahead and have your baby at home. I'm not saying that your baby couldn't die in the hospital, but at least then you can blame the doctor (who should have been able to avoid the death). If it happens at home, you can only blame yourself.

10:07 AM  
Blogger Ex Utero said...

I fail to see why everyone calls them "methodologic problems" with the Washington State manuscript. I trained in Washington State and I saw some of those infants. The fact is a large of segent of midwives out there used to think they could deliver any baby down to 34 weeks gestation. That study changed that clearly erroneous assertion. There was nothing methodically flawed about that study. Obviously, a lot of 34 weekers were being delivered by midwives at home and twice as many of them died when compared to hospitals. But the study also stratified the patients and examined infants greater than 37 weeks and they were also twice as likely to die in home deliveries as compared to hospital deliveries.

I know certain people don't want to believe this study and there are so many studies put out in predominantly non-American journals that seem to counter it, but it just happens to be the only major study not done by midwife advocates. It is not a study that informed parents should be told to ignore - I don't care if you're a CNMW, a laction consultant, or a ludite. It's not ethical. People should be allowed to make up their own minds based on the quality of good data. Not swayed by meta-analyses where the studies are mismatched by decades and the sirens call of hospital avoidance. What has happened is that the home delivery movement has changed its stance in response to that paper and they now don't deliver infants below 36 weeks at home, and they subtly discount the study as being not applicable to the way home delivery is practiced. That's also not ethical. That paper has saved countless live (at the very least in the 34 to 36 week gestation category) and those author's deserve our respect and admiration, not dismissal because its facts are inconvenient. Dismissing it is not logical, its cultural politics. The study is still relevant.

Also, the cochrane analysis is only as good as the person who chooses to do it. One of the often unrecognized biases with the cochrane system is that analyses are done by volunteers (and thus they bring a bais to the table by the nature of the questions they choose to formulate and the way in which they frame their analyses).

10:09 AM  
Blogger Flea said...

Amy and others,

Regarding newborn head size:

There are epigenetic factors to consider as well.

Prenatal care and maternal nutrition (for good or ill) has led to newborns with larger head sizes on average.

In general I believe that fetal/maternal deaths due to cephalo-pelvic disproportion would be higher today than in the pre-Caesarean era because of this factor.

best,

Flea

10:23 AM  
Blogger Jamie said...

You are indeed misrepresenting me, Dr. Amy, along with many of the homebirth families and providers of my acquaintance. The doctor and nurse-midwife who attended my two homebirths looked honestly at the maternal and infant death rates associated with home vs. hospital birth. I would never work with a practitioner who believed that "natural" meant "safe."

It is inconsistent for you to say simultaneously that infant death is part of birth and that the doctor attending a hospital birth "should have been able to avoid the death." Some babies die. If you can point me to sound research demonstrating that more of them die as a result of planned, attended homebirth, please do. I'm always willing to learn more, and if the data were to demonstrate that homebirth is unsafe it would affect my choices in future pregnancies.

It's true that more homebirthing women plan to initiate breastfeeding. It's also true that iatrogenic breastfeeding complications are much more common following hospital birth. Johnson & Daviss don't propose a causal link, but Kroeger and Smith do. Their work is well worth reading.

You are welcome to your opinion on the wisdom of hospital birth and the interventions recommended in mainstream American obstetrics. But I object to your mischaracterization of "the home birth crowd" as a monolithic and naive group.

11:20 AM  
Blogger Amy Tuteur, MD said...

"It is inconsistent for you to say simultaneously that infant death is part of birth and that the doctor attending a hospital birth "should have been able to avoid the death.""

I should have phrased it with more care. Infant death is part of "natural" childbirth. Preventing such "natural" deaths is what obstetrics is all about. Deaths at home births are almost always avoidable.

As I said above, the decision about home birth should be left to the individual woman; she is the one who will be most affected by the consequences (with the exception of the baby, of course). It is important to recognize, though, that there is not a scintilla of scientific evidence that home birth is in any way beneficial to a baby.

Forgive me if I sound harsh, because I am not trying to be harsh. It's just the reality that home birth is always about the mother, her needs, her beliefs, her desires. It involves putting her baby at risk, to avoid risk to herself.

11:58 AM  
Anonymous Anonymous said...

Just curious about how you explain hospital deaths due to unecessary interventions. I find it a shame that you seem to think babies will only die at home. Also, babies born in hospitals also are born with neurolgical conditions due to the delivery.

Babies die. In hospital and at home. It's terrible. It's sad. It's life.

Women, though, often birth at home because of the morbidity rates of hospital births, not mortality rates.

Perhaps if hospital staff stopped being fear mongers and treated birth as a natural, inherently safe occurance and showed respect and compassion to women allowing them to choose how to birth in hospital more of them would go there.

12:29 PM  
Anonymous Anonymous said...

"It is inconsistent for you to say simultaneously that infant death is part of birth and that the doctor attending a hospital birth "should have been able to avoid the death." Some babies die." Jamie

That bears repeating. As someone whose baby could not be saved by doctors, I blame no one. Some situations are unavoidable & doctors & midwives are just human. I really think its ignorance that lumps all homebirthers together as selfish and uninformed.

2:37 PM  
Anonymous J said...

As a non-nurse midwife, I would suggest that my job is carefully watch for many of the signs and symptoms of things that can go wrong. I believe, as many physicians do, that getting pregnant is one of the most dangerous things the average American young woman does. I believe wholeheartedly (and obviously, as I still work in this field) that I can do just as good a job watching for abnormalities as an ob and a hospital. Especially since I have the same labs, same u/s facilities, and same monitoring capabilities. And I always have the benefit of a personal relationship with the woman, which sometimes is important and sometimes doesn't matter.

Re: the Washington State study
Using birth certificate data to determine safety of home birth has some intrinsic flaws. For example, at the time of the study, there was not a clear distinction between types of providers and the intended place of birth. Washington has now changed the data collection to get better information.

11:44 PM  
Anonymous Anonymous said...

Very well presented discussion Dr. Amy. I agree wholeheartedly. Very important point that correlation is not the same as causation.

9:46 PM  
Blogger I am a Milliner's Dream, a woman of many "hats"... said...

Dr Amy said: Childbirth is inherently risky. In fact, women are at greater risk during pregnancy and delivery than at any other time in their lives except old age.

Homebirth or hospital aside, I must say that this statement is really disturbing to me. Birth is normal. Pregnancy is not an illness--but a wellness condition. It is the only thing we go to the hospital for (assuming a hospital birth, of course) which is not an illness or injury.

There are certainly women with medical conditions prior to pregnancy, or complications of pregnancy which put them in a different category, but as a rule pregnancy and birth are NOT a risky proposition.

I spend my LIFE teaching women how to safely negotiate their chosen birth path--and that putting their baby at risk is not an option, how to ask the right questions, know their options (ALL their options) and how to birth the way they want to, if they have a normal, reasonable labor.

In the absence of the exceptional situations though...I cannot agree that birth is risky in the norm.

Hh

11:23 PM  
Anonymous Shamhat said...

The unproven assumption that neurological damage is always caused by mistakes by the birth care provider during labor is the cause of the high malpractice premiums that doctors are always bitching about. I wonder, if this mother had presented herself to the hospital earlier--note that this was indeed a hospital birth--would you be reassuring her that it was just Mother Nature's cruel trick, and not the OB's fault?

8:41 AM  
Blogger mermaidgrrrl said...

My partner and I both work at a major city hospital in peri-operative services. She worked for 10 years at the operating suites for the Womens Hospital section in the operating theatres, witnessing many hundreds of C-section deliveries. It is for this reason that we would always choose a birth centre or home birth over the hospitals labour ward. She has seen babies with "unplanned laparotomies" by surgeons who are reckless with the scalpel. Babies with cuts on their faces, arms and backs. Doctors who treat suturing the many layers of the womans body after the section as if it were a race. When the labour ward is very busy and more women are coming in through emergency to deliver EVERY labouring woman has her syntocinin turned up to speed the delivery for the convenience of the staff and lack of space. This often leads of course to higher rates of foetal distress and C-section and forceps delivery. This is not some dodgy 2 bit hospital in the burbs. This is maybe the biggest hospital in the southern hemisphere. A friend of mine who had her baby the other day was given a ridiculously high dose combined spinal/epi and was then berated by staff for not being able to push when she had zero sensation or movement from the chest down. If a woman isn't familiar with hospitals and anaesthetics then she doesn't know what sort of epidural to ask for. Don't think that all women who choose home birth or birth centre births are naifs in the woods. I know many, many registered nurses and midwives who work in critical care services who have chosen a birth centre or home birth to avoid the very terrible things they have seen in their line of work.

10:03 AM  
Blogger Amy Tuteur, MD said...

"There are certainly women with medical conditions prior to pregnancy, or complications of pregnancy which put them in a different category, but as a rule pregnancy and birth are NOT a risky proposition."

Well, this is exactly my point. Women have a tremendous risk of death and serious disability because of pregnancy and delivery. If you are teaching woman anything different, then you are not telling them the truth.

According the US government, in 2003, the risk of death from pregnancy was 12.1/100,000 live births. By the way, this represents a 99% decrease in mortality since 1900, in case you are wondering about the success of modern obstetrics.

In 2002, pregnancy was the 8th leading cause of death among women 15-19, the 8th leading cause of death among women 20-24, and the 10th leading cause of death among women 25-34.

Death, maternal and fetal, is natural. It has been a leading cause of death through history, and it remains a leading cause of death today, even in the US. The central tenet of the home birth movement, that pregnancy and childbirth are inherently safe, is completely untrue.

11:25 AM  
Anonymous Jane said...

I disagree with your post, and unfortunately not that respectfully. I find it an insult to my intelligence when one assumes I have not done the research and not prepared myself for a homebirth.

One does not make a decision lightly. One weighs the risks, analyzes the benefits, and chooses which risks they feel most comfortable with.

How hard is it for a laboring mother to walk into the hospital and stick out her arm for an IV? A planned homebirth, with proper attendants does not happen by accident. We buy our own supplies, for goodness sake.

And what Jamie said.

11:57 AM  
Blogger Sarah said...

While I'm terribly sorry for all involved in this tragedy, it was not caused by homebirth. It was caused by inadequate monitoring by an uncertified attendant. Similar tragedies have occurred in hospitals.

Amy, I'll look forward to seeing that list of references as long as your arm. The point is _not_ 'Do you want to risk your baby's life and health for the sake of your experience?' The point is: Can you come up with any actual, valid evidence that a full-term, healthy, properly positioned baby is at more risk being born at home than in the hospital? I'd be delighted to listen to any actual evidence, but assertions and anecdotes aren't data.

And, yes, it is a fallacy to assume that anything is safe simply by virtue of being natural. It's just as fallacious to assume that anything is safe simply by virtue of being technological.

4:16 PM  
Blogger Sarah said...

Also - could Neonatal Doc please give me the reference for the statement for ten per cent of babies needing some sort of resucitation at birth? And, for a more useful figure for this debate - what percentage of healthy babies from unmedicated deliveries need more resuscitation than a certified midwife can deliver at home? Thank you.

4:25 PM  
Blogger Amy Tuteur, MD said...

Let's start with some baseline statistics:

Pregnancy is one of the leading causes of death of young women.

The infant mortality rate (intrapartum to 28 days old) in the US is approximately 7/1000, of which 60% are due to prematurity/low birth weight.

The leading causes of neonatal death for term babies are congenital defects, maternal pregnancy complications, respiratory distress and placenta/cord accidents, none of which can be treated at home.

Okay, let's start by looking at two major studies, one done by a hospital group and the other done by Ina May Gaskin's group.

Outcomes of planned home births in Washington State: 1989-1996,Obstet Gynecol. 2002; 100(2):253-9, Pang et al.

We examined birth registry information from Washington State during 1989-1996 on uncomplicated singleton pregnancies of at least 34 weeks' gestation that either were delivered at home by a health professional (N = 5854) or were transferred to medical facilities after attempted delivery at home (N = 279). (Comment: in other words, these were women whose midwives had advised them that homebirth would be safe for them.)These intended home births were compared with births of singletons planned to be born in hospitals (N = 10,593) during the same years. Infants of planned home deliveries were at increased risk of neonatal death (adjusted relative risk [RR] 1.99, 95% confidence interval [CI] 1.06, 3.73), and Apgar score no higher than 3 at 5 minutes (RR 2.31, 95% CI 1.29, 4.16). These same relationships remained when the analysis was restricted to pregnancies of at least 37 weeks' gestation. Among nulliparous women only, these deliveries also were associated with an increased risk of prolonged labor (RR 1.73, 95% CI 1.28, 2.34) and postpartum bleeding (RR 2.76, 95% CI 1.74, 4.36). CONCLUSION: This study suggests that planned home births in Washington State during 1989-1996 had greater infant and maternal risks than did hospital births.

Here's the study done by a homebirth advocate, Ina May Gaskin:

The Safety of Home Birth: The Farm Study
A. Mark Durand, MD, MPH
Am J Public Health, 1992;82:450-452.

Women with preexisting diabetes or hypertension, Rh negative blood with positive antibody screen, weight greater than 135 kg, and hematocrit on intake lower than 28 were considered ineligible for care at the Farm. In addition, before 1985, women with prior cesarean section were also considered ineligible.

The results for this study show that were 17 deaths in 1707 home births for a perinatal death rate of 9.6/1000.

So in a group of low risk (virtually all white) women with term babies the death rate at the time of delivery was significantly greater than the neonatal death rate that includes women of all races, prematurity and pregnancy complications of all kinds. That's a pretty damning indictment of home birth.

We can start with these papers. After you explain this, I can offer more papers.

5:41 PM  
Blogger Sarah said...

Thanks!

Presumably you already know that the Washington State study has been criticised on the grounds of the classification of planned homebirth vs. planned hospital birth, but I'll explain it briefly in case anyone else is still reading this: Although the authors set out to compare planned homebirth to planned hospital birth, they actually had *no way of telling for sure* which were planned homebirths. They went on educated guesswork, and it's quite possible that the 'planned homebirth' group actually included several high-risk unplanned homebirths that raised the death rate and skewed the figures.

The abstract of the American Journal of Public Health study doesn't seem to match what you're saying, but I'll order the full text to read it. It'll take a little while, though, as I don't know when I'll get to the library.

6:39 PM  
Blogger I am a Milliner's Dream, a woman of many "hats"... said...

Dr. Amy--

You're confusing me and I'm not a stupid person, or young and inexperienced.

You quoted my comment:

There are certainly women with medical conditions prior to pregnancy, or complications of pregnancy which put them in a different category, but as a rule pregnancy and birth are NOT a risky proposition.

And then you wrote:

Well, this is exactly my point. Women have a tremendous risk of death and serious disability because of pregnancy and delivery. If you are teaching woman anything different, then you are not telling them the truth.

I'm not clear on how you expect us to send the message that, "Pregnancy is one of the leading causes of death of young women." Lock women up to keep them safe?

You're making my head spin and talking in circles, and I feel as if you think you must condescend to make me understand. I'm not crazy about being called a liar, because I know birth is normal, (so I think I'll swear off this conversation.) :)

Hh

6:53 PM  
Blogger Amy Tuteur, MD said...

I'm sorry I wasn't clear. I was referring to a point I made before you wrote your post.

My point was that the homebirth movement is based on premise that is completely untrue. So when you wrote "but as a rule pregnancy and birth are NOT a risky proposition", you were confirming my assertion that people who promote home birth tell mothers something that is patently false. If you start with a false premise (pregnancy and birth are not risky), you will end up with a false conclusion (that homebirth is as safe as hospital birth).

I hope that makes it clear and I apologize for any confusion.

8:00 PM  
Blogger Sarah said...

I wouldn't personally consider a one in ten thousand risk to be a 'tremendous' risk. I'd also point out that that is not going to be the across-the-board risk for each individual woman, but an average that includes risks that are much higher for some women, and much lower for others.

8:15 PM  
Blogger Amy Tuteur, MD said...

Sarah:

"Although the authors set out to compare planned homebirth to planned hospital birth, they actually had *no way of telling for sure* which were planned homebirths. They went on educated guesswork, and it's quite possible that the 'planned homebirth' group actually included several high-risk unplanned homebirths that raised the death rate and skewed the figures."

I understand the claim and I have heard it before, but I don't see any indication in the actual paper that the planned homebirths were anything other than planned homebirths. If I am missing something, please point it out to me.

"I wouldn't personally consider a one in ten thousand risk to be a 'tremendous' risk. I'd also point out that that is not going to be the across-the-board risk for each individual woman, but an average that includes risks that are much higher for some women, and much lower for others. "

First of all, all the women had the same risk since they were all uncomplicated vaginal deliveries at term from the vertex presentation. Not a single mother had any risk factors or they were automatically excluded from the study.

Personally, I would consider it to be a high risk for an uncomplicated vaginal delivery, but that's not really the point. The point is that it is HIGHER than the neonatal mortality rate for all babies, REGARDLESS of race (which is a risk factor, unfortunately), prematurity, and maternal complications.

According to this paper, at least, the chance of a white woman with an uncomplicated term pregnancy in the vertex position losing her baby at a home birth was HIGHER than the chance of any woman, at any gestational age, with any complication losing her baby in a hospital delivery.

Ina May quotes this study all the time, which is extremely disingenuous at best. The study itself neglects to mention the actual death rate, it just lists the number of deaths so you have to do the calculation in order to establish the death rate and then compare it to the national death rate.

8:37 PM  
Blogger neonataldoc said...

Help...I've created a monster. 56 comments? Sarah, I think the 10% figure for babies needing resuscitation is from the Neonatal Resuscitation textbook, but I'm at home now and the book is at work so I can't cite the specific reference.

9:48 PM  
Blogger Jamie said...

Pang states: “Because Washington State birth certificates do not identify which home births are planned, we defined planned home birth as those singleton newborns of at least 34 weeks gestation who were delivered at home and who had a midwife, nurse or physician listed as either attendant or certifier on the birth certificate.” No one, but no one in this conversation, is advocating unplanned or unattended homebirth. I asked you explicitly for references other than the Pang paper, Dr. Amy.

Deaths resulting from lethal malformations were included for the homebirth group, skewing the results. Surgical births were excluded for the hospital group, further skewing the results. When they're talking about one or two events in a thousand, misclassifying an outcome makes a difference. Here's a critique from Henci Goer.

Sarah, you can find what appears to be the full text of the article on The Farm outcomes here. Dr. Amy does not mention the fact that four of the deaths (see Table 5) resulted from complications of prematurity. Those babies would not have been delivered at The Farm; the table includes information on all deaths without clarifying, as far as I can tell, which deliveries occurred where. Six of the deaths were the result of lethal congenital anomalies; one resulted from suspected child abuse.

The 17/1707 calculation is meaningless for assessing the safety of out-of-hospital birth since we don't know how many of those babies were actually delivered at The Farm. Dr. Amy's spin contradicts the author's conclusions. (BTW the study was not "done by Ina May Gaskin" but by an MD, MPH named A. Mark Durand.)

Durand says: "Based on rates of perinatal death, of low 5-minute Apgar scores, of a composite index of labor complications, and of use of assisted delivery, the results suggest that, under certain circumstances, home births attended by lay midwives can be accomplished as safely as, and with less intervention than, physician-attended hospital deliveries."

Try again. Oh, and if you're looking at results from 1971-1989, is it really statistically appropriate to compare them with current infant mortality stats?

1:01 AM  
Blogger Sarah said...

Amy - Thanks for responding. The 1 in 10 000 figure wasn't from the Durand study but was referring back to another comment of yours in which you gave 12.1 per 100 000 as the national mortality figure for childbirth and described that as 'tremendous risk'. Sorry for the confusion - the reason I put that comment in where I did was because I'd been skimming somewhat due to the length of the comment thread and hadn't spotted that particular statement until Milliner's Dream commented on it.

The Durand study really doesn't seem to say what you're claiming it says. I'll discuss that in more detail later, as I have to go and give the baby breakfast. (Thanks for the link, Jamie - very helpful.)

3:23 AM  
Blogger Ex Utero said...

surgical births should not be tallied against hosptial births because the included both failed home births, extreme high risk births, and pre-scheduled c-sections. That's somebody's bias talking, not logic.

9:03 AM  
Blogger Jamie said...

I wrote that last comment in haste because my computer began the making ominous whining noises that precede a spontaneous shutdown. Let me clarify: if one could do a study in which 10,000 low-risk women planned to have homebirths and 10,000 low-risk women planned to have hospital births, one outcome would be that a significantly larger number of the women planning hospital births would have C-sections. We should look at the complication rates following C-sections in both groups, of course. Without knowing which births were planned for home, we can't do that with the Pang data. The rate of post-operative complications makes a difference in overall outcomes.

9:36 AM  
Blogger Amy Tuteur, MD said...

Jamie:

“Because Washington State birth certificates do not identify which home births are planned, we defined planned home birth as those singleton newborns of at least 34 weeks gestation who were delivered at home and who had a midwife, nurse or physician listed as either attendant or certifier on the birth certificate.”

Yes, that's what it said. It is you who are suggesting that the homebirth group includes women who accidentally gave birth at home. It might; it might not. You have no way to know this. You are just hoping that this is so, so that you don't need to accept the findings.

The Farm Study:

Durland is a friend of Ina May Gaskin's. She invited him to do the study and provided access to the data. She quotes the study all the time (it is prominently featured on her personal website) and she claims that it supports the safety of homebirth with LAY MIDWIVES when it most certainly does not.

"Deaths resulting from lethal malformations were included for the homebirth group, skewing the results."

Jamie, you can't exclude these deaths. They occured in women who were told their risk of having a baby die at home were zero. These are precisely the kind of women that destroy the homebirth argument. A baby with an unanticipated heart defect who dies at home when it could have been saved at a hospital with a vent, medication and emergency surgery is a terrible indictment of the home birth movement.

"Dr. Amy does not mention the fact that four of the deaths (see Table 5) resulted from complications of prematurity."

Again, the same point as above. At the time these women went into labor, their providers thought they were safe to deliver at home. Otherwise they would neven have been part of the study.

"Based on rates of perinatal death, of low 5-minute Apgar scores, of a composite index of labor complications, and of use of assisted delivery, the results suggest that, under certain circumstances, home births attended by lay midwives can be accomplished as safely as, and with less intervention than, physician-attended hospital deliveries."

This statement is absurd. Perhaps home birth is safe under certain circumstances, but THIS study actually shows that the death rate was was 9.6/1000. The author and Ina May Gaskin know this, and as far as I am aware, they have never publically denied this.

"Oh, and if you're looking at results from 1971-1989, is it really statistically appropriate to compare them with current infant mortality stats?"

Nope, I was too lazy to look up the actual stats, but I already know from years of studying this stuff that it doesn't change the conclusion. Clearly, you believe that the cases and controls must be matched in order for the results to be valid. I agree with you. So, then, explain to me why Durand did not do so. He claimed that the Farm's statistics were as good as those of 14,000+ planned hospital deliveries in the surrounding area. Well, it's hardly a resounding success if it compares the death rate at the Farm with the death rate of 14,000+ rural women, a large portion of who are African American, poor, with no access to prenatal care, and includes all possible complications.

If we want to make the appropriate comparison, we'd need a control group of white, relatively wealthy women who stared prenatal care early, who presented at term and attempted a vaginal delivery of a singleton in the vertex presentation. Since, as I said above, prematurity accounts for over 50% of the deaths in the US birth rate, I guess the appropriate comparison rate would be in the range of 4% or so. If you really want me to nail it down, I can do so, but it isn't going to help; almost certainly, it will make the safety record from the Farm look even worse.

9:48 AM  
Blogger Amy Tuteur, MD said...

Okay, now let's address Henci Goer's critique of the Washington paper:

"The study doesn't match populations according to risk factors."

I agree. Had the authors done so, the results from the home birth group would probably have been even worse.

"The study doesn't indicate which of the homebirth babies who died or had complications were actually born in the hospital. Pang and colleagues make much of the fact that 10 of the 20 babies who died had diagnoses of congenital heart disease or respiratory distress. They argue that the outcome in these cases might have been different had the baby been born in the hospital. An additional three babies in the homebirth group had major congenital anomalies, another situation where hospital birth might affect survival. Most of these babies probably were hospital births."

Once again, this is no defense, it is actually an indictment of home birth. Thirteen of the 20 babies who died suffered from UNANTICIPATED congenital anomalies.

"The study doesn't consider whether more babies died of congenital heart problems or other major anomalies in the homebirth population because these conditions were more common in the homebirth population."

Oh, please. That doesn't even deserve the time to comment on it.

"The study doesn't examine case histories of the deaths."

So? What is this even supposed to mean?

Bottom line: Henci Goer's critique is a desperate effort to convince people to ignore the results. She makes 4 arguments and all 4 are wrong.

Jamie, Sarah, et al:

I go back to what I said originally. If you want to have your baby at home, that's your decision. However, when a provider is counselling patients, they are ethically and legally mandated to provide all relevant information, because the patient is entitled to make an informed decision. I have been studying this issue for more than a decade and I can assure you that there is not a single study that demonstrates that home birth is in any way better for a baby than hospital birth, and there is considerable data that home birth is unsafe.

Remember, if you start from the wrong premise (that birth is not risky when, indeed, it is quite risky for both mother and baby), you are going to end up with the wrong recommendations. All women deserve to know the truth and make their decisions based on the truth. I wish it were different, but it is not, death in childbirth is natural and all too common.

10:11 AM  
Anonymous Shamhat said...

Two statements from Amy Tuteur:

"I'm not saying that your baby couldn't die in the hospital, but at least then you can blame the doctor (who should have been able to avoid the death)."

"...you can't exclude these deaths. They occured in women who were told their risk of having a baby die at home were zero."

This is exactly the reason that women choose hospital birth, electronic fetal monitoring (which has never been proven to affect any outcome other than cesarean rate), ainduction of labor at 39-40 weeks, etc--a belief that if they do what the doctor says the baby will be "healthy."

Now, putting aside the bizarre notion that to many people "healthy" means "no chromosomal abnormality," this is not a promise that modern medicine can keep.

Amy, I can guarantee you that no home birth midwife ever told a client that babies never die. And the fact that OB's DO lead their clients to believe that they control life and death and lifetime disability is the cause of the OB malpractice crisis.

10:40 AM  
Blogger Sarah said...

Amy, I'm probably going to regret asking this, and I should probably bite my tongue and be more respectful, but I really want to know: Are you making the critique of the Durand study up as you go along?

After all, first you claim that the Durand study showed a perinatal mortality rate higher than normal - except that your 'normal' figures come from today's statistics rather than perinatal mortality stats at the time, and you omit to mention the fact that Durand actually included a control group and that neonatal mortality rates actually _weren't_ any higher in the homebirth group than in the control group. Then, when Jamie calls you on this, you claim that Durand's control group consisted of rural women from the surrounding area and would have included a high proportion of women with no prenatal care and with complications.

In fact, according to the study, Durand picked his control group from the National Natality Survey and deliberately excluded any woman who wouldn't have been eligible for homebirth at the Farm at that time. So, the two groups were indeed comparable in terms of having healthy normally-progressing pregnancies. They had also had similar amounts of prenatal care (actually, the control group had had slightly more prenatal visits on average, although I don't know whether the difference was statistically significant - an average of 8.9 visits in the homebirth group and 10.3 in the hospital group). There were differences in some other potential confounders, but Durand states that the results were adjusted for these.

Oh, and it's also not true that the study neglected to give the mortality figures as a rate. The mortality rate for the homebirth group is the first figure in Table 5. You can find it fairly easily, if you look. I honestly don't know where you're getting some of the stuff you're saying.

With regard to the critique of the Washington State study, I think you're missing the point. We don't know *whether or not* the 'planned homebirth' group actually included unplanned homebirths, so the appropriate thing to do is to bear this flaw in mind, be very wary of the results of this study, and give more credence to studies in which it is possible to establish the planned place of delivery.

11:04 AM  
Blogger Amy Tuteur, MD said...

"you claim that the Durand study showed a perinatal mortality rate higher than normal - except that your 'normal' figures come from today's statistics rather than perinatal mortality stats at the time"

Here's the data:
Infant, Maternal and Neonatal Mortality Rates in the US, 1971-1998

During the time period of the Farm Study, neonatal mortality rate dropped from 14.2/1000 to 6.7/1000 for an average of 9.1/1000. Neonatal mortality for babies born to white women dropped from 13/1000 to 5.7/1000 for an average of 8.3/1000. Keep in mind that these are neonatality rates, not perinatality rates. The neonatal mortality rate includes any babies who died within 28 days after birth, so the corresponding perinatality rates are lower.

Nonetheless, the rate of perinatal deaths at the Farm exceeded the rate of neonatal deaths for the time period. The comparison is even more detrimental for the Farm when you restrict it to white women.

"Oh, and it's also not true that the study neglected to give the mortality figures as a rate. The mortality rate for the homebirth group is the first figure in Table 5."

It was left out of the conclusion section and it is left out of the abstract. Since it is the single most important piece of data in the entire paper, one can reasonably assume that they were trying to bury it. You can also reasonably assume that the decision to bury means that they understand that the paper shows that home birth is not safe.

Please believe me, these papers show that home birth is not safe. Why would I say otherwise? Obstetricians don't need more business. The problem for us is that we cannot serve everyone of the poor who need us. We could easily rest on our laurels; no one disputes the fact that we have dropped the mortality rate 99% since 1900.

I don't speak only as an obstetrician, either. I speak as a mother of four. My only interest is the health and well being of babies.

11:58 AM  
Blogger Sarah said...

OK. So now you're going with _neonatal_ mortality figures and comparing them to perinatal mortality figures, which is an apples-and-oranges thing. I'm not sure on what basis you're assuming that the neonatal figures would automatically be higher. After all, that would depend on what the in utero death rates in the third trimester are as compared to death rates between days 8 and 28 of life.

But what I really don't see is why you are so insistent on rejecting the control group in the study. You've compared the homebirth mortality rates with mortality rates in a different decade, you've compared them with mortality rates in a different group, and, when pressured to acknowledge the existence of the control group in the study, you've made a number of statements about it that were downright ludicrous in their inaccuracy. You seem to be doing everything to evade the central fact that the mortality rate in the homebirth group was *not statistically significantly different from that of a comparable control group.* And _that_ is the central point of the study.

There really isn't a lot of point just asking someone to believe you. I'll believe you if you can back up what you're saying with data. If you can come up with a _valid_ reason for rejecting the comparability of the control group in the study in favour of a completely different group, I'll listen. If the other studies you say you have proving the dangers of homebirth are any better, I'll listen. But I'm going to need a better reason to believe you than the mere fact that you say I should.

6:21 PM  
Anonymous Kris said...

What if your daughter hadn't come around? I'm assuming the midwife did the resusscitation...what if you were bleeding out from your placenta? Who would she choose to help?

You're assuming the midwife attends the birth alone. I don't know many midwives willing to take the risk of attending two "patients" alone. I take two assistants with me to every birth who are trained in neonatal resuscitation, adult CPR, starting IVs, able to give injections, etc. on my order, this way there is no deciding who gets the help they need.

I carry more experience and equipment for a maternal and neonatal emergency than any EMT because I AM the first responder, they are a fast ride.

6:31 PM  
Blogger Jamie said...

First off, I'd like to retract one of the things I said in my hasty wheezing-computer comment last night: the 17/1707 figure is not meaningless. Neither is it especially useful in isolation.

While I'm talking about retractions, though, I'd like to request one from Dr. Amy. You asked me to correct you if you were wrong about my assumptions. I corrected you, but you are soldiering on with this straw man statement that homebirthing women and homebirth providers think homebirth is automatically safe. We view childbirth as a robust process, but I have never spoken with a homebirth provider who guaranteed a good outcome, or with a homebirthing woman who expected such a guarantee. Even the unassisted birth folks, who strike me as frankly dangerous, acknowledge that death is part of childbirth. Laura Shanley, whose ideas I do not endorse and mention only because she is such a clear example of the "more natural is better" viewpoint, says, "No one, however, regardless of their "expertise," can guarantee that a baby will be born safely. Some babies die. It's simply nature's way." The homebirthing women who are responding to you are saying you're incorrect about our starting point, but you continue to say we're starting there. Please don't.

Now, the data. It is baffling to me that you would call Ina May disingenuous for citing the Durand study while you quote neonatal mortality stats from the wrong decade. A rate of 13/1000 (using the 1971 number for white women, even though The Farm was racially diverse) and a rate of ~7/1000 aren't in the same ballpark.

You may be, for all I know, a stellar doctor. I do not find you a persuasive epidemiologist. The AJPH is a peer-reviewed journal dedicated to the study of public health. Neonatal mortality is a hugely important number in public health -- are you really suggesting that the author tried to bury an important finding, like too many dead babies, and neither the editors nor the peer reviewers picked it up? That's a serious accusation and you don't have enough information about the distribution of the deaths to make it plausibly (i.e., did deaths peak along with The Farm's population, in the late 70s/early 80s? were they related to now-abandoned standards of practice? was there a non-linear change in neonatal death rates during the 80s associated with a technological advance?). Isn't it more probable that your simple averaging of 1971 and 1989 neonatal mortality rates doesn't tell the whole story?

Henci Goer's question about higher rates of anomalies among homebirthing women is not stupid. It was a question also asked in the Cawthon study, which used data from six of the same eight years as the Pang study and came to very different conclusions. Cawthon suggested that homebirthing women may be less likely to abort a non-viable baby than women planning a hospital birth. I can only offer anecdotal support for that conjecture, but I, like many of the homebirthing women of my acquaintace, am a committed Catholic and would not opt for termination or preterm induction of a baby with a fatal anomaly. The death of an anencephalic baby doesn't make homebirth dangerous.

And let's talk, too, about lethal anomalies. It is naive to assume that a baby described as having a lethal anomaly could have been saved in a hospital setting. (Are y'all rearranging unbalanced translocations in your hospital?) For some babies, immediate access to skilled medical care makes a critical difference. In most cases, homebirth midwives can identify the need to transfer in time for the baby to receive that care. And I am still waiting for the data to show that the cases in which that doesn't happen outnumber the cases of iatrogenic problems affecting babies born in hospitals.

8:34 PM  
Blogger Amy Tuteur, MD said...

Sarah:

Here's the bottom line:

The death rate in the Farm group was 9.6/1000.

The death rate in the US for babies born to white women in 1980 (the control group) was 7.4/1,000.

As far as I can tell from Figure 2, the Farm group was exclusively white, while the NFS group was 17.5% non-white.

The Farm group contained 1.1% smokers while the NFS group contained 12.1% smokers.

In the Farm group, 1.5% of the babies were premature. In the NFS group 5.7% of the babies were premature.

In the Farm group, 1.3% of the babies were postdates. In the NFS group 4.7% of the babies were postdates.

In the Farm group, 52% of the women were college educated. In the NFS group, 37.5% of the group was college educated.

So, to begin with, the groups were not comparable. Based on characteristics of the mother (race, education level and smoking) and gestational age (prematurity and postdates, the Farm group had much lower risk patients.

According to the authors of the study:

"Exclusion criteria include no prenatal care, out-of-hospital birth, nonphysician attendant, prepregnancy diabetes or hypertension, anemia (hematocrit lower than 28), weight greater than 135 kg, and Rh negative blood with positive antibody screen."

However, exclusion criteria did not include pre-existing medical conditions, pre-eclampsia and eclampsia, gestational diabetes and other medical conditions that increase risk.

The authors offer us no information on the occurence of these serious pregnancy complications in the two groups. There were undoubtedly significant numbers of each of these pregnancy complications in the NFS group since it is representative of the country as a whole. They do not tell us what the occurence rates were in the Farm group. It's a rather curious omission since these represent some of the most serious complications of pregnancy. I suspect that the authors did not mention it, because removing those women from the control group would have made their statistics look even worse.

Either way, the Farm Group is a much lower risk group than the control group. Right away that is a very serious problem.

Second, according to the authors of the study, the control group is a "sample of physician-attended hospital births derived from the 1980 US National Natality/National Fetal Mortality Survey."

In 1980, the national neonatal mortality rate was 8.5/1000 and the rate for white women was 7.4/1000.

So, although the Farm group was more highly educated, had very few smokers, had fewer premature babies and fewer postdates babies, the death rate was 9.6/1000. The death rate for white babies born in 1980 was 7.4/1000. If you do the division, the death rate in the Farm group was 30% HIGHER than the death rate in the control group (and this is despite the fact that the control group was at much higher risk to begin with).

So, based on that information, how are we to interpret the study?

10:34 PM  
Blogger Amy Tuteur, MD said...

Jamie:

"The AJPH is a peer-reviewed journal dedicated to the study of public health. Neonatal mortality is a hugely important number in public health -- are you really suggesting that the author tried to bury an important finding, like too many dead babies, and neither the editors nor the peer reviewers picked it up?"

I'm not suggesting it; I am stating it. Plenty of published studies are crap. There are a variety of reasons for this. The biggest offenders are pharmaceutical companies who fund drug studies.

I've looked through this paper and cannot find a head to head comparison of death rates from the control group. Perhaps I have an abridged version. If so, please point me to the statement.

"And let's talk, too, about lethal anomalies. It is naive to assume that a baby described as having a lethal anomaly could have been saved in a hospital setting."

I know. That's why it is so suspicious that the authors do not tell us the specific anomalies. They obviously have that information and it would get them off the hook if these anomalies were incompatible with life. Why didn't they tell us then, or why haven't they added the information to their website since it could bolster their claim?

10:45 PM  
Blogger David E. Williams said...

Fascinating discussion here that I'm reading as I prepare this week's Grand Rounds. On a related note, I wrote about my support for the prosecution of unlicensed midwives and the foolhardiness of homebirths at the Health business blog. http://www.mppllc.com/pages/2006/04/prosecution-of-midwives.html

11:02 PM  
Blogger neonataldoc said...

Thanks, David. I read your post. There has to be some middle ground here. Can't we agree that improvements should be made to make hospital deliveries "friendlier" and more palatable, but that home deliveries are just a tad too risky?

3:27 PM  
Blogger Michelle said...

"I am a neonatologist in an urban area of the midwest. The more I practice and study medicine, the less I know."

I agree. Your ingnorance is showing.

The natural birth, health movement is happening. And the one place in medicine where doctors, hospitals and insurance companies make a LOT of money is in Obstetrics.

It doesn't take a rocket scientist to figure out the turf war has begun. Good Luck! Gloves Off!

We already know doctors don’t fight fair. First do no harm left your Hippocratic Oath many years ago.

4:15 PM  
Blogger Sarah said...

Amy: You say that you suspect that the control group had higher rates of complications than the control group. To which I presume the appropriate response would be "It might; it might not. You have no way to know this. You are just hoping that this is so, so that you don't need to accept the findings." ;-)

As for the other differences between the groups, Durand states he adjusted for confounding factors (third paragraph up from the end of the 'Methods' section), and I've already pointed that out to you.

With regard to the whole perinatal vs. neonatal thing, I've just rechecked and realised I also made a mistake - the Farm study is looking at perinatal _plus_ neonatal deaths, if I'm remembering the respective definitions of the two correctly. IOW, the authors are looking at third-trimester in utero deaths _and_ deaths in the first 28 days of life. Which means that the comparison you seem to have been making - to neonatal death rates only - is an inaccurate comparison which will make the Farm group look artificially worse by comparison. I only just noticed this, so please correct me if I have it wrong.

But what's bothering me here even more than the fact that your figures don't seem to stand up is the way you've been making the argument. If you'd simply started out by saying "This study claims to show that home birth for selected women carries no increased risk compared to hospital delivery, but I question their findings and here's why", then I'd still have disagreed with your arguments, but you'd have a whole lot more credibility in my eyes right now. However, instead, you just claimed that this study showed homebirth to carry higher risk. You have then gone on to misrepresent what the study said on more than one occasion.

Whether you were deliberately lying or just plain had it wrong I don't know, though I'm enough of an optimist about human nature to be willing to believe in the latter. But the worrying bit, to me, is the way that you have so consistently and completely misrepresented what this study said. Which, I'm afraid, leaves your credibility in shreds.

5:45 PM  
Blogger Sarah said...

Michelle: 'First, do no harm' has never been in the Oath. That's a widely held myth. It's actually a separate saying, though it may, for all I know, have been Hippocrates who said it.

5:49 PM  
Blogger Jamie said...

Neonatal Doc, thank you for hosting this discussion. Unfortunately, we can't agree that homebirths are too risky until I see some better data.

Dr. Amy, if you have concerns about the statistical weighting in the Durand paper, why don't you shoot Dr. Durand an email and ask him for more information? I'm sure he can tell you more about why the controls had a 33% higher death rate (see Table 4). (Oh, and by the way, I was mistaken about The Farm women being racially diverse -- a reread of the study says they were 98% white.) If you want more information about the deaths of babies at The Farm, I expect Ina May Gaskin would respond graciously to a courteous request. She is far more forthcoming about her morbidity/mortality stats than any practitioner I've known personally.

Instead you accuse them of deliberate dishonesty, using faulty logic to strengthen a wobbly case. Pharmaceutical companies fund studies with skewed results, absolutely. It doesn't follow that MANA is sending epidemiologists on junkets to Aruba to generate misleading positive press on homebirth.

I wouldn't mind your skepticism about The Farm data if you were an equal-opportunity skeptic, but you take the Pang study at face value. Good risk assessment and advance planning are a critical component of safe homebirth. Pang states that the birth certificates she studied don't indicate whether homebirths were planned. You deny that the probable conflation of planned attended homebirths with precipitous unattended homebirths has any effect on the validity of her conclusions. You fail to explain why Cawthon's study of much of the same data led her to conclude that planned homebirth is a safe option for low-risk women. (That's a PDF link, for anybody with a slow connection. Google will give it to you in HTML format if you prefer.) Your dismissal of Henci Goer's critique is unconvincing.

In short, Dr. Amy, this is sounding a lot like, "Pay no attention to the man behind the curtain." The question looming larger for me is this: why are you so invested in these two studies? Why are we debating outcomes from 35 years ago in rural Tennessee? Why aren't we talking about Johnson and Daviss? Why, if hospital birth is clearly advantageous for babies, does the World Health Organization not recommend against homebirth? Why do they say, instead, "It is safe to say that a woman should give birth in a place she feels is safe, and at the most peripheral level at which appropriate care is feasible and safe (FIGO 1992). For a low-risk pregnant woman this can be at home, at a small maternity clinic or birth centre in town or perhaps at the maternity unit of a larger hospital." (from the end of section 2.4 of this WHO publication)

If homebirth were really riskier for babies, it would be evident in The Netherlands, where roughly 30% of women deliver at home (and where, oddly enough, they're leaving us in the dust on neonatal mortality, with a figure of 3.9 neonatal deaths per thousand births in the latest year for which data are available). Is this really a public health failure in The Netherlands, or are we missing something in the US? Where are the data from Great Britain, where homebirth is a small but legal part of the landscape, to show its alleged hazards to babies?

I can understand why a doctor would be more comfortable with hospital birth. For Neonatal Doc in particular, who inherits a disproportionate share of the complications resulting from lousy homebirth choices, that preference makes sense to me. But a subset of American women prefer to birth their babies at home, and a subset of American HCPs are willing to attend those deliveries. Your broad-brush mischaracterization of that diverse population as selfish foolhardy thrillseekers is unjust and inaccurate. You are welcome to your preferences, but until proven otherwise they're preferences, not dogma.

When you denigrate homebirth, you denigrate providers who are committed to evidence-based practice and a high standard of care. You denigrate women like me, who take seriously our responsibility to protect our babies, who pre-register at the hospital (a half-mile away) because we recognize that unexpected transfers happen, who will remember their homebirths forever as transformative, transcendent, miraculous.

I hope I can encourage you to reconsider your views on families interested in homebirth. I hope, too, I can encourage you to look critically at the fuzzy thinking that abounds in mainstream American obstetrics. For instance: if we know that EFM doesn't improve outcomes, why must a low-risk woman get special permission in many hospitals to avoid it? Why are obstetricians reluctant to acknowledge that interventions have risks as well as benefits? (Case in point: Dr. Amy has not admitted once that iatrogenic complications occur, that sectioned babies have more TTN, or that babies whose mothers receive Nubain during labor are at higher risk for respiratory difficulty.) I hope I can encourage you doctors who have spoken here against homebirth to look at problems like those and be just as outspoken in your opposition.

I think that's all I'm going to say here. Thanks for listening.

5:53 PM  
Blogger Amy Tuteur, MD said...

Well, as it happens, I actually have corresponded with Ina May Gaskin. About 10 years ago, I headed a message board for Moms Online (now known as Oxygen) called Ask the OB-GYN. There was an extended discussion of homebirth that took place over several weeks. I heard from Marsden Wagner, and from Ina May Gaskin.

Dr. Wagner wrote almost exclusively about non-American data. Ina May Gaskin wrote to defend the Farm study. If I recall correctly (it has been 10 years after all), she did not deny that the death rate at the Farm was 9.8/1000. She claimed that they had learned from the Durand study and the conclusion was still valid, the conclusion being that under certain circumstances (modified from those of the study to incorporate what they had learned from the study) homebirth would be safe.

At the time (I think this was early 1995, because I remember typing one handed while nursing my youngest child) we talked about the fact that the Farm study was relatively recent. The impression I got was that the Farm would have future data that would firmly establish the safety of homebirth. From the vantage point of 2006. the data in the Farm study is quite old. I have always wondered why they never published any further data. In any other area of medicine, a paper about a study that ended 20 years ago would not be considered relevant. What has happened at the Farm since then?

I notice that on the Farm website, they list more recent statistics, but I could not find any statistics about deaths. Why is that?

It suggests to me they have not been able to show the safety of homebirth. I wonder if the data from the Farm since 1986 actually shows that homebirth is not safe in their hands. I can't imagine that they would deliberately supress good outcomes that would help them make the case for homebirth.

The paucity of data in the field raises my suspicions. There have been very few papers at all, and almost all of them suffer from serious problems. If there is a great deal of evidence that home birth is safe, why aren't we hearing about it from the midwifery community.

The Farm Study and the BMJ study (which he haven't really discussed) both show something important. No matter how low risk a patient is, there is still a significant chance of an unanticipated congenital anomaly or an abruption or a cord accident. When those things happened at homebirths, the babies died. Interestingly, the authors of both studies do not give any details of the neonatal deaths which prevents us from drawing conclusions about whether they might have lived if delivered in a hospital. Again this is surprising, because if the authors could show that the deaths were unavoidable, they would substantially strengthen their arguments. Strange that they chose not to do so.

I agree wholeheartedly with Neonatal Doc that we could do a great deal to improved the maternal experience in a hospital. I actually blog about the deficiencies in the health care system in my own blog, Treat Me With Respect. My personal feeling is that the health care system is broken, and the experience of being a patient can be and often is a nightmare.

None of that changes the fact that a baby who is born in the hospital has a better chance of surviving than a baby who is born at home.

In the vast literature about obstetrics, probably millions of papers in each decade, there have only been 3 significant studies of homebirth safety in the last 12 years. All three of these papers report significant numbers of fetal deaths and all three papers suffer from serious methodological problems rendering them essentially useless.

I know that homebirth advocacy is a matter of faith and nothing I say or do or show ever had any chance of changing the minds of anyone who is already committed to it. However, I suspect that many people who have not yet made up their minds have also been reading, and I hope I have offered some food for thought.

10:01 PM  
Anonymous maribeth, CNM said...

I am a primarily homebirth CNM (also attend births in a birth center and hospital). Let's see... in my 8 years of L&D nursing in various hospitals, I saw: 1) a neonatologist hook the DeLee to O2 instead of suction -- bilateral pneumo, delay in getting the chest tubes in, 02 deprivation, damaged baby. 2) THREE women lose their uteri to docs pulling on cords and causing uterine inversion with subsequent massive hemmorrhage 3) a nurse inadvertantly give a newborn HEMABATE instead of HBIG -- acute hypertension with stroke, weeks on Ecmo, baby died. 4) Hemorrhage -- the nurse drew the stat CBC right above the IV line (duh) doc freaked out about Hct of 3, instead of looking at her patient's real status, did a totally unnecessary hysterectomy. 5) A baby dropped on the floor by a doc (don't break the friggen bed down you lazy bums) 6) about a ZILLION "emergency" c/sections for "fetal distress" with apgars of 8 and 9. Let's not forget that the risk of stillbirth is doubled in every pregnancy following a c/section. I could go on and on. I got out of hospital because healthy, low-risk women are SAFER out of hospital, with trained midwives. The WHO agrees. With due respect, Dr. Neo, you are taking a non-professional midwife's outcome and well, throwing the baby out with the bath water regarding homebirth. And to make an important point, let's not forget that birth is not primarily a medical event: it is a milestone of bonding, of potential for empowerment for women and families, etc etc. These "intangibles", so respected at home, very well might make for better parents... healthier relationships.... healthier communities... a more peaceable world... etc as a result. The hospital is for sick people.

11:36 AM  
Blogger Robin Tell said...

After all of this high-level debate, I should probably make a disclaimer: I have no professional training that bears on the discussion. I'm just a soon-to-be first-time dad who'd done a smidgen of reading up and talking to folks leading up to childbirth.

That said, I know dogmatic thinking when I see it. Dr. Amy, since you're doing most of the talking for the institutional side here--the main thing that bothers me about your discourse is that you don't acknowledge it when the other side scores a point. Right from go you've been insisting that midwives promise mothers magical, perfect safety. At the outset that was at least a foolish assertion, if not a deliberate straw man; you didn't acknowledge it when Jamie called you out on it, but if you repeat it again after her correction you're just plain lying. I've never heard of anybody making such a dumb claim. My midwife certainly hasn't.

A related claim is that home birth is only an indulgence undertaken for the sake of the mother's warm fuzzy experience. Also not true, though I realize that there is plenty of talk about that experience. That's a perq, not a motive; we're doing home birth because we don't want either my wife or the baby to be drugged up, sliced up, or bullied around. (Yes, that's loose language, though I have specific antecedents for each. Please don't miss my central point here, which is that my motive is nothing like what you have been consistently claiming it is.)

So I don't have years of study to arm me with a lot of statistics, but here are a few statements that I offer up for factual confirmation or denial:

- The US rate of caesarians is higher than the WHO recommended rate, and higher than most rich countries'.

- There is no medical reason for the shaving.

- There is no medical reason for the enema.

- There is no medical reason for starving the mother leading up to labor.

- There is no medical reason for episiotomies. And here, hey, an actual reference!
http://www.scienceblog.com/cms/node/7755

- There is no medical reason for making a laboring mother lie on her back.

- There is no medical reason for handing out corporate freebie packages of formula, which some say are not just lame substitutes for breast milk but actually damaging.

- 35 isn't a magical age at which childbearing suddenly becomes more dangerous, it just happens to be the age at which the risk of miscarriage in general rises to the point of being *equal* to the rate of miscarriage caused by an amnio.

- Amnio is nevertheless routinely advised for mothers much younger than 35, even though the vagueness of the results of that test make it pretty useless for mothers with no particular risk factors.

I guess I'm listing things a little randomly here, but the point is that the current medical model is anything but a paragon of rationality. If the above doesn't sway you on this, consider that most hospitals still circumcise little boys--not often by default and without asking the parents, as many did when I was born in 1972, but commonly nevertheless. And, most damningly, that if you ask a doctor what the purpose is, you'll generally get a mouthing of a transparent rationalization about hygiene. As if it didn't just *happen* to be an uninterrupted tradition tracing back a few thousand years to a proto-Semitic initiation/membership ritual.

If anybody has ever done a study supporting the salubrious hygienic effects of circumcision, I will eat my hat. I mention all of this just as a shot across the bow of your apparently invulnerable, but inconsistently supportable, conviction that the medical establishment in its current incarnation is always at the forefront of human knowledge and has solid, rational reasons for everything it does.

It is not medical to expect women to deliver in 24 hours beginning to end--it is financially convenient. It is not medical to start clucking about how late the baby is on the first day bang after forty weeks, let alone before. It is not medical for every single nurse everywhere to make worried noises about how big the baby is getting, no matter how big the baby seems to be, every single time the mother is weighed. I stand by that: every single goddamn time. I not only invite you but implore you to give me real counter-examples, the more recent the better. That's not a level-headed medical assessment. That's a habitual greasing of the skids for caesarians.

And "habitual" is the word. It's the greatest forte of our society, as doctors; we do surgery like nobody, surgery such as the world has never seen. And when you've got a hammer in your hand, all problems look like nails.

To our host--I am of course all in favor of incremental reforms addressing these and other specific complaints. By all means let us have a meeting of the roads. But in the meantime, even that is a sentiment all too little heard among your colleagues, and I'm not going to meekly come back into your fold and wait for you to get around to examining your own assumptions. The medical profession is just way too slow about doing that. How long did doctors let babies go blind, knowing the risk and the cure, because they wouldn't be so indelicate as to ask women about their sexual histories? How many are still routinely performing episiotomies right now, in the wake of findings that they do no good and armed with no findings to the contrary? (Again, confirm or deny, I'm making an educated guess only.)

Back to Dr. Amy, on the subject of the "experience" that you allege home-birthing mothers want, let's re-examine a quote of yours:

"I'm not saying that your baby couldn't die in the hospital, but at least then you can blame the doctor (who should have been able to avoid the death). If it happens at home, you can only blame yourself."

What is this about, if not the mother's experience? Someone to blame, a shield against guilt? The comforting notion that at least you did everything you could. That is actually, in a deeper way than it seems, bound up with the very essence of the cultural difference between the medical establishment and the home-birth "crowd." You guys are always itching to "do something," not least because you know you're more likely to be sued for waiting than you are to be sued for jumping the gun.

Closing question: would you say there is any possible middle ground between "childbearing is the most dangerous thing women ever do" and "childbirth is totally safe because it's so durned natural"? I would assert, for example, that the most dangerous thing women routinely do is drive on highways. Yes, pregnancy has risks, it always will. But must the worst cases always be trotted out when someone mentions home birth? Is it really scientific to terrorize all pregnant women with anecdotes? It's not only doctors who do this--almost everyone in our culture does it. It is the most common thing we heard from people in early pregnancy (in later pregnancy it's been eclipsed by "boy or girl" of course). Anecdotes can be told about your establishments as well, and that will make you suddenly come over all fatalistic.

But don't you think there's something to the idea that you're actually influencing the outcomes with this ceaseless drumbeat of scary stories? It's a little Heisenberg, here. You don't figure the actual birth process depends a bit on emotional states, on the mother's confidence? You don't think some of those "failure to progress" diagnoses might actually be caused by all this "pregnancy is dire peril" talk?

10:49 PM  
Anonymous Anonymous said...

I can't believe I'm wading into the fray here, but as a second-time mom planning a first-time home birth in the next few weeks, I am appalled at the representation of home birthing mothers put forward in this debate. In my experience, the home birth parents I have known have been the -most- informed group of consumers available, while the women around me who have hospital births tend to do so passively and thus have ended up with massive and (in my opinion) potentially unnecessary interventions.
I'd like to respond to a few points: 1) I don't believe that I am guaranteed a healthy or live baby. I also don't think that my decision to home birth will affect that outcome. Babies die. Some babies die at home and some in hospital. I hope mine doesn't, but I don't think that any provider is so infallible that they can guarantee me a healthy child. My midwife is the LAST person to suggest this-- by contrast, the doctors of my acquaintence seem to assume that nothing bad can ever happen in hospital. 2) I don't think that all home or hospital births are created equal, and I think that that is clouding this discussion. All I can say is that for me, living in a major urban centre, I know I am a two minute ambulance ride from several hospitals and will be attended by two (registered) midwives with plenty of equipment. I'm just not convinced that my birthplace will affect any affectable (i.e. non fetal anomoly, etc.) outcome, but it will undoubtedly affect my ability to labour well and efficiently and bond with my child immediately-- all of which are good for the baby. (Incidentally, my (altogether fabulous) midwife-attended hospital birth with #1 took place in Toronto during SARS and there is nothing like a potential epidemic to make you reconsider safety of birth venues) I am in no way unwilling to transfer, but I trust my midwife not to transfer me unnecessarily, nor to allow me to stay home overlong. I can't see myself building that kind of relationship with an OB/GYN.
Finally, all of Dr. Amy's talk of "even in the U.S..." is driving me up the wall: why isn't anyone discussing the fact that the lowest maternal and infant mortality rates are occurring in the countries with the highest rates of homebirths, and that the U.S. is an appalling 27th (I believe) for both rates despite the overwhelming hospitalization of childbirth? Hello?
Last thing: I wouldn't have a home birth under any and all circumstances, but I am really delighted to live in Ontario in 2006 where there are choices that are both emotionally and physically safe for me and my baby available to me. Characterizing that choice as uninformed narcissism is both patronizing and unsound. Thanks for listening.
-May

12:10 AM  
Anonymous maribeth, CNM said...

Dr. Amy, who has a very real economic interest in dissuading homebirth and promoting cesarean delivery, says: “I have been studying this issue for more than a decade and I can assure you that there is not a single study that demonstrates that home birth is in any way better for a baby than hospital birth”. However, the World Health Organization (WHO) report - subsection on Place of Birth – says “It has never been scientifically proven that the hospital is a safer place than home for a woman who has had an uncomplicated pregnancy to have her baby. Studies of planned home births in developed countries with women who have had uncomplicated pregnancies have shown sickness and death rates for mother and baby equal to or better than hospital birth statistics for women with uncomplicated pregnancies”.

Homebirths take dollars out of obstetricians' pockets and power out of their egos. They are enormously threatened, and justly so. Understanding that, who do you trust more, Dr. Amy or the World Health Organization? It's naive to think that this is not about money. If anyone believes the average OB has maximizing the wellbeing of mothers and babies as their primary intention, rather than defensive medicine and personal convenience, you haven't spent any time at all in modern obstetrics.

Dr. Amy says she and her colleagues have plenty of business. Yes, but would they if America had an 80+% midwife-attended birth rate or 30+% home birth rate? The Netherlands has each, and likewise one of the lowest maternal and infant mortality rates.

I refer everyone to an enlightening read called “Official Medical Plan to Eliminate the Midwife, 1910-1920” found at http://www.collegeofmidwive
s.org/legal_legislative01/s
ynopsis.htm.

I mean really, let’s not take this lightly, Lexus’ and cruises to the Caribbean are on the line here…

1:49 AM  
Anonymous maribeth, CNM said...

All this talk about the Pang and Farm studies, when there is a current, well done study from the BMJ.

BMJ 2005;330:1416 (18
June),doi:10.1136/bmj.
330.7505.1416

Outcomes of planned home births with certified professional midwives: large prospective study in North America

Kenneth C Johnson, senior epidemiologist1, Betty-Anne Daviss, project manager Surveillance and Risk Assessment Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, PL 6702A, Ottawa, ON, Canada K1A OK9, 2 Safe Motherhood/Newborn Initiative, International Federation of Gynecology and Obstetrics, Ottawa, Canada

Correspondence to: K C Johnson (ken_lcdc_johnson
@phac-aspc.gc.ca)

Objective
To evaluate the safety of home births in North America involving direct entry midwives, in jurisdictions where the practice is not well integrated into the healthcare system.

Design
Prospective cohort study.

Setting
All home births involving certified professional midwives across the United States (98% of cohort) and Canada, 2000.

Participants
All 5418 women expecting to deliver in 2000 supported by midwives with a common certification and who planned to deliver at home when labour began.

Main outcome measures
Intrapartum and neonatal mortality, perinatal transfer to hospital care, medical intervention during labour, breast feeding, and maternal satisfaction.

Results
655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.
Conclusions Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.

1:56 AM  
Anonymous Kidsdoc said...

I am a pediatrician and horribly, horribly frustrated at this debate. Let's face some facts: med school does not teach doctors to strap the expectant mother to her bed, apply restraints to keep her feet in the stirrups and dope her into unconsciousness while simultaneously yanking her child out with medieval-looking forceps all while yelling "PUSH DAMMIT, PUSH!" Really. I swear.

There is this thing called communication. It does require two people. Talk to your OB. Don't choose one based on the first name in your insurance handbook. Talk about your birthing plan. There are MANY OBs who are happy to have and expect to have this conversation with their patients. If they seem uncomfortable with the discussion, FIND A NEW OB. Discuss what hospital you would like to have your baby in, if you have a choice in your community. Do they encourage breast feeding? Do they allow babies to room-in with mothers? These are considered STANDARD PRACTICES now. Use your voice! We're just doctors, we're not that scary.

Are c-section rates too high? Yes, they probably are. There have been many studies documenting it and it has been widely discussed in OB and pediatric circles and standard practices ARE changing in response. It's not an instantaneous change, it will take time, but it is happening. And let's also acknowledge the part that rampant malpractice-suits play in this problem.

I applaud all the home birth mothers who do everything they can to make the birth as safe as possible (2 minutes away from hospital, certified midwife, ob back-up, low risk pregnancy)--but you are still taking a gamble that everything will proceed normally. Was it in the NRP handbook that I read your risk of death on the first day of your life is the highest is will be until you're 72 years old?

Until there is nation-wide regulation of midwives and birthing centers there will continue to be tragedies like Neonatal Doc's patient(s). Just last week I saw a baby whose mother gave birth at home, 30 minutes from the nearest hospital, with a certified midwife who allowed her to wait 9 days after her membranes ruputured until the child was born. Oh yes, and the GBS wasn't tested because the baby was only 35 weeks and they "hadn't gotten that far yet." So don't tell me that these things don't happen or are rare. I have heard this story over and over again. Was the baby okay? Well, so far. But see, just because the baby looks ok so far, doesn't mean she may not have late-onset GBS sepsis, or underlying CP, or grade 2 or 3 intra-ventricular hemmorrhage.

So yes, I applaud your attempt to make home-birth as safe as possible, and I celebrate that in this country you have the choice to give birth in whatever way you feel is perfect for you, but I do expect you to acknowledge that it is an added risk to your child, and I expect you to understand why those of us who care for the children who suffer from long-term disabilities because of your choice may try to explain to the next pregnant woman why a hospital birth can be a safer option.

2:35 AM  
Anonymous difficult patient said...

You already have a million (okay, 84 . . .) comments, but I had to comment. If I had tried to deliver my firstborn at home, we both would have died (she was posterior and I Hemorrhaged. Later, my son was born with the umbilical cord wrapped around his shoulder . . . Thankfully, they were both born in hospitals, and we are all healthy and happy. Thanks for your post.

3:06 AM  
Blogger Amy Tuteur, MD said...

Maribeth, CNM:

The poor hospital outcomes you detailed (in one of your original posts) were the result of malpractice on the part of the obstetrician or the nurses, not the result of appropriate treatment. Are you suggesting the midwives are different from regular people and incapable of malpractice?

As far as economic self interest is concerned, I don't practice obstetrics any more and when I did, my problem was that I could not accept all the patients who needed me and not the other way around. For a number of years in my career, I practiced in a clinic in an underserved area, could barely accommodate the patients in the area, and gave away thousands of dollars of free care.

You get paid, don't you? All midwives get paid. When people realize that homebirth is not safe, they don't use your services. Therefore, you have an economic motive to insist on the safety of homebirth (despite lack of evidence). If homebirth is safe; there are no shortage of patients for obstetricians, since the majority of pregnant women do not meet the criteria for home birth. If home birth is recognized as unsafe, you are unemployed! Economic incentives, indeed.

As far as the BMJ study is concerned, it also suffers from serious problems rendering it essentially useless:

It is based on self reports by midwives. Would you base a study on the safety of hospital births on self reports by doctors?

Second, when you do the calculations, the actual death rates are:

2.6/1000 singleton births
2.8/1000 twin births
25/1000 breech births!

Moreover, since the authors do not show that any of these deaths were due to anomalies incompatible with life, they leave us with the conclusion that many or all of these babies might have survived in a hospital.

Bottom line: it makes no economic difference to me whether women choose to risk their babies at home, I only write about this because of my concern for babies. Home birth midwives are out of a job if homebirth is recognized as unsafe. How could they possibly acknowledge the risks and still earn money?

In that vein, please tell us what, if anything, would ever convince you that homebirth causes dead babies? Is there really any evidence that you'd be willing to accept? Isn't it true that there is nothing, no evidence of any kind, that would convince homebirth midwives to stop and give up the money that comes along with it?

7:06 AM  
Blogger Amy Tuteur, MD said...

One of the things I find most ironic about the homebirth movement is that despite the fact that there is so much overt and covert hostility to traditional medicine, virtually everything that midwives do is copied from doctors.

Everything that midwives know about normal and abnormal pregnancy, labor and birth is information disovered and studied by doctors.

How does a midwife determine a candidate for homebirth? She uses all the tests invented and utilized by doctors: prenatal blood tests to rule out Rh disease, serial measurements of fundal size to assess fetal growth, auscultation of the fetal heart to assess health, blood and urine tests to screen for gestational diabetes and pre-eclampsia, AFP testing to screen for neural tube defects, ultrasound to investigate abnormal growth patterns, etc. etc. etc.

Then, at the time of labor, midwives show up with an array of tools invented and used by doctors such as sutures and surgical instruments. Most midwives carry pitocin and methergine for bleeding, medications developed and used by doctors. If they carry resucitation equipment, it is because they have copied from pediatricians.

They auscultate the fetal heart during labor and assess it for dangerous patterns (identified by doctors). They assess labor using parameters derived by doctors. They even evaluate the baby using Apgar scores.

Sometimes, I think that the only difference is that homebirth midwives undertake risks with mothers and babies that no doctor, no matter how proud of her medical knowledge, would dare to undertake without the support of other doctors such as pediatricians and anesthesiologists.

8:44 AM  
Blogger Robin Tell said...

Kidsdoc--yes, of course some reforms are creeping along, and power to them. And sure, it varies by provider, that's true in every sphere. But you must be kidding if you think doctors aren't scary. Many of you, perhaps most, carefully tend that imposing mien of infallible and potentially forceful authority. (If you say you know what I mean but people are working on it, I'll believe that. If you say I'm making it up, I'll have to see that as deluded.)

Anyway, we do use our voices, those of us who've done this much research; but who wants to have to argue with the doctor the whole way down the line? Maybe a more sympathetic OB can be found, and maybe not.

The things you call "standard practice now" look to me like fringe practices within medicine. It's true that I haven't heard of a woman being strapped to the bed since the 70s--but I know two stories from the last two years wherein a woman was scolded for getting up and henpecked back into bed. In one case--my sister, as chaplain, saw this one--the woman was on the edge of the "failure to progress" decree, and only seemed to make progress when she stood up, walked around or leaned over the sink. And again and again, the nurse (who was against doing any of this) reacted to the first sign of progress by frantically urging the woman to get back into the bed.

Did med school teach her to do this? Probably not explicitly. But something did, cos there she was, doing it. Something to do with all those years of internship under doctors and nurses who did their schooling a few decades before? There is an oral tradition in medicine, apart from the official curriculum--hence vestiges like circumcision--and that tradition still sees pregnancy as an illness, birthing mothers as distressed and imperilled, and doctors as firmly in charge of things. It may not be presented as cartoonishly as in your first paragraph, but it is received wisdom tracing back in an unbroken line to decades not so long ago when it was every bit that cartoonish.

You want us to acknowledge that home birth is certainly a heightened risk? You must prove it or at least show strong evidence. I hope you will not just write me off when I say you have not done this. Overall statistics do not exist; the list of references as long as Dr. Amy's arm has proven to be as long as two titles whose significance is debated; and though you do not admit it, those of you from the medical sphere are making a predominantly emotion-driven case. Your irritation with the putative irresponsibility of those who do not heed your hard-won expertise snaps loose ever and anon through your language. But your professional culture is specific, your convictions are inherited, your loyalty is mandated, your sleepless internships are a matter of hazing as well as legit training, and though I think Maribeth overstates when she paints your motives as always personally profit-driven, the industry as a whole does indeed answer to its very real financial drives, and too often your doctrines are tainted by incrementally developed rationalizations of financial convenience. In seeking to eliminate midwives, you are in fact seeking to eliminate your competitors.

Meanwhile, speaking of acknowledging--does anybody on the institutional side want to pick up the gauntlet of present-day statistics in the Netherlands?

Dr. Amy: indeed midwives have availed themselves of all sorts of precautions from the medical world. You would curse them for medieval witch doctors if they didn't. But it is silly and irresponsible to say that these trappings represent everything they do. They know about vastly helpful birthing postures and practices for which they comb the world, and which are generally unfamiliar to doctors, who default to that good ol' supine position. They know, for example, how to deliver breech babies--which I understand today's med students are no longer being trained to do (confirm or deny) as breech is considered pretty much automatic grounds for caesarian at this point. And they know how the mother's mental and emotional state influences the birthing process, how deeply psychological it all is--and why wouldn't it be? But these concerns are largely invisible to your profession, and so people who do study them appear to you to have studied nothing.

Disappointing, in other news, that you found nothing to address in my post above. But as observed before: you do not bother to acknowledge points made by the other side, or anyway you only recognize the ones for which you have a ready comeback.

An erratum, incidentally: a friend in the profession tells me there is a medical reason for starving birthing mothers. The issue is apparently that once in a great while, a generally anaesthetized woman can vomit in labor and inhale the vomit, which is a wildly dangerous situation though rare. Right? Also true is that it would basically never happen to a woman not anaesthetized during birth. Right again?

10:53 AM  
Blogger Kim said...

Holy cow!

Find a doctor you like.

There are hospitals with home-like birthing centers. Family can participate.

Get yourself a doula who can speak for your when you are having difficulty and who is there for YOU

If you deliver vaginally, your baby is not "rushed" away from you, in fact I've worked in hospitals where you delivered and roomed-in all in the same room!

Me? Three c-sections and a miscarriage. First C-section due to occipital posterior presentation and decreased fetal pulse back in 1980.

Now, I'm a nurse, so hospitals are familiar and comforting to me.

Home birth? Gee, if I was one of those women who popped out their babies after four hours of labor, you betcha (with appropriate back up).

But if I could do it all again, For that first birth,I'd still choose a hospital, but this time instead of a 75 year old male dinosaur of an OB who treated me like I was nothing, I'd get a certified midwife and a doula. I may still have needed the section, but I would have felt more in control of what was happening - in the hospital.

Then again, this WAS 1980 and I had never heard of a doula or midwife.

11:06 AM  
Blogger sailorman said...

The home birth movement claims there are some benefits to home births. And you know what? We don't disagree. Yes: it's more pleasant for the mother. Yes: a midwife will never ask you to have a caesarian.

But it it safer? In other words, do the benefits OUTWEIGH the risks?

Let's find out why you think so.

Simply put:
in order for home births to be ranked as "safer" or "equally safe" in comparison to hospital births, you MUST have one or more of the following be true:

Option 1:
Claim: Homebirthing has a higher rate of survivability for "preventable" deaths than hospital birthing.
For this purpose, a "preventable" death is something which is NOT caused by malpractice--it's natural (cord around throat; infection; heart valve, etc).
Do you plan to claim this is true? This doesn't seem likely from a logical standpoint: we all know there is a decent list of neonatal issues which can only be treated in a hospital, but there is not a list of medical issues which can only be treated by a midwife. If you choose to make your stand based on this point, you'll almost certainly lose.

Option 2
Claim: Home births have a higher rate of "preventable" infant deaths. But the malpractice rate of midwives is low enough to compensate for the fact.
Note: This is essentially an argument against "complexity". Hospitals are more complex and have a statistically more probable rate of issues.

Do you plan to claim this is true? Read on.
For this argument to be sustainable, a home birth advocate must first claim that the rate of caretaker-caused issues is lower for midwives. Nothing really exists to justify this claim. They're LESS trained, so if anything there's a reasonable presumption malpractice is higher. And don't forget to normalize your malpractice: certainly if you use a fixed standard for malpractice, midwives commonly do things which would get an OB sued. If you want to claim a lot of midwifery practice is not "malpractice" then for this option you have to give similar flexibility to hospitals.

But EVEN IF you agree with the first part regarding malpractice, if you want to make a stand on this options, you must ALSO claim that the discrepancy erases the issues raised by Option 1.

In other words, it's not enough if hospital problems kill X babies out of 10,000. If you're going to avoid hospital deliveries based on risk, you ALSO need to include the fact that hospital procedures save Y babies out of 10,000, AND you must claim X > Y.


You could also use a decision chart. Coming soon!

12:40 PM  
Blogger sailorman said...

Decision tree as promised. Take the "home birth statistics test"!
There are two of them, the "dead infant" and "healthy infant" charts.

STARTING WITH A HOME BIRTH DEATH:
1) look at an infant death in a home birth.

2) Did the infant die from something which could be treated in a hospital, but not a home birth?
-If NO, you pass--they're equal. Repeat with your next death.
-If YES, hospital “wins” in theory. But for outcome measures, proceed to question #3.

3) If the birth WAS in a hospital, WOULD the infant have been treated? (obviously not everything gets addressed—hospitals miss stuff sometimes)
-If NO, you pass--they're equal. Repeat with your next death.
-If YES, hospital “wins” in theory. But for outcome measures, proceed to question #4.

4) If the infant would have been treated in a hospital, would the treatment have been successful?
-If NO, you pass--they're equal. Repeat with your next death.
-If YES, hospital “wins” in theory. But for outcome measures, proceed to question #5.

Note: if you've gotten this far, the hospital delivery is "ahead" one life. Read the next question carefully!

5) If the infant had been successfully treated, would the hospital have somehow killed him through other means?
-if NO: hospital wins. An infant is alive, who would not have been alive.
-if YES: hospital and home birth are equivalent.

Note: this could theoretically be run in reverse. But there's not much point. After all, nobody really claims home births are SAFER than hospital births, just AS safe. But feel free to retype it if you want; good luck modifying Question #1.

STARTING WITH A HOME BIRTH SUCCESS:
Look at an infant born at home. 40 weeks, vertex, healthy mother, good prenatal care-you choose the infant.

6) If the birth HAD BEEN in a hospital, would the hospital have delivered him alive? In other words, would the act of delivery (not including any medical intervention) have been successful?
-If NO, home birthing “wins”.
-If YES, you pass--they're equal. For outcome measures, proceed to question #7.

7) If he WAS delivered alive, and the midwife performed any medical intervention, would the hospital have performed the intervention with equal success?
-If NO, homebirth "wins".
-If YES, you pass--they're equal. For outcome measures, proceed to question #8.

Note: If you’re here, you’ve got a healthy baby boy. Congratulations!

8) After delivery and any intervention, would the hospital somehow kill the baby through other means?
-If NO, they're equal. HOWEVER, this “equality” can be changed by questions #1-6.
-If YES home birth “wins”

Anyone want to post their predicted results?

12:52 PM  
Anonymous Anonymous said...

Why all the energy arguing about which approach "wins"? Why not lobby for more birthing centers within hospitals, where midwives can practice a lower-intervention approach WITH the safety of multi-specialty backup?
If all these homebirthing women are strong and opinionated and informed enough to select a home birth, I refuse to believe that they and their midwives and support teams can't fend off the odd unneeded scalpel-or-pitocin-wielding doctor in a hospital-surrounded setting.
Most hospitals are increasingly interested in attracting patients-as-consumers; if women want safety AND control/choice, this seems to be the solution. Where's the rallying cry for that option?
If you are a midwife, why not practice in a hospital, with a full range of support available right there - how is that different than knowing the ambulance is right there if you need it? If you're an OB, why not have the midwives manage "normal" deliveries that otherwise would be a night up for you and a lower payment than a section or other procedure??If you're a hospital, why don't you want the revenue of patients who would otherwise choose a homebirth?
If you're a parent, why wouldn't you choose this?
I'm confused.

2:41 PM  
Blogger sailorman said...

We want to "win" in two respects:
1) we want to convince mothers that any temporary unpleasantness involved in being in a hospital instead of at home is more than cmopensated for by the increased survival rate of babies;
2) We want to stop homebirth advocates from arguing against medical care, and disseminating or "hinting at" false information.


A birthing center attached to a hospital IS what the hospital folks (like me) are asking for. Our first child was delivered in a baby factory (30+ births/day) which was safe, but hugely impersonal and fairly unpleasant. Still: level 1 pediatric trauma center, so a VERY nice place to be if things went south.

Even that enormous place (in Rhode Island) had an "Alternate Birthing Center" an elevator ride away. All the benefits of a natural birth with a full surgical team on call.

Birth 2 was with a midwife, but in a hospital. (OB attending but not involved until needed for episiotomy). Birth 3 will be the same, though in a different state.

Given those options, I don't see how any midwife could ethically advise a client to stay at home. Perhaps they're just not good at statistics. Perhaps they're lying to themselves. In any case, they're making a mistake.

3:44 PM  
Blogger Mrs Independent said...

"When a mother opts to have a C-section in a questionable case of fetal distress, she is saying in essence: put the risk on me, not on my baby. In fact, when a mother chooses to deliver in a hospital, she is accepting an increased risk that she may have a medical intervention, necessary or unnecessary, performed on her. When a woman chooses to deliver at home, she is saying in essence that the baby should bear the additional risk. She'd rather protect herself from interventions, and let the baby carry the risk of death or brain damage."


Sorry I haven't managed to read all these comments yet, but this one leapt out at me.

This commenter makes the assumption that medical interventions in labour affect only the mother, which is just plain wrong.

Medical interventions - synto, epidural, pethidine, Continuous EFM, maternal position (e.g. on bed) - these things all affect the baby one way or another. Pethidine cuases increased risk of jaundice and can cause poor sucking reflexes,and depress breathing. Poorly used synto can cause severe contractions that lead to fetal anoxia and distress. Sticking a woman flat on her back, scared or unsupported can reduce her ability to labour effectively and can stop her baby working with her in labour too.

I find the assumption that parents who choose homebirth are selfish and choose homebirth for their own benefit completely ridiculous.

4:32 PM  
Blogger Amy Tuteur, MD said...

"Medical interventions - synto, epidural, pethidine, Continuous EFM, maternal position (e.g. on bed) - these things all affect the baby one way or another. Pethidine cuases increased risk of jaundice and can cause poor sucking reflexes,and depress breathing. Poorly used synto can cause severe contractions that lead to fetal anoxia and distress. Sticking a woman flat on her back, scared or unsupported can reduce her ability to labour effectively and can stop her baby working with her in labour too."

There is NO medical evidence that properly used medical interventions cause any risks to the baby. If you believe otherwise, feel free to provide the appropriate medical references.

Pick up any obstetric textbook and it will tell you that a mother should not be placed on her back and tell you why. That's because doctors discovered these things when trying to take the best possible care of pregnant women.

4:46 PM  
Anonymous Anonymous said...

My first delivery, in a hospital, was a nightmare--caused by an impatient OB who didn't want to be there (and yes, he said that as soon as he walked in the room!) That experience led to severe PPD, not to mention 10 months of debilitating pain from the unnecessary episiotomy that extended into a 4th degree tear(caused by an OB who told me I had 3 pushes to get the baby out or he would use foreceps, despite the fact that neither my baby nor I was showing any signs of distress).

Compare that to my homebirth, where I was assisted by 2 licensed midwives and a student midwife. I had a 3 1/2 minute shoulder dystocia (resolved, in large part, because I was mobile and able to move--unlikely in a hospital setting given the number of epidurals given there). My baby then needed resuscitation, which my midwives were trained in and able to perform. My baby, who came out blue and limp, had apgars of 7/9. I was treated as a person, with respect--so was my baby. There was no PPD. There was no pelvic floor damage, despite the fact that she was 1 1/2 lb. larger than her brother.

What hospital proponents refuse to acknowledge is the mammalian instinct to "fight or flight" in a threatening situation. Going to a hospital, surrounded by strangers staring at our private areas, being asked questions during a contraction, being hooked up to monitors which have not been proven safe but which we have no right to refuse, being unable to eat or drink--all of these and more can cause a labor to stall or even stop.

I have seen a woman stall at 7 cm after having arrived at the hospital, despite an adequate contraction pattern prior to admittance. Could that have had something to do with the fact that they refused to let her husband and her doula (me) into the examining room with her? That she was stripped of the known comforts and subjected to the questions and exams of complete strangers? The mind has a powerful effect on the progress of a woman's labor. But hospital personnel don't care--they'll just hook up the Pitocin! Let's ignore the fact that Pitocin contractions are much more painful than normal contractions (I know, I've experienced both). Let's ignore the fact that Pitocin can lead to non-reassuring FHT's. Let's ignore the fact that most women who receive Pitocin then ask for an epidural in order to cope with these unnatural contractions, with all of the resulting complications that may be a part of an epidural--the potential for a fever (which leads to the baby going to the NICU and being subjected to horribly invasive and painful tests since they don't know for sure that the maternal fever was caused by the epidural), BP problems, an inability to push effectively, and an increased risk of instrumental delivery. All caused by the inability of the medical personnel to see that what happens to the woman is not about convenience, it's not about choosing her comfort over her baby's life--they are usually interchangeable. Amazing things happen when you treat a woman with respect. I have seen both as a doula--women who are treated with respect and given the ability to make informed choices, vs. those who are not treated with respect, who are treated like they are a part of an assembly line, who are told they have to do something they don't want because it's "hospital policy". I have seen a women be coerced into having an IUPC in place because the OB didn't think her contractions were adequate, only to throw the IUPC across the room in order to catch a baby--mom was complete and baby was at a +3 station. What message is modern obstetrics sending women--your body is defective, your contractions aren't strong enough, your pelvis is too small, you have failed.

The mind works similar in out of hospital situations as well. I have transported a laboring woman to the hospital because her husband wanted the homebirth more than she did, or because the birth led to issues with unresolved sexual abuse in the woman's past. Women will have safer deliveries if they are able to deliver where they feel most comfortable, with few exceptions.

Animals in labor can be about to deliver and will have their labor stop if they feel threatened in any way. Women have that same instinct; it is stronger in some of us than in others, in part colored by our past experiences. Im general, if we don't feel it's safe to have our baby, we won't--at least not without a lot of interventions. And those interventions each carries a risk to us, and to our babies.

Regardless of where a woman chooses to birth, she deserves to be treated with respect. She deserves to be able to make informed true choice, without coersion or threats. She deserves to choose if she wants to labor in bed or if she wants to walk or if she wants to use a birth ball. She deserves to not feel like she's in an asssembly line. She deserves to actively birth her baby, rather than acting as a passive participant, if that is what she chooses. Women deserve the right to choose what they want based on their past experiences and the situation that they now find themselves in. I firmly believe that by doing this, women will be better mothers, they will trust their instincts more, they will have fewer cases of PPD, there will be fewer cases of child abuse. I know, because I've lived with this as well as with its opposite. I know what not being treated with respect did to my confidence. I know I was not a good mother for my son's first year of life--it's hard to be a good mother when you are severely depressed. It's not just an issue of hospital vs. home--it's an issue of how the medical community, on average, treats pregnant and laboring women, and how these women then internalize the message.

As a result of my traumatic hospital birth experience, I have devoted my life towards helping women. I became a doula and am now a licensed midwife because I want to help women avoid having to go through an experience like I went through. And for the record, I am trained in in how to handle emergency situations, such as cord prolapse, shoulder dystocia, placental abruption, PPH--among many others. I am also trained in NRP & CPR, I bring oxygen and medications to births. I bring a fully qualified assistant. I also use herbs, homeopathy, position changes, water therapy, massage, and many other methods--and I have seen them work wonders. Most importantly, I respect the mother's right to choose what is right for her and her baby. I do not hesitate to transport to the hospital if it is necessary--and I am trained to know when that is. My goal is not just a healthy baby--it is also a phsyically & emotionally healthy mother. And that is why I assist women in the home or in the birth center, and why I have chosen that route for myself. I am looking forward to have my baby at home again in a few weeks; this baby will be greeted into the world by the same midwife who delivered her sister, the same midwife who trained me and whom I now assist and who assists me with our births. I know there are risks--there are risks at home and at the birthing center and at the hospital. It is up to each individual woman to decide which risks she is most comfortable with. Birth is as safe as life is; there are no guarantees. I tell my clients that at the interview; they make their own informed choice. How many OB's do the same? How many OB's use true informed choice? Perhaps I just hear of the bad ones, but I get an awful lot of clients because of an OB's scare tactics.

6:43 PM  
Anonymous FRECTIS said...

One of the things I find most ironic about the homebirth movement is that despite the fact that there is so much overt and covert hostility to traditional medicine, virtually everything that midwives do is copied from doctors.

Allow me: "As the practice of medicine became highly competitive, physicians and medical students were advised that their presence at a delivery would insure the entire family as grateful patients thereafter. For example, the outspoken and highly influential Dr. Walter Channing, of Harvard [Dr. Amy's alma mater], objected strongly to the practice of midwifery by women in his "Remarks on the Employment of Females as Practitioners in Midwifery," (1820) an pointed out that "Women seldom forget a practitioner who has conducted them tenderly and safely through parturition-- they feel a familiarity with him, a confidence and reliance upon him which is of the most essential mutual advantage... It is principally on this account that the practice of midwifery becomes desirable to physicians. It is this which ensures to them the permanency and security of all their other business." Fox, C.G. Toward a sound historical basis for nurse-midwifery. Bull. Am. Coll. Nurse-Midwifery 14(3):76-82 (August) 1969.

So it would seem the other way around, Amy. The medical movement, that is, physicians actually learned all they know from midwives about providing personalized care to the woman and her family. Unfortunately the evolution of the profession saw the medicalization of midwifery, added in surgery, renamed it obstetrics, and has ever since made the concerted effort to abolish it as evident by the "midwife problem" of the early 20th century.

If there is anything that has been successful, it has been to teach the public what a potential calamity one night of good orgasms might be if they result in a pregnancy.

Pick up any obstetric textbook and it will tell you that a mother should not be placed on her back and tell you why. That's because doctors discovered these things when trying to take the best possible care of pregnant women.

And pick any obstetrician in the metro area where I live and you'll end up flat on your back (with help if necessary) in spite of what the books they read say. I guess they don't know how to put their discoveries into practice when taking the best possible care of pregnant women. Maybe you could come to provide them an inservice?

7:37 PM  
Blogger sailorman said...

I knew this was coming. Or something like it....

Anonymous said...

My first delivery, in a hospital, was a nightmare--caused by an impatient OB who didn't want to be there (and yes, he said that as soon as he walked in the room!) That experience led to severe PPD, not to mention 10 months of debilitating pain from the unnecessary episiotomy that extended into a 4th degree tear(caused by an OB who told me I had 3 pushes to get the baby out or he would use foreceps, despite the fact that neither my baby nor I was showing any signs of distress).


Anecdotal evidence isn't all that relevant. And blaming a 10 month recovery pwriod on the hospital? You sound pretty sure you know what was best, what was right... you DID get a healthy baby, right? And that WAS the goal?

Compare that to my homebirth, where I was assisted by 2 licensed midwives and a student midwife. I had a 3 1/2 minute shoulder dystocia (resolved, in large part, because I was mobile and able to move--unlikely in a hospital setting given the number of epidurals given there).

OK, you hate epidurals. I'm not sure how they're relevant as you can always say no to one. Do you really intend us to believe a hospital would be LESS able to resolve the dystocia?

My baby then needed resuscitation, which my midwives were trained in and able to perform.

Lucky you! Others aren't so lucky, however.

My baby, who came out blue and limp, had apgars of 7/9. I was treated as a person, with respect--so was my baby. There was no PPD. There was no pelvic floor damage, despite the fact that she was 1 1/2 lb. larger than her brother.

See comment above.

What hospital proponents refuse to acknowledge is the mammalian instinct to "fight or flight" in a threatening situation....being hooked up to monitors which have not been proven safe but which we have no right to refuse....

Who's refusing to "acknowledge" it? Yes, hospitals are scary sometimes. Happy? I'm not sure where the whole "not been proven safe" line is coming from though.

I have seen a woman stall at 7 cm after having arrived at the hospital, despite an adequate contraction pattern prior to admittance

Tell you what. You want to trade anecdotes? You think yours are relevant? Why are they MORE relevant than the "I have seen babies dead or permanently disabled" ones? They're certainly not as bad.

Could that have had something to do with the fact that ...she was stripped of the known comforts and subjected to the questions and exams of complete strangers?

Are you seriously suggesting not examining people? Or not taking a history? Or trusting you (a third party) to give it percectly accurately?

.Let's ignore the fact that Pitocin contractions are much more painful than normal contractions (I know, I've experienced both).

Nobody ignores it. Or disputes it.

...All caused by the inability of the medical personnel to see that what happens to the woman is not about convenience, it's not about choosing her comfort over her baby's life--they are usually interchangeable.

See, the funny thing is that I's switch "home birth people" for "medical personnel" here. Unlike you, however, I value the baby's life over the convenience of the mother or doula. They are NOT interchangeable to me.

Women will have safer deliveries if they are able to deliver where they feel most comfortable, with few exceptions.

this is the problem with your post. You're RIGHT. Comfort guarantees safety most of the time. It's those niggling little "exceptions", otherwise known as "infant mortality", that cause the problem.

Regardless of where a woman chooses to birth, she deserves to be treated with respect. She deserves to be able to make informed true choice, without coersion or threats. She deserves to choose if she wants to labor in bed or if she wants to walk or if she wants to use a birth ball. She deserves to not feel like she's in an asssembly line. She deserves to actively birth her baby, rather than acting as a passive participant, if that is what she chooses. Women deserve the right to choose what they want based on their past experiences and the situation that they now find themselves in.

NOBODY is disagreeing with you. Nobody.

I firmly believe that by doing this, women will be better mothers, they will trust their instincts more, they will have fewer cases of PPD, there will be fewer cases of child abuse.

This is pushing it. Pitocin and an epesitomy are unpleasant but not gindicators of child abuse. Are you seriously implying otherwise? You'd be famous if you did the study.

I know, because I've lived with this as well as with its opposite
Do you "know" all the women in the statistics? This is why anecdotes are often misleading.


And for the record, I am trained in in how to handle emergency situations, such as cord prolapse, shoulder dystocia, placental abruption, PPH--among many others. I am also trained in NRP & CPR, I bring oxygen and medications to births. I bring a fully qualified assistant.

I don't want to impugn your training. But there is almost NO WAY you and your assistant are as "fully trained" as a board certified OB. Neither can you administer all medications. There's training and training, if you catch my drift.

I also use herbs, homeopathy, position changes, water therapy, massage, and many other methods--and I have seen them work wonders.
I have never seen homeopathy work. It would be a wonder if it did. Other than that, have you never seenmodern medicine work wonders? Do you care to compare the two?

Most importantly, I respect the mother's right to choose what is right for her and her baby.
But you don't seem to respect her right for INFORMED consent. Your statements about safety, about medical training, about homeopathy, are wrong. Do you still feel like you're empowering her?

My goal is not just a healthy baby--it is also a phsyically & emotionally healthy mother.
My main coplaint is the tendency to put "mother emotional health" ahead of "babyu physical health".


I know there are risks--there are risks at home and at the birthing center and at the hospital. It is up to each individual woman to decide which risks she is most comfortable with. Birth is as safe as life is; there are no guarantees. I tell my clients that at the interview; they make their own informed choice.

From what you're posting here, their choice is not truly informed.

How many OB's do the same? How many OB's use true informed choice? Perhaps I just hear of the bad ones, but I get an awful lot of clients because of an OB's scare tactics.
Interesting question, given your posts here. What you are calling "scare tactics" are probably what truly informed consent looks like. Making choices is scary. Being told everything will be OK (even if it's not true) is a powerful drug. But it's not an ethical one.

8:01 PM  
Blogger Kristina said...

As a doula and med-student-in-waiting, I have one word for you: Cytotec. No wait, I have two words for you.. Pitocin. Maybe I have more, like NPO, or FTP being 'failure to wait', or the other interventions or drugs that are used on women because they have always been used, or because they are convenient, but not because of scientific research showing a benefit. I asked my OB about NPO being an archaic thing to do to women in labor and he said that 1 or 2 women per year die from aspiration and that it *saves lives*. Well, what abou Cytotec? What about some of these drugs used in labor that have a much higher risk to women that are given routintely? Can you truly blame women for wanting to avoid *routine* intervnetion that does not benefit *their* situation whatsoever?

Hospitals are there for sick people and emergencies, and when a healthy woman has an illness or emergency, that is where she should give birth.

Physicians see the dark side of homebirth and criticize it as a whole, never acknowledging the studies that have been done showing homebirth to be on par in safetey with hospital birth, and possibly even *gasp* less interventive. What is so wrong with a woman hoping for a life affirming, empowering experience? What is wrong with her taking her birth, the responsibility for which belongs to her, into her own hands? Why do physicians forget that midwives don't take any woman who knocks on their door, that women are screened and that only low risk women are approved for home birth? That midwives are trained in emergencies?

I'm going to be an obstetrician, and as a doula I have seen some truly frightenening things in birth and been truly grateful that the provider was calm and collected and able to help the situation. Midwife or OB- I have seen babies come out very bad, I have seen shoulder dystocia, and beyond all of the trauma of these events were the bedside manner of the care providers attending the women. They truly made or broke the experience. When providers forget that these are human beings with souls that they are attending and not just their 'c-section in room 3', they should quit. If I ever become that cold, I will fire myself.

I deeply, deeply appreciate your perspective, coming from the place of the guy who has to pick up the pieces of the baby when birth goes bad. But please, please bear in mind that birth goes bad *where ever you choose to have it.* That physicians don't have a higher record for saving women, or making birth safer, than midwives do. Have you seen the Farm (www.thefarm.com)'s statistics? How do they do that if homebirth is so terribly dangerous?

As a woman I remind you that while to the medical model, a 'good birth' is one where the 'outcome' is good, baby and mom are safe and healthy, to the *woman*, there is SO much more than that and allopathic medicine forgets that. Women have a RIGHT to want to *experience* their births and not just be marched through L&D to get their Pitocin at 12PM and their cesareans later that night. Parents are extremely emotionally attached to their births and they will *never forget* how they were treated or what they experienced. It changes us at the core of who we are! How can wanting that experience to be powerful, be a bad thing? It impacts their self-worth, self-perception, breastfeeding, parenting, their marriages, and from there, society. Birth DOES matter- the science and medicine of it, but the experience matters *just as much*.

I do not make light in any way of the precious life you had to care for. I value what you do and believe it is of great importance. But do you judge women who birth in teh hospital so harshly when babies die from uterine ruptures from hyperstimulation from Pitocon, or from shoulder dystocia from a mother birthing flat on her back, or meconium from distress from Cytotec, etc?

Humbly,

Kristina Kruzan
www.dynamicdoula.com

9:09 PM  
Blogger Amy Tuteur, MD said...

Frectis:

I'm not precisely sure what you are trying to say with quotes from 1820 and 1969. I recognize that part of the self justification of the homebirth movement is to accuse obstetricians of losing income and patients. Unfortunately for your argument, none of this is true and I challenge you to provide proof for your allegation.

The unfortunate problem in the US is not that there are so few patients that obstetricians have to worry, it is that there are so many patients who don't have access to good care. The homebirth crowd consists of a teeny tiny number of women. You couldn't possibly be a threat to organized obstetrics even if you tried.

Furthermore, you are very quick to make assumptions. You don't know anything about me as a physician or a person. I no longer practice medicine so I couldn't be worried about my income from medical practice. However, when I did, I was a salaried physician who was required to be in the hospital for my on-call time. Therefore, there was no financial or time advantage to me to perform a C-section. No one would have been happier than me if all my patients had vaginal deliveries.

I always worked with midwives, both in my neighborhood clinic practice and in a large HMO practice. In our HMO we had a 20 midwives who managed most vaginal deliveries. They were extremely well trained and capable and only called me when they needed me, but, you know what, they needed me more than every now and then.

I have delivered babies in every position you can possibly think of on any surface that the patient requested. Except in emergencies, I attempted to honor every request in every birth plan. I generally delivered babies in low light (a teacher of mine taught me that "only moths are attracted to light, not babies"). My C-section rate during my years of practice ranged from 10% up to 16%. It could have been lower, but the midwives delivered lots of my patients.

You know what? None of that changes the fact that homebirth puts babies at risk.

It is not right or fair for you to demonize obstetricians. I am a woman just like you. I have given birth to four children and had a nurse/doula at all four deliveries. I'd be the first person to say that medicine has a very long way to go in treating patients with respect. Yet none of that changes the fact that homebirth puts babies at risk.

Let's just stick to the facts of the argument please.

9:13 PM  
Blogger Kristina said...

Oh, and I have to cynically add...

Thank goodness for the safe, controlled environment of the surgical suite where women don't have to worry about ANYTHING going wrong, where they are *excused* from participating in the birth of their child in ANY way, and where bonding takes a back seat to protocol. Boy, it's a good thing that surgeons can *rescue* women from the danger of vaginal birth.

Ugh. An emotional response, but what do you want, I'm ovulating. ;)

9:15 PM  
Anonymous FRECTIS said...

I'm not precisely sure what you are trying to say with quotes from 1820 and 1969.

I was refuting your allegation that midwives have physicians to thank for the pleasure of practice. The comments might be dated, but nonetheless, they are documented. By doctors even.

I recognize that part of the self justification of the homebirth movement is to accuse obstetricians of losing income and patients.

Oh, I wasn't talking about economics at all, that was the guy from Harvard at the start of the medical movement in the US.

The unfortunate problem in the US is not that there are so few patients that obstetricians have to worry, it is that there are so many patients who don't have access to good care. The homebirth crowd consists of a teeny tiny number of women. You couldn't possibly be a threat to organized obstetrics even if you tried.

Yawn. Self-aggrandizing talk from a physician to a midwife. What's new?

It is not right or fair for you to demonize obstetricians.

I have done nothing of the sort. You are doing a fine job of that yourself, along with the women who have posted their horror stories here and elsewhere. As you say doctors are not threatened by midwives, I am not threatened by you because for every nightmarish birth that occurs in the hospital, I have a potential client the next time she becomes pregnant. In my relatively short career the numbers of women driven to out of hospital birth (birth center and home) and midwifery care due to dissatisfaction outnumber the women who desire the exceedingly tired argument of the "ethereal experience" of birth. I have no reason to steer women away from hospital births and frequently redirect them back to medical care because they are not good candidates for home birth for a myriad of reasons, not least of all is my professional risk to attending an inappropriate candidate for midwifery care.

10:29 PM  
Blogger Robin Tell said...

Oy. Sailorman, hello. And here we go.. you're longer-winded than me, even!

Most important point first: either produce evidence for your repeated statement that mortality rates are higher for home births than hospital births, or stop making it. I suspect you're wrong. I also think the statistics by which to justify a clear judgement on the question have simply never been collected. In the absence of such, it would be nice if the much-vaunted scientific rigor of the medical world would kick in and compel you folks to stop claiming to know what you cannot possibly know.

So in order: your test for equality and decision trees.

For this purpose, a "preventable" death is something which is NOT caused by malpractice--it's natural (cord around throat; infection; heart valve, etc).
Interesting. Leaving aside what we would clearly agree on as "malpractice" (e.g. showing up drunk in the ER or something), are you also excluding deaths caused by conditions that only arise in hospitals? Babies and mothers endangered in unnecessary c-sections, for the main example, but also anaesthetized mothers inhaling vomit and any other hazards which would never arise other than in the context of dramatic medical interventions? I wouldn't call these things malpractice exactly, but I would certainly want to make sure you're not excluding them as preventable deaths.

there is a decent list of neonatal issues which can only be treated in a hospital, but there is not a list of medical issues which can only be treated by a midwife.
Not wrong, exactly; a doctor is empowered to do anything a midwife is empowered to do. But that doesn't mean the doctor is at all likely to do what a midwife will do (invest not just hours but months in putting the mother at ease, allow her to proceed at her own pace and in varied postures, for easy instances). And there are, noted above, hazards posed only by what a doctor will too eagerly do, and a midwife seldom or never will.

They're LESS trained, so if anything there's a reasonable presumption malpractice is higher. (I'm picking this out as just the most egregious of your many "it doesn't seem likely to me" statements which are really the bulk of your argument.)
So, you think more training means more judgement, fewer mistakes. This is probably true in many cases, surgery being an obvious example. But it is not axiomatic. Years of training can be based in whole or in part on bad assumptions. Few professions in the world, for example, are more exquisitely and exhaustively trained than priesthoods--not even yours. And yet the priesthoods are at loggerheads with each other regarding the most fundamental elements of their own function.

Moving on to your decision tree, there are two basic problems. First: you consider no objectionable outcomes other than infant death. Since this is the outcome in a smallish minority of all birth venues under consideration, doesn't it make sense to consider other dangers worth avoiding? Drugged babies, cut babies, mothers undergoing major abdominal surgery for the wispiest of reasons? Second: you seem to take it as read that more intervention is always safer and better than less; always better for "stuff to get addressed." Skepticism about this view is as fundamental as anything in the home-birth movement.

Moving on to your reply to one of the anonymouses:
Anecdotal evidence isn't all that relevant. ... you DID get a healthy baby, right? And that WAS the goal?
But I thought anecdotes weren't relevant? Most individual anecdotes end in a healthy baby. Survival is pretty minimal as a highest goal, though, isn't it?

You have a conundrum: you assert, admirably, that thoughtful birthing centers are what all the medical folks are arguing for. And yet, such centers are few, not to be found at all in some areas (my region has one out of a good handful of hospitals), and irrelevant anecdotes like this "you get three pushes before I intervene" one continue to crop up at alarming rates. I can understand, for the sake of your argument, why you want to disregard this. And I think we can all agree that birthing centers attached to hospitals are a fine option. But they are far from being the mainstream of institutional obstetrics. So you can either join us for a conversation about the pros and cons of obstetrics as it is actually being practiced, or we can all agree that certain reforms would improve the picture if only they were more widespread.

OK, you hate epidurals. I'm not sure how they're relevant as you can always say no to one.
In theory, sure. In practice doctors almost never provide full information about choices like this. They apply tons of pressure in favor of their favorite interventions, and in the case (for example) of a woman whose English is poor, I doubt very much if a doctor is ever likely to make sure she understands the choice or has even tentatively made it before acting.

Do you really intend us to believe a hospital would be LESS able to resolve the dystocia?
A derisive tone does not constitute an argument. Yes, I believe (and intend you at least to give real consideration to the idea) that midwives have a better handle on shoulder dystocia than doctors. How often do you see a doctor suggest that a woman try on her hands and knees for a while? Old indio women in Guatemala have known for time out of mind that this frequently addresses the problem. What do your doctors do? That's not a rhetorical question, I'm asking. What's the usual drill?

Who's refusing to "acknowledge" it? Yes, hospitals are scary sometimes. Happy?
I'll be happy when you propose to ameliorate the problem. Now that you've acknowledged that hospitals can frighten women, can you take the next step and acknowledge that the emotional state of women has a dramatic effect on their dilation?

I'm not sure where the whole "not been proven safe" line is coming from though.
Neither am I. That uncertainty constitutes no evidence either way. Shall we just ask?

Hey, anybody got the references on whether those monitors are safe?

Are you seriously suggesting not examining people? Or not taking a history? Or trusting you (a third party) to give it percectly accurately?
Midwives are able to take histories without making women feel harassed. You know how they do it? They take months doing it, building an active rapport in the process. It works. Have you got another suggestion?

Unlike you, however, I value the baby's life over the convenience of the mother or doula. They are NOT interchangeable to me.
I think what was meant was "they tend to go together anyway." Original commenter can confirm or deny of course.

this is the problem with your post. You're RIGHT. Comfort guarantees safety most of the time. It's those niggling little "exceptions", otherwise known as "infant mortality", that cause the problem.
This seems to be the final hammer blow of your argument, which is a restatement of your favorite refrain: that home births have higher mortality rates than hospitals. So again I invite you to show some evidence.

As a sort of footnote:
I have never seen homeopathy work. It would be a wonder if it did.
...
Your statements about safety, about medical training, about homeopathy, are wrong.

First you give us a vague anecdotal hunch, and then you assert "homeopathy doesn't work" as fact. Did you do some research or something between those two paragraphs? Or are you letting your lack of proof ossify into a presumedly proven lack?

Homeopathy doesn't make any sense to me either, frankly. I've rarely used it, never noticed any particular results. But as it happens, the most recent thing I remember hearing about it is that some responsible research turned up in support of it.
http://www.guardian.co.uk/Archive/Article/0,4273,4152521,00.html
http://www.newscientist.com/article/mg18624940.300.html
In another blurb the Ennis paper is referenced: Inflammation Research, vol 53, p 181. JSTOR doesn't seem to archive "Inflammation Research" so I can't get a look at the paper, which would most likely be over my head anyway.

So whatever this is, it's nothing like proof that homeopathy works. But it seems like enough ground for a reasonable person to regard the question as unsettled. In fact, it seems enough doubt that I'm not so sure it's at all reasonable to dismiss it as though all were known.

Being told everything will be OK (even if it's not true) is a powerful drug. But it's not an ethical one.
Ain't it the truth.

10:42 PM  
Anonymous colleen said...

So this is a little late, but I have a few things to say that haven't been said.

Let me state my biases up front:

- I believe that hospitals provide slightly better outcomes for low risk babies than homes. I had my daughter in the hospital, and will have my other children there too. I'm not personally comfortable making any other choice.

- I believe that having a baby in a hospital is for some women an experience that is at best ok and at worst seriously traumatic.

And now for my actual comments:

The thing that interests me most about this discussion is that it is so much one of doctors versus midwifes when during hospital births (especially the low-risk, full-term, vertex presentations we're trying to compare here) a woman in labor barely sees the doctor; most of her care is provided by a nurse. While the personal and professional beliefs of the nurse (or nurses, if labor crosses a shift change) greatly influence the experience of a woman who labor and delivers in a hospital, there is no opportunity to choose these folks beforehand, or even to talk to them to know what you are getting yourself into. Having the most progressive, best-informed doctor in the world doesn't help if the nurse adds his or her own restrictions and refuses to page your doctor. So why is it that hospital births provide no mechanism for choosing the significant care providers for the birth?

While I think that babies are slightly more likely to survive a hospital birth, the difference is still slight -- certainly in the noise in terms of all of the decisions you make as a parent in the process of raising a child. Hell, never riding in a car would probably make a larger difference in your child's ultimate survival, but no one finds that a practical choice to make. In any case, human beings are notoriously poor at risk assessment, and the few (all flawed somehow) studies to be done haven't shown huge differences in safety between home births and hospital births. So in the absence of new data and better studies, it doesn't seem like many opinions are likely to change anytime soon.

Likewise, the ability of midwives to provide advanced care in the event of unpredictable complications is not going to change. So why are women choosing home births? Is it possible to make other choices more attractive?

Here are reasons people I know have chosen home birth:
- they got to choose their attendants
- they had long term (>6 month) relationships with the people attending the birth, so they were not naked and vulnerable and in pain in the presence of complete strangers
- they knew that whatever informed choices they made about the birth (positions, eating, drinking) would be respected
- they knew that everything that happened would be done with their consent
- they wanted to avoid unnecessary medical interventions

So what I wonder is, why can't women get those things in a hospital setting? Sure, maybe malpractice claims drive number five, but there aren't any reasons I know of that women can't be treated with respect in hospitals, that they can't feel comfortable in knowing that procedures won't be done without their active consent, that they feel safe in protesting when they do not feel comfortable with what is happening to them. Those are easy things. They are cheap. It would be more difficult in this age of cost cutting and schedules, but certainly not impossible, to let women choose their nurses and doctors. It works fine for midwives and their assistants to operate this way.

Planned home birth is not a default method of birth. It requires time and research and expense. So if women prefer to do all of that to avoid the loss of autonomy and fear and stress that come with a hospital birth, it seems like the real problem here isn't the safety of home births; it's the misery of hospitals.

Two last points: I know a couple who recently had their daughter, their second child, at home with a CNM. Their first child, born in a hospital had an undiagnosed congenital heart defect (tetralogy of fallot) that caused him to need resuscitation, significant support, and relatively immediate surgery to survive. You might imagine that they would be enthusiastic supporters of hospital birth, but they had such a miserable experience in labor with their son (before any hint of trouble) that they chose a home birth for child #2 despite some maternal risk factors. They decided that the relative certainty of a miserable experience in the hospital outweighed the less probable unfavorable outcome with their second child.

Finally, people rave about what a positive experience it is to have a child at home; why doesn't anyone have that kind of reaction to the experience of being in the hospital for a birth?

10:51 PM  
Blogger Amy Tuteur, MD said...

We appear to be drifting away from the topic under discussion. Most of us have been discussing the safety of homebirth, not the mother's experience, not whether obstetricians are nice people, not whether obstetricians need more money, etc.

The homebirth advocates have presented 3 papers as demonstrating the safety of homebirth: the Farm Study, the Washington study and the BMJ paper. All three of these papers show that a greater percentage of babies died at home than in the hospital.

These papers confirmed what you might expect. The babies who died at home, died from events that could not be predicted beforehand like congenital anomalies, cord accidents and placental abruption. There were other babies who died at home from predictable causes such as the huge death rate in the breech birth group and the deaths from post dates.

The breech deaths were definitely preventable and the postdates deaths were very likely preventable. Many of the deaths from other causes were likely preventable by immediate surgery and neonatologist resucitation.

I am still waiting for an explanation for this. The studies that purport to show homebirth safety actually show the opposite, and more babies died at home than in the hospital. Precisely what type of evidence do we need?

11:25 PM  
Anonymous colleen said...

Anonymous said:
Regardless of where a woman chooses to birth, she deserves to be treated
with respect. She deserves to be able to make informed true choice, without
coersion or threats. She deserves to choose if she wants to labor in bed or
if she wants to walk or if she wants to use a birth ball. She deserves to
not feel like she's in an asssembly line. She deserves to actively birth
her baby, rather than acting as a passive participant, if that is what she
chooses. Women deserve the right to choose what they want based on their
past experiences and the situation that they now find themselves in.


sailorman responded:

NOBODY is disagreeing with you. Nobody.

The actual experience of many many many women in hospitals disagrees with Anonymous's assertion, though. I don't know of any studies asking women about their birth experiences, but I don't know anyone who is happy with how their hospital birth went, and I know many women who have had babies in hospitals. As an anecdote, I had my daughter 10 weeks ago. Without even thinking hard I could list 20 significant things that were done to me without my consent. And I was well-informed, reasonable, and flexible. The only thing I really wanted was to know what was happening to me and why, and that didn't happen. I don't know anyone that it _does_ happen for.

sailorman also said:

My main complaint is the tendency to put "mother emotional health" ahead of
"baby physical health".


Sure, but why is this an either-or situation? Why aren't we valuing both "mother emotional health" and "baby physical health"? Especially when at the end of the day increased value on the former is way more likely to reduce home birth deaths than arguing over how risky home births are or are not?

If hospital births didn't suck so much, fewer people wouldn't be trying to avoid them.

11:25 PM  
Anonymous maribeth, CNM said...

Dr. Amy, my practice offers birth at home, at a CABC and state accredited birth center, and at a hospital. Our fee is the same no matter where a woman chooses to birth (though the hospital charges). I have no economic incentive at all.

This post really exposes a lot of misunderstanding about professional midwifery, and reveals an awful lot of false assumptions held like gospel truth. Dr Amy, you think midwives don't consult, collaborate, refer and work closely with other professionals (physician and other)? That shows your lack of knowledge. Do you know any midwives, have you ever worked with one? Your critique that midwives base practice in part on learning from other disciplines is inane. What else would you have? Do you not as well? I would hope all professionals learn from others before them, from other disciplines, and especially from the specialties. I think very highly of obstetrics as a surgical specialty, and appropriate avenue for high risk pregnancies. Of course I can learn from OBs, and neonatologists, and perinatologists and lots others too. Guess what, they could even learn from me too.

Dr. Amy, do you really think that the "majority" of women would not qualify as appropriate home birth clients? So you think most pregnant women and babies are sick, or if not yet sick, on the verge of sickness, maybe on the verge of death, and in dire need of advanced medical care. No wonder you’re out of OB, how scary for you that must have been. You post that no medical intervention, used appropriately, has ever been shown to cause harm or damage to babies.

Well, there is that pesky pitocin – jaundice thing ….. And that pitocin – amniofluidembolism thing and yeah the epidural – neonatal fever thing…..or putting a scalp lead into a GBS+ babies head, sure to help… And oh, the unnecessary primary c/section for a fine baby but then there is the stillbirth or previa or accreta that mother may face in her next pregnancy…oh, and of course we know C/S babies don’t do as well as vaginally borne babies….

Yet earlier you stated that at least if a family had a dead baby in the hospital it would be the doctor’s fault. I am very, very confused. Midwives are not saying it’s a doctor’s fault. YOU said it was.

How is it, then, that other countries – again, those with the best outcomes and sound fiscal economics in health care – have certified midwives as primary caregiver for pregnancy and birth? Do you argue the American way is better? How can anyone of sound health care policy mind believe that when they read the data?

There is this tone of ‘hospital birth is better’ because safety should be more important than the “birth experience”. There are a few leaps in logic here. The Cochrane Database – which medical professionals know to be THE SOURCE – does not say hospital birth is safer than out of hospital birth.. The WHO explicitly states that the hospital is no safer than home. But some of you guys here seem to think your opinions and personal bias’ are actually more convincing than the WHO or Cochrane Database? Dream on. That’s who you’ve got to compete with.

So, the experts are in the middle. Neither place has been proven safer than the other. But, WE have the “birth experience” and wildly happy moms and babies (remember: proven to be just as safe as if they were in the hospital). And YOU have unnecessary interventions (a zillion annoying things that hurt and annoy and make birth very much more difficult and less successful), you have a lot of dehumanization of women, a lot of struggle over the locus of control, and you turn what should be one of the very most amazing days of a couple’s life into something really quite disappointing.

11:33 PM  
Blogger Robin Tell said...

Okay, so to an anonymous poster who asked why anybody would choose home birth over lobbying for hospital-attached birthing centers: I think folks across the spectrum are without all that much antipathy toward that particular option, at least relatively. But it's a little facile to say that option is the only one worth talking about.

The class of risks that most drives people toward home birth (my experiential assessment, I have no statistic) is the iatrogenic--the dangers that are actually caused by doctors. The big thing we're all fighting about here is how many, and how common, those are. Those of us on the home birth side tend to cite a bunch of medical procedures that we see as dangerous. The institutional folks respond in one or both of two ways: that a given procedure isn't dangerous after all, or isn't as dangerous as not performing it; and that it really isn't that common anyway, whatever it is. And on the offensive, they allege more or less that we're a bunch of fluffy-brained amateurs who kill a lot of babies through neglect.

With that basic framework in mind, the problem with hospital-attached birthing centers is that they are still under the dominion of the same doctors who call the shots in the hospitals. They have a culture, they have a self-perpetuating set of ideas some of which are valid and some of which are not, and by and large they sincerely believe they know better than anyone else and that everybody ought to do what they say. I'm sorry, but it's true; any patient obliged to sit through appointments with half a dozen randomly selected doctors would run smack up against that God complex. It is ubiquitous. And in defense of it, to prove it, they brandish the cross they have borne: the years and years of intense training and initiation. Surely, they say, no one who has done less than the same devotions can question their knowledge. (Incidentally, high-ranking Scientologists will make the same claim, just as reliably. Try one if you don't believe me.)

Now, to be clear, I am not just saying the whole medical establishment is bunkum. What a bizarre, oversimplified world that would be! No, they are in the field and on the forefront of medical research across the board--of course they can't help but be, with a government-sanctioned monopoly on it, but still, they've obviously earned their gravitas. They transplant hearts, they reattach severed limbs, they scan the inner workings of human brains in real time. Miraculous, and I don't mean to say not.

But there are some areas where they're weaker than others. How could there not be? Cancer, for example--to this day our basic approach to cancer is to bombard the entire body with something deadly--and yes, childbirth. The authoritarian approach that has quietly, incrementally, crept into their culture and their training, in part because of those lamented malpractice suits (a real problem for which I can offer no immediate solution)--the bossy approach just doesn't cut the mustard when it comes to the semi-voluntary act of childbirth.

The medical response, in a slow but observable mission creep spanning decades, has been on balance to excise the voluntary element from the whole business of childbirth.

And yes, by the way, I hear the several of you saying that you yourselves have adopted some more enlightened practices (and even the one or two claiming that the whole profession has, which is flatly false). And the birthing centers are a step in the right direction--and ften they are staffed by midwives well aware of the problems people like me would cite, who assert themselves as they can and perhaps often persuade doctors to wait longer than they otherwise might before intervening.

But the doctors still have controlling authority, and the doctors still have that itchy trigger finger when some intervention they have at the ready might or might not be applicable. They believe that some large number of women simply don't have big enough pelvises for babies. They believe that long pregnancies are inherently unsafe, that long labors are inherently unsafe. They believe not only that a breech baby must be surgically removed, but that a baby who's facing forward--"occipital posterior presentation" or something, right?--has committed a sectionable offense.

Anyway. Not to go on and on forever, the problem with the attached birthing center is that it's still firmly lodged under the twitchy eye of medical authority. Since that happens to be the source from which a persistent set of problems emanates, it has its own problems even if it is to some substantial degree an improvement over the 50s-era hospital setting.

11:50 PM  
Blogger Robin Tell said...

Okay, back to Dr. Amy.

There is NO medical evidence that properly used medical interventions cause any risks to the baby. If you believe otherwise, feel free to provide the appropriate medical references.
Well, if you regard any intervention that does cause a demonstrable risk as improperly used, by definition, this becomes a tautology. How about causing risks ever? Like, what are the rates of complications caused by a given intervention, as measured against all instances of the intervention, whether you think it's proper or not?

The reason I make this distinction is that it's the latter figure the mother has to reckon her chances against. The prospect of a lawsuit is no comfort.

I don't know any medical sources, unfortunately. I know anecdotally that a woman can't push as well with an epidural as she could without it--and that inability to push in one of a whole lot of factors that tend toward the "failure to progress" diagnosis. And that "failure to progress" is pretty much a one-way ticket to a c-section.

And I accept as axiomatic that major abdominal surgery is always a risk. Would you dispute that? Because if all those setps hold, then you've got some portion of women getting shunted into avoidable surgery by the establishment's fondness for epidurals. That's one example--I think other people in here have better ones.

Pick up any obstetric textbook and it will tell you that a mother should not be placed on her back and tell you why.
All right, somebody else already countered with the glaringly obvious: doctors and nurses to this very day routinely badger women onto their backs on a bed, whether the books says so or not. You've said elsewhere that you, personally, did not. Well, good on you! But are you denying that the run of OBs and nurses do in fact put women on their backs? Or are you just avoiding the subject?

That's because doctors discovered these things when trying to take the best possible care of pregnant women.
Oh, be real. Sure, doctors may have REdiscovered this--but you may be quite sure that many people had figured it out before there were such things as doctors. Happily, that old common knowledge is pretty well documented. Doctors have the distinction of being the only people ever to undiscover it, an uncomfortable while before some minority of them got round to rediscovering it. If in fact they can be said to have discovered it at all, rather than having their noses rubbed in it by mothers or midwives. I note you have no source for your whimsical conjecture here.

The homebirth crowd consists of a teeny tiny number of women. You couldn't possibly be a threat to organized obstetrics even if you tried.
The current stock of midwives couldn't remotely handle the client load your profession does, of course.

But what midwives represent is a fundamental challenge to the premise of your profession, which is that birth is dangerous dangerous dangerous and only specialized doctors can handle it. If they ever achieve something more like mainstream status with the public, your whole model is endangered. Not because demand will be less--but because your rigamarole is overgrown to begin with.

Of course, there will always be a place for OBs, because there is such a thing as a problematic pregnancy, and any midwife must occasionally transport a mother to a doctor. But going straight to a hospital as a default--someday people will shake their heads at the very idea. It's a misconception at square one.

None of that changes the fact that homebirth puts babies at risk.
Not a fact. Your cherished belief, obviously, but you just have not shown that. Which gets back to what you prefer as our central subject:

I am still waiting for an explanation for this. The studies that purport to show homebirth safety actually show the opposite, and more babies died at home than in the hospital.
And here it's tough. I am, again, in no position to give you a professional assessment of a medical research paper. Perhaps this is why you have thus far ignored every word I've said?

But it's kind of important, in its way. Remember, my relationship to the subject is that I'm soon to be a first-time father. I'm young, a grad student in urban planning, and basically I know squat about obstetrics, I'm going on a smattering of reading and conversation with some wonks who pay attention to these issues. And yet I think as parents go, I've done a good bit more active research than most. It is on the basis of knowledge such as this that we all make our choices.

So on the central question of those comparative mortality rates, here I am, left to choose between expert-sounding people without really following all of what they're saying, without reading the papers whose validity is being debated, armed only with my very weak notion of statistics anyway. What to do?

In this context, the most straight-to-the-heart debate on this page was between you and Jamie, before she left the conversation. Good debate, I thought, refreshingly rigorous. And here's the critical difference I see between you, using the skills I do have, in this case a working understanding of how rhetoric goes: Jamie addressed every single point you made. I didn't notice any exceptions; if you thought it was worth saying, she thought it was worth answering.

You, on the other hand, ignored her points at will. You answered only the things you felt like answering. You never acknowledged even a subtlety, let alone a hit. You have yet to utter the word "Netherlands." And in Jamie's second-to-last comment she posed several questions for your treatment of the statistics--why you flattened a decade into an average, and a couple other things, I don't remember exactly--and you let them slide on by, reverting to restatements of your favorite points.

That's about when I, as a layman with eyes in his head, start pouring salt on whatever you've got to say. (It doesn't help that you don't consider me worth addressing.) If you don't have professional expertise, you have to pick the expert who doesn't seem to be cutting corners...

12:50 AM  
Blogger Robin Tell said...

Oh, and on review, one more thing. Possibly the most interesting question left hanging in the air on this thread, actually.

Sarah said she'd looked back at the Farm study and found that it was reporting neonatal and perinatal deaths combined, which you were contrasting to a control statistic of neonatal deaths alone.

Confirm or deny, please.

1:45 AM  
Blogger PDXEMT said...

A few brief comments on EMS response to out-of-hospital births when the infant needs resuscitation.

One anonymous commenter talked about her experience, saying

Here is the frightening fact!
THE MEDICALLY TRAINED PERSONNEL
(EMTs) DID NOT:
have an infant mask,
proper cords to attach the extra one my midwives had
training in infant intebation
NOT ONE OF THEM WAS TRAINED IN INTEBATION!
The second midwife handed ALL the equipment needed to one of the six emts (yes six) and marched out to the ambulance with my daughter.


As an EMS provider, anonymous, I am very sorry for what happened, because this is not the standard of care anywhere that I've ever worked. Every ambulance I've ever been on has had infant masks, and while EMTs do not know how to intubate, there should have been paramedics responding to this call. A paramedic has the training (including PALS certification) and equipment to resusitate a depressed neonate, including intubation if necessary.

Now, we're not experts in neonatal resuscitation. (We're more of generalists.) I would gladly work with a competent and certified nurse midwife on-scene. But we do know the basics, including, at the paramedic level of training, intubating neonates. The standard of care for EMS is that we are able to resuscitate newborns -- hell, the whole point of EMS is to resuscitate anyone and everyone! -- and it's a shame that the system did not work in your case.

That is not the way it's supposed to be.

2:10 AM  
Blogger Amy Tuteur, MD said...

Robin Tell, Maribeth, CNM:

I don't agree with a great many of your assertions, but to address them one by one would get away from what we are discussing here.

We are talking about whether homebirth is safe.

Three papers presented. All three show that more babies died at home than in the hospital. Furthermore, based on the information presented by the studies' authors, most if not all of these babies died of preventable causes.

Confronted with this, many people are trying to change the topic to the hospital experience, to whether obstetricians are good or bad, or anything else but the matter at hand.

No one has been able to explain the excess deaths in the homebirth group. Furthermore, while all sorts of wild charges have been hurled at all sorts of medical procedures, I have not seen even a single one substantiated by any data of any kind.

I don't deny your sincerity, but sincerity is not enough in a scientific debate, you must offer scientific evidence. Otherwise, it is merely your opinion.

6:43 AM  
Blogger sailorman said...

How about this:

I'll retract all my comments except the decision tree and the "one of these options" part. If you think home birth is safer, can you explain why?

It SEEMS (though I'm not sure) that the main reason is people believe "babies get killed in hospitals". E.g. "some babies which would have lived in a home birth do not live in a hospital".

Now, unlike home births, hospital data (especially for deaths) is pretty good.

Got any evidence to suport your point?

7:48 AM  
Blogger Jamie said...

I don't plan to be one of those people who says, "I'm done with this argument!" and then keeps popping back in, but I just can't let Dr. Amy's recent assertions stand.

Sailorman, the thing to keep in mind is that hospital interventions pose some degree of risk to mother and baby. Going to a hospital affects the birth process. For some women, it stalls labor. Hospitals may use pitocin or rupture the amniotic sac to speed up the process. Either option poses a small but quantifiable risk to the baby. They also make labor more painful, and pharmacological pain management poses small but quantifiable risks to babies. A numb mother may have a harder time pushing effectively, and assisted delivery (forceps or vacuum) poses not-enormous but quantifiable risks to babies. Even the cleanest hospitals harbor nasty pathogens, and those too pose a small but not zero risk to babies.

It's this accumulation of small risks in a typical hospital birth that explains why your flowchart doesn't tell the whole story. Those interventions, with the possible exception of rupturing the membranes, don't happen at home.

Dr. Amy, the source I cited for the effects of Nubain was the PDR; the source for the C-section/TTN correlation was the American Journal of Perinatology. Maybe you are reading the other JAMA, the Journal of the American Magicians' Association, because otherwise your denial of the existence of iatrogenic complications is remarkable. As far as I can tell, the PDR editorial department has not been infiltrated by the homebirth mafiosi (mafiose, I suppose it would be, since homebirth advocates are typically female), intent on making hospitals look bad.

You are the one who brought up the Pang study, after I asked you for another selection from your list as long as your arm, and the one refusing to acknowledge its significant problems. You are the one who misinterpreted the Farm study, which states clearly that controls (even statistically weighted for the variables you mentioned) experienced a 33% higher rate of neonatal death. And you are the one failing to observe that the BMJ study's death rate for vertex babies is more than respectable. If you'd been responding to me instead of to your straw-man stereotype of homebirth advocates, you'd have noticed that I've been talking about vertex babies all along.

(For the record, as an additional data point to contradict your "homebirthers take it all on faith" idea, I would never attempt to deliver a breech baby at home. My kids' heads have been too big for me to feel that it would be in any way prudent.)

There are a number of studies, many of which are linked on two separate pages in my second comment here, in support of planned attended homebirth by low-risk women. If you wish to continue ignoring the research that challenges your assumptions while putting the best possible spin on the results that might seem to support them -- well, I suppose that's a comfortable way to view the world but it makes for sloppy epidemiology.

10:35 AM  
Blogger Robin Tell said...

I see. Well, that's almost disappointing; I'd half expected Dr. Amy to refute Sarah's point with relish, the second time it was brought up.

Perhaps someone else here can say whether Sarah's standing allegation is true? To wit: that the Farm study reports neonatal and perinatal deaths combined, and Dr. Amy's comparison figure is of neonatal deaths alone during the same years.

If true, your rebuttal is in flames, and somebody ought to go back and present us with a number treated exactly like the one Dr. Amy is using, only with the perinatal deaths added in. I'd like to do this myself, but I don't know how, don't know where your comparison numbers are coming from in the first place.

If nobody on the institutional side can be bothered to fact-check this, it's a problem for your self-image of rigorous empiricism. Right?

As to the rest--well, Dr. Amy is happy to ramble far afield when she feels like it, but now she says she doesn't have to address anything she doesn't want to because she has decreed to topic to be narrowly defined as the "safety" of home birth, apparently represented only by overall mortality figures, which she only sometimes feels like checking. No recognition of the Netherlands, no recognition of the WHO, no recognition of this Cochrane database, and Sarah's question still hangs in the air.

(Sailorman, if you're still wondering, yes, I am standing on the grounds of your "claim #1." I think that home-birth figures are as good as or better than hospital figures. The figures do not exist to prove this--which means they also do not exist to disprove it. Unfortunately we must resort to inference from other information.)

10:56 AM  
Blogger Amy Tuteur, MD said...

Jamie:

"your denial of the existence of iatrogenic complications is remarkable"

No, no, no. You keep switching the subject. I have never denied that there are iatrogenic complications. I have said two things:

1. Despite the existence of iatrogenic complications, homebirth has a higher perinatal death rate than hospital birth.

2. The medications and procedures being vilified are safe when used as prescribed. In addition, the benefits of various medications and procedures dwarfs the known side effects.

So, for example, the number of lives saved by C-section is in the millions, perhaps 10's of millions or more. Balance that against the risk of TTN and the odds are very much in favor of C-sections. It's simply absurd to say that it makes sense to risk a baby's death at home for lack of a C-section to protect it from risk of TTN.

"If you wish to continue ignoring the research that challenges your assumptions while putting the best possible spin on the results that might seem to support them -- well, I suppose that's a comfortable way to view the world but it makes for sloppy epidemiology."

Good try, but I suspect no one is fooled. I've dissected those papers for you ad nauseum and you have failed to explain the fact that the death rate at homebirth is higher than in the hospital in each of the three studies. C'mon Jamie, you wrote on your own website today that you had never even read the papers in question until we began to discuss them. It just reinforces the conclusions that homebirth advocacy is a matter of faith not fact.

11:03 AM  
Blogger sailorman said...

"Sailorman, the thing to keep in mind is that hospital interventions pose some degree of risk to mother and baby. Going to a hospital affects the birth process. For some women, it stalls labor. Hospitals may use pitocin or rupture the amniotic sac to speed up the process. Either option poses a small but quantifiable risk to the baby. They also make labor more painful, and pharmacological pain management poses small but quantifiable risks to babies. A numb mother may have a harder time pushing effectively, and assisted delivery (forceps or vacuum) poses not-enormous but quantifiable risks to babies. Even the cleanest hospitals harbor nasty pathogens, and those too pose a small but not zero risk to babies."

Great. I did, in fact, address these issues in my posts.

So, from your comment, you seem to claim that:

Hospital deliveries contain MORE inherent risks to the mother/baby, during a 'normal' delivery, than home births. This is a NEGATIVE EFFECT of hospital delivery.

However, this does not answer the overall question of safety. So it's not really a theory on its own.

As I have said--and as you appear to ignore--you ALSO need to address the question of what happens in "abnormal" births. Let's start there.

First: Do you acknowledge that there are some deaths or serious injuries from home births which result from problems which could have been handled in a hospital?

I assume you do.

Next: We can assume the midwives involved are not idiots, and that had these issues been known beforehand they would not have been home deliveries. But a midwife can't always tell. Do you acknowledge that some proportion of apparently-qualified home deliveries are in fact NOT appropriate candidates for home delivery? And that a fairly large proportion of those problems could have been handled in a hospital?

Again, I assume you do.

I hope you'll agree that there will always be some home deliveries where you say "oh shit, should've delivered in a hospital". And out of those "oh shit" moments, some number of infants--let's call it "X"--end up dead or disabled, when they would have been fine in a hospital. This is a POSITIVE EFFECT of hospital delivery.

OK, now for the final question: Are you asserting that hospitals kill/injure as many babies (or more babies) than they save? In other words, are you claiming that the negative effect of hospitals outweighs the positive effect?

I think this is really a risk apportionment discussion disguised as a discussion on home birth.

From my various conversations with home birthers, it seems like they focus HUGELY on minimizing immediate and personal risks:
-risk of discomfort and/or pain
-risk of needing to take drugs to counter an infection
-risk of needing to have an episiotomy
-risk of feeling like you didn't have the birth you "want"
-risk of thinking that something you are doing to your baby will have detrimental long term effects

OTOH, the medical establishment focuses primarily on different risks:
-Risk of fetal death or serious injury
-Risk of maternal death or serious injury.

We believe that it is better to give a C section and stick an infant on antibiotics even if the combined risk from those procedures is 10% than to take a 15% chance of a fetal or maternal death. And so on.

It's sort of like the vaccine debate: People avoid them because they hurt, or because they have vague fears about the mercury, or because they "don't like" them. They even do this with vaccines which prevent against VERY dsngerous diseases. This makes emotinoal sense, maybe (if there is such a thing) but not logicl sense.

If you're a midwife, or a doctor, your decisions are supposed to be logical and scientific in nature.

11:18 AM  
Anonymous maribeth, CNM said...

I am interested to post more later, but I'm interested - Sailorman, what is your background / relation to labor and birthing? 10-15% chance of maternal or fetal death, what are you referring to???

You way over estimate the value of "emergency" care available in most hospitals. Yes, if you happen to live near a tertiary center and choose to undertake the risks of delivering in one (my local one has a 70% pitocin rate and a 40+% operative delivery rate), a c/section can be done in 12 minutes or so. But the majority of people in the US don't, so even at a hospital, a c/section takes 30+ minutes (as we've covered) to call in the team. This can all be arraged while in transfer. Professional idwives do have oxygen, can start IV lines, etc etc. I have seen three babies die from cord prolapses in hospital, even when c/sections were done within 15 minutes. I think the thing you don't understand is that at home or in a birth center, true unpreventable emergencies (cord prolapse, shoulder dystocia, etc) happen very rarely, while in hospital, they happen all the time (doctors breaking water way too early, attempting to deliver the shoulders prior to rotation, pulling the shoulders down into the transverse and causing shoulder dystocias, etc....)

Dr. Amy, what percentage of women do you believe truly NEED a c/section?

Anyway, I'll be traveling until tomorrow night but plan to respond to earlier points then, if the converstation is still alive!

8:18 PM  
Blogger Amy Tuteur, MD said...

Maribeth, CNM:

I think the appropriate C-section rate is probably about 10%, maybe a little bit less.

By the way, I came across some interesting data regarding hospital birth.

In 1900 only 5% of births took place in the hospital; in 1950, over 90% of births took place in the hospital. Look what happened during those 50 years:

1900 neonatal mortality 100/1000
maternal mortality 850/100,000

1920 neonatal 72
maternal 780

1930 neonatal 60
maternal 600

1940 neonatal 38
maternal 300

1950 neonatal 30
maternal 80

So, as birth switched from being almost exclusively at home to almost exclusively at the hospital, the neonatal mortality rate dropped by 70% and the maternal mortality rate dropped over 90%.

By now, over 99% of births take place in the hospital and the neonatal mortality rate in in the range of 7/1000 and the maternal mortality rate is about 12/100,000.

I'd say that's pretty resounding confirmation of the medical model of birth as opposed to the "wellness" model of homebirth midwifery.

9:39 PM  
Anonymous Anonymous said...

Homebirth statistics are drawn from birth certificates, which until recently did not specify either intended place of delivery nor presence of a birth attendent. This is why European studies are important and enlightening.

Homebirth statistics include unintentional, unattended births (which from case reviews are most notably precipitous premature deliveries) and can still demonstrate statistics at least equal to controlled hospital outcomes. And this is precisely why, as previously elucidated, expert organizations have never claimed hospital delivery to be safer than home birth.

The Johnson-Daviss 2000 study, which is controlled, is methodologically sound and very important in the field. It can stand up to criticism and will likely impact policy.

Another excellent American study is below. As this reviews outcomes from freestanding birth centers, findings are likely transferable to certified nurse midwife attended homebirths. More evidence on the safety and efficacy of homebirth follows.

NEJM Volume 321:1804-1811 December 28, 1989 Number 26

Outcomes of care in birth centers. The National Birth Center Study

JP Rooks, NL Weatherby, EK Ernst, S Stapleton, D Rosen, and A Rosenfield

We studied 11,814 women admitted for labor and delivery to 84 free-standing birth centers in the United States and followed their course and that of their infants through delivery or transfer to a hospital and for at least four weeks thereafter. The women were at lower-than-average risk of a poor outcome of pregnancy, according to many but not all of the recognized demographic and behavioral risk factors. Among the women, 70.7 percent had only minor complications or none; 7.9 percent had serious emergency complications during labor and delivery or soon thereafter, such as thick meconium or severe shoulder dystocia. One woman in six (15.8 percent) was transferred to a hospital; 2.4 percent had emergency transfers. Twenty-nine percent of nulliparous women and only 7 percent of parous women were transferred, but the frequency of emergency transfers was the same. The rate of cesarean section was 4.4 percent. There were no maternal deaths. The overall intrapartum and neonatal mortality rate was 1.3 per 1000 births. The rates of infant mortality and low Apgar scores were similar to those reported in large studies of low-risk hospital births. We conclude that birth centers offer a safe and acceptable alternative to hospital confinement for selected pregnant women, particularly those who have previously had children, and that such care leads to relatively few cesarean sections.

Health economists have calculated that using midwifery care for 75% of the births in the U.S. would save an estimated $8.5 billion per year. (Madrona, Lewis & Morgaine, The Future of Midwifery in the United States, NAPSAC News, Fall-Winter, 1993, page 15)

From: Obstet Gynecol. 1998 Sep;92(3):461-70.

Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study.

Murphy PA, Fullerton J.

Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA. pam15@columbia.edu

OBJECTIVE: To describe the outcomes of intended home birth in the practices of certified nurse-midwives. METHODS: Twenty-nine US nurse-midwifery practices were recruited for the study in 1994. Women presenting for intended home birth in these practices were enrolled in the study from late 1994 to late 1995. Outcomes for all enrolled women were ascertained. Validity and reliability of submitted data were established. RESULTS: Of 1404 enrolled women intending home births, 6% miscarried, terminated the pregnancy or changed plans. Another 7.4% became ineligible for home birth prior to the onset of labor at term due to the development of perinatal problems and were referred for planned hospital birth. Of those women beginning labor with the intention of delivering at home, 102 (8.3%) were transferred to the hospital during labor. Ten mothers (0.8%) were transferred to the hospital after delivery, and 14 infants (1.1%) were transferred after birth. Overall intrapartal fetal and neonatal mortality for women beginning labor with the intention of delivering at home was 2.5 per 1000. For women actually delivering at home, intrapartal fetal and neonatal mortality was 1.8 per 1000. CONCLUSION: Home birth can be accomplished with good outcomes under the care of qualified practitioners and within a system that facilitates transfer to hospital care when necessary. Intrapartal mortality during intended home birth is concentrated in postdates pregnancies with evidence of meconium passage.

Birth. 1997 Mar;24(1):4-13; discussion 14-6.

Meta-analysis of the safety of home birth.

Olsen O.

Department of Social Medicine, University of Copenhagen, Denmark.

BACKGROUND: The safety of planned home birth is controversial. This study examined the safety of planned home birth backed up by a modern hospital system compared with planned hospital birth in the Western world. METHODS: A meta-analysis of six controlled observational studies was conducted, and the perinatal outcomes of 24,092 selected and primarily low-risk pregnant women were analyzed to measure mortality and morbidity, including Apgar scores, maternal lacerations, and intervention rates. Confounding was controlled through restriction, matching, or in the statistical analysis. RESULTS: Perinatal mortality was not significantly different in the two groups (OR = 0.87, 95% Ci 0.54-1.41). The principal difference in the outcome was a lower frequency of low Apgar scores (OR = 0.55; 0.41-0.74) and severe lacerations (OR = 0.67; 0.54-0.83) in the home birth group. Fewer medical interventions occurred in the home birth group: induction (statistically significant ORs in the range 0.06-0.39), augmentation (0.26-0.69), episiotomy (0.02-0.39), operative vaginal birth (0.03-0.42), and cesarean section (0.05-0.31). No maternal deaths occurred in the studies. Some differences may be partly due to bias. The findings regarding morbidity are supported by randomized clinical trials of elements of birth care relevant for home birth, however, and the finding relating to mortality is supported by large register studies comparing hospital settings of different levels of care. CONCLUSION: Home birth is an acceptable alternative to hospital confinement for selected pregnant women, and leads to reduced medical interventions.

2:24 AM  
Anonymous Anonymous said...

Reading through the orginal article and all the following comments have been interesting indeed. Although one important item stood out through every single posting from the Doctors and the midwives. IF there is some type of problem in a home birth that could not be handled by the midwife they would then rush them to the hospital. Doesn't that really mean anything to you at all? From my standpoint it clearly shows that in the end the hospital is better equipped to handle birthing.

We all obviously agree that you cannot predict if there will be complications right? Seems silly to me that so many of you are getting so excited about trying to catch people in lies or trying to prove someone else wrong. You've all chosen the sides you believe in and I seriously doubt anything could change your minds.

The bottom line is a competent hospital staff will take over for a midwife when they run into a problem they can't handle. I would even go so far to say that none of the home birthing advocates that have posted here would even think about attending a birth without a hospital backup. Even with a hospital only "5" minutes away (uh huh) that short amount of time could be the cause of the infant's death.

6:05 AM  
Blogger Amy Tuteur, MD said...

Anonymous 2:14 AM:

Thanks for the studies. The first study is of birth centers, not homebirths. The third study is a meta-analysis which isn't really a study at all. It is just looking at aggregrate results of selected studies chosen by the authors.

So, on to the one study of homebirth that you supplied, the Fullerton and Murphy study:

1. The first problem is that the results of the study are self reports by midwives. The authors of the study appear to have made extensive efforts to corroborate the midwives reports. Nonetheless, they could not obtain hospital charts for 20% of the women who were transferred in labor to the hospital.

2. Of 1221 beginning labor with the intention of delivering at home, 5 babies died for a neonatal death rate of 4.1/1000. According to the midwives report, 4 of the 5 deaths were stillbirths. Again, according to midwife personal report, 2 of the stillbirths occurred in labor but before the midwife got there; this is where the self-reporting becomes problematic. Did those deaths really occur in labor, but before the midwife got there, or did the midwife choose to protect herself by claiming that she had nothing to do with the death?

The authors of the study choose to remove these two stillbirths from their calculations. I imagine that there reasoning was that since it couldn't be ascribed to the midwives (if their self reports were true), they couldn't be ascribed to homebirth. They arrived at the quoted neonatality rate only because they subtracted these deaths. The actual neonatal mortality rate was 4.1/1000. Removing these deaths is inappropriate. They occurred in women intending to deliver at home and laboring at home.

Leaving aside the first 2 deaths for a moment, there were 2 other intrapartum deaths (stillbirths). Both occurred in women who were greater than 42 weeks gestation and meconium was present during labor. These were entirely preventable deaths.

The final death occured within the first 24 hours and the authors provide no information on the cause.

The 4 intrapartum deaths are hardly a ringing endorsement of homebirth, since the intrapartum death rate in a hospital setting is vanishingly small.

3. A curious, but unexamined finding is that of the 97 women transferred to the hospital prior to the onset of labor, 10 had IUFDs (intra-uterine fetal demise). Since there were 1318 women enrolled in the study, the pre-labor stillbirth rate was 7.6/1000. The baseline IUFD rate (for all women, not just low risk) is 5.1/1000, this is pretty remarkable. It is 50% greater than the population as a whole. It raises the possibility the the prenatal care in the midwifery group was substandard.

So, the bottom line is:

The actual neonatal mortality rate was 4.1/1000, almost twice as high as what the authors claim.

At least 2 of the 5 deaths were preventable and could have been avoided by following standard obstetric recommendations.

The pre-birth stillbirth rate of the midwife group was 50% higher than expected, raising serious questions about the prenatal care offered by the midwives in this study.

So, out of the three studies you referenced, one was not about homebirth and one was not an actual study. The one true homebirth study had a neonatal mortality rate for homebirth that was higher than expected and was due in large part to preventable deaths.

8:27 AM  
Blogger Robin Tell said...

Yikes, this volume is getting hard to keep up with.

Sailorman first: through your first couple of "I assume you do" question, we agree, though bearing in mind this is a small number of cases under discussion. Then you say:
OK, now for the final question: Are you asserting that hospitals kill/injure as many babies (or more babies) than they save? In other words, are you claiming that the negative effect of hospitals outweighs the positive effect?
And then you change the subject, leaving it unclear whether you continue to assume we do, or whether you're now assuming that we can't possibly be claiming that.

I do so claim. Hospitals turn normal births into crises, which is why I think it best not to go to one until you already know you have a legit crisis. Hospitals are good at crises, but presented with harmless situations they have an alarming tendency to escalate them into crises. (And that, to the anonymous poster who suggested that since crises are transported to hospitals then all births should just default there, is your answer.) Apart from deaths and obvious injuries caused by fidgety interventions, there are a lot of incremental ill effects that are caused or may be caused by these and by other practices which are little more than institutional bad habits.

Some of the drawbacks are as much bureaucratic as medical; the ever-shrinking acceptable labor duration, and episodes like the "three pushes or I intervene" story we heard here. Or a parallel story from a woman I know whose hours-old infant was in the NICU: she was given twenty minutes to get the baby to suckle before the staff started it on corporate formula from a bottle. Twenty minutes. As if it were pushing a button.

Other possibilities you'd probably scoff at: that the baby's vaginal passage sends a volley of hormonal signals through the mother's body that kickstart colostrum and such properly. That the baby's lungs, full of fluid, have a tougher time getting started on air if they aren't properly squeezed out by the passage. That the all-over massage of the passage is needed for the baby's nervous system, and babies not experiencing it are shakier, for longer, neurologically. And indeed the passage may kick off who knows what cascade of hormonal signals in the newborn.

This stuff is hearsayish and maybe speculative, so to a certain extent I can't even blame you for scoffing. It is also perfectly plausible and probably understudied.

It's unfortunate, but medical researchers don't bother to study things that doctors are dismissive about. And nobody outside the medical profession has access to the facilities or the raw numbers of patients to do studies comparable to those done inside it. Even if they did, what medical journal would publish a study by a bunch of midwives? So wherever doctors are habitually skeptical, the data is usually lacking because they're too skeptical to bother investigating. And then the lack of data is cited as support for the skepticism, etc.

But there we are; the complexity and layered multitasking of our hormones and developmental signals are by no means inadequate to the task of using vaginal birth as a developmental landmark, and a lot of people suspect it does function that way. But technophiles, in the grand modernist tradition that comes down to us really from the Enlightenment, are always awfully quick to think we can just artificially compensate for anything that comes up. We believe we can drive species to extinction and suffer no unexpected consequences; we believe we can feed crops on invented fertilizers without rotation and have those crops be nutritionally equal to those raised in undepleted soil; we believe we can replace mother's milk. And we are too ready to assume that we can skip the actual birth without harm or loss to the baby or the mother. The sin is the same the whole way round--an astounding readiness to believe we've thought of everything.

And yet nobody has ever created a working arcology. We still miss things. As a general rule--and an unsatisfyingly non-statistical one, I understand--I believe there is a presumptive value to leaving well enough alone unless intervention is needed.

To the letter of the law, I imagine you'd all agree with that. But the more accustomed you are to doing caesarians, the quicker you are to conclude that one is needed. (c-sections just an example, same goes for other interventions.)


So, next you move on to recasting the whole conversation by characterizing the arguments of other home-birth advocates not actually present on this page:
From my various conversations with home birthers, it seems like they focus HUGELY on minimizing immediate and personal risks:
-risk of discomfort and/or pain

Sorry, who promises to take the pain away? Who has taught young women all over the country to think birth is too much to face and they'd better always beg for an epidural on principle, precisely to take the pain away?

-risk of needing to take drugs to counter an infection
I guess I've heard that. I wouldn't call it a major strain of argument; I do however think that we prefer to avoid taking drugs to counter a presumed infection. For example, the strep B test; a woman might test positive one day and negative the next, correct? Fluctuations are constant among women who have any strep B population, and at a low ebb the bacterium is not really dangerous. But nobody's got a test to check for it at the time of labor, so hospitals test weeks in advance--and act as though the result is a reliable predictor of the state of affairs at the time of birth, which they know it is not. Correct?

-risk of needing to have an episiotomy
It's been mentioned several times, but once more won't hurt. There is no such thing as "needing an episiotomy." This is the finding of a legit major study from within the past year, it was all over the news; episiotomies accomplish nothing but harm. They confer no benefit whatsoever. Nobody can ever possibly "need" one. This is not just midwives talking, this is a study by your own. Get with the times. Episiotomy=voodoo.

-risk of feeling like you didn't have the birth you "want"
It's true. It's not the insignificant decorative concern you make it out to be, but yes, women want a certain experience and not another. Is this less true of women who plan epidurals out of fear, or have elective c-sections to avoid stretch marks?

But anyway, as has been repeated multiply, this is not a fashion choice. The talk about a good experience is based on an assessment of real risks and follows from it. And for that matter, since a woman's psychological state has everything to do with her ability to birth a baby, a good experience reduces those real risks you say are your only concern.

-risk of thinking that something you are doing to your baby will have detrimental long term effects
Not so much risk of thinking it, but risk of it actually being true. Does that not seem legitimate to you?

Vaccinations... that's a whole parallel discussion as extensive as this one, so let's not dig into it. Suffice to say that it is indeed a good analogy: the institutional types are for intervening just because they have the power to, and they unsupportably dismiss their opposition as ignorant because they themselves are generally ignorant of the opponents' reasons. (I am not against vaccinations across the board, incidentally, I just believe that contra your blithe assurance, it's a damnably complicated subject. Check "Vaccinations: A Thoughtful Parent's Guide" by Aviva Jill Romm for a non-hysterical evaluation.)

A footnote: it accomplishes little to brandish terms like "logical" and "scientific," so overused in internet arguments. These are simply not the monolithic and verifiable qualities they're cracked up to be. And "science" anyway is a process, a method of inquiry; quoting or applying notions learned through science is not the same as doing science and it is a non sequitur to describe it is "being scientific." The only thing subject to being judged either scientific or unscientific is an investigation. The term applies to no other thing.

11:30 AM  
Blogger Amy Tuteur, MD said...

Robin Tell:

"the complexity and layered multitasking of our hormones and developmental signals are by no means inadequate to the task of using vaginal birth as a developmental landmark, and a lot of people suspect it does function that way."

"It's unfortunate, but medical researchers don't bother to study things that doctors are dismissive about."

Really? I doubt it. Below is just a partial list. I know that it is axiomatic in the homebirth movement that obstetricians suppress information about or refuse to study important phenomena that are relevant to supporting the case for homebirth. Well, once again, they're wrong.

Stress during labor and delivery and early lactation performance. DC Chen, L Nommsen-Rivers, KG Dewey, B Lonnerdal, American Journal of Clinical Nutrition

Influence of the mode of delivery on initiation of breast-feeding.
V Vestermark, CK Hogdall, M Birch, G Plenov, K, Eur J Obstet Gynecol Reprod Biol, 1991.

Breast-Feeding and Its Relation to Smoking and Mode of Delivery. GM Leung, TH Lam, LM Ho, Obstetrics & Gynecology, 2002.

Risk Factors for Suboptimal Infant Breastfeeding Behavior, Delayed Onset of Lactation, and Excess Neonatal Weight Loss. RJ Cohen, Pediatrics, 2003.

Stress During Labor and Delivery Is Associated with Delayed Onset of Lactation among Urban Guatemalan Women. R Grajeda, R Perez-Escamilla, Journal of Nutrition, 2002.

Labor Pain Effects on Colostral Milk Beta-Endorphin Concentrations of Lactating Mothers.
V Zanardo, S Nicolussi, C Giacomin, D Faggian, F, Biology of the Neonate, 2001.

The Association Between Cesarean Delivery and Breast-Feeding Outcomes Among Mexican Women. R Perez-Escamilla, I Maulen-Radovan, KG Dewey - Obstetrical & Gynecological Survey, 1997.

Maternal and Fetal Stress Are Associated with Impaired Lactogenesis in Humans. KG Dewey, Journal of Nutrition, 2001.

What Contributes to Breastfeeding Success After Childbirth in a Maternity Ward in Finland? MT Tarkka, M Paunonen, P Laippala - Birth, 1998.

The Impact of Peripartum Factors on the Onset and Duration of Lactation. E Sievers, S Haase, HD Oldigs, J Schaub, Biology of the Neonate, 2003.

12:26 PM  
Blogger Robin Tell said...

Dr. Amy...

1. Despite the existence of iatrogenic complications, homebirth has a higher perinatal death rate than hospital birth.

Perinatal alone, now? Where does this figure come from? I don't mean to be a broken record, but I'd like to have clarified which studies you are evaluating for perinatal, which for neonatal, and which for the two combined, and against what control. I do of course mean to remind you again about Sarah's earlier question on the Farm study; if I had access to the paper itself I'd have tried looking it up on my own, by now.

2. The medications and procedures being vilified are safe when used as prescribed.
That can't actually apply to everything I'm vilifying, as some institutional habits aren't prescribed at all. But can you give some examples? For, say, two specific vilified procedures, what's the prescribed application and how does it compare to the general practice in actuality?

C'mon Jamie, you wrote on your own website today that you had never even read the papers in question until we began to discuss them. It just reinforces the conclusions that homebirth advocacy is a matter of faith not fact.
This isn't just a bizarre cheap shot, it's pointless. Jamie isn't a doctor or a midwife, right? She's a concerned mom. You expect her to have read all the literature before you argue with her? Have you ever grilled your own hospital-choosing patients on papers from medical journals? I'm guessing not--but maybe people are allowed to agree with you on faith, but can only disagree with a dissertation in hand.

In your next post you posit a 10% c-section rate as desirable. I think that's remarkably gung-ho, not surprisingly. But I also gather the current rate in the US is up over 20%. Am I wrong? What would you say causes this? (If you say it's caused by all the durned midwives messing up, I will spit in my coffee.)

Then you go through a little statfest about improvements between 1900 and 1950. This sort of fare goes over well at commencement speeches, but as a study, it's got an awful damned lot of variables. But just as you think MDs personally invented every device and technique now used by MDs, including squatting, you seem ready to assume that they were responsible for all these changes and that midwives are still living in 1900. You don't figure there were trends in the mothers' baseline health, in diet, in hygienic practices (cheerfully co-opted by midwives), or in transportation during those years?

Well, anyway. I don't take that particular post as serious argument on your part, I figure it was more of a flourish.

Now, the harder part, your answer to a study.

Thanks for the studies. The first study is of birth centers, not homebirths.
Fair point, I had that thought too. Let's agree to set it aside.

The third study is a meta-analysis which isn't really a study at all. It is just looking at aggregrate results of selected studies chosen by the authors.
Well, no, it isn't a study exactly... it's six studies. Even if four of those six were the other four we've had presented thus far (your arms are growing!), it introduces two more. And critically, unless the meta-analysis was done incorrectly, the results are very directly germane here. Do you challenge them for any practical reason? Meta-analysis may not contribute new raw data, but that doesn't make it worthless--what are you doing here if not meta-analysis?

1. The first problem is that the results of the study are self reports by midwives. The authors of the study appear to have made extensive efforts to corroborate the midwives reports. Nonetheless, they could not obtain hospital charts for 20% of the women who were transferred in labor to the hospital.
Is your objection to the 20%, here? Or are you just casting general aspersions against midwives' data, as you earlier have? All data is reported by somebody. It's a basic hazard of collecting data. If your point here is just "midwives are lying so-and-sos and you can't trust 'em" then I promise I can find people to spout equally suspicious generalities about doctors.

Again, according to midwife personal report, 2 of the stillbirths occurred in labor but before the midwife got there; this is where the self-reporting becomes problematic. Did those deaths really occur in labor, but before the midwife got there, or did the midwife choose to protect herself by claiming that she had nothing to do with the death?
Here you sink to slanderous speculation, and it's beneath you to be so childish. You can dismiss any study if you want to challenge the honesty of its raw data. But you need more of a justification than "I don't trust midwives." In fact, the usual clincher is an attempt to repeat the experiment, or several attempts, that consistently produce results unlike the disputed results. Short of that, or at least real probable cause, you're just advertising your prejudices.

The authors of the study choose to remove these two stillbirths from their calculations. I imagine that there reasoning was that since it couldn't be ascribed to the midwives (if their self reports were true), they couldn't be ascribed to homebirth. They arrived at the quoted neonatality rate only because they subtracted these deaths. The actual neonatal mortality rate was 4.1/1000. Removing these deaths is inappropriate.
Now this, on the other hand, I'm inclined to agree with. Excluding deaths, in a study that's centrally concerned with deaths, has to be extremely cautious and clear in its undertaking. I'm not quite sure why these deaths shouldn't count. Is the travel time of a midwife not part of the system of midwifery, and of the risks undertaken? If you figure the process of midwifery extends from early pregnancy through to birth and somewhat beyond, then those two deaths fell under the midwives' watch.

There is a caveat to this, and I don't know whether it'll be particularly illuminating or not. The main thing about these exclusions, at least for the purpose of providing a meaningful comparison between home birth and hospital birth, is that they must be conducted by the same rules on both sides. The parallel must be rigorous. So in other words, if the stopwatch of "intrapartum" starts with the first contraction for midwives, then it does likewise for hospitals. Fair enough? So the quick little fact check I'd want to do there, just to be careful, is whether women who begin laboring at home, call their OBs and make their way to the hospital, only to show up with a fetus that died en route, are counted as intrapartum deaths for the hospital crew, or excluded. Just holding to the parallel, right? If a midwife's travel time to the house counts as under her watch, then the mother's travel time to the hospital counts under the hospital's watch.

Personally, I don't really care whether such deaths are excluded or not, per se. I only care that the tallying is the same on both sides of the comparison. Apples to apples. Anybody got any information on the procedure there? How transit deaths for hospital-bound fetuses are recorded in general--or even better, how they were recorded in the numbers we see in that study.

there were 2 other intrapartum deaths (stillbirths). Both occurred in women who were greater than 42 weeks gestation and meconium was present during labor. These were entirely preventable deaths.
I quote this mostly to acknowledge it; this is directly medical and I'm in no position to argue. Do you mean to say, just to be clear, that these were "preventable" because under no circumstances would you allow a woman to carry a fetus to 42 weeks? And if so, are there established statistics showing that pregnancies past a certain duration begin to show more deaths? Just asking for information here.

The 4 intrapartum deaths are hardly a ringing endorsement of homebirth, since the intrapartum death rate in a hospital setting is vanishingly small.
Again, as long as we're talking apples to apples, this is fair. How is intrapartum defined in a hospital?

the pre-labor stillbirth rate was 7.6/1000. The baseline IUFD rate (for all women, not just low risk) is 5.1/1000, this is pretty remarkable. It is 50% greater than the population as a whole. It raises the possibility the the prenatal care in the midwifery group was substandard.
Accepting these numbers, I can't argue. This is a big concern. I'm curious to see what other factors might be involved--Julie's earlier discussion of home-birthing mothers also being more likely to take their chances with babies likelier to have defects, for example, though that alone wouldn't seem to account for such a large difference under any circumstances--but it's a fair accusation as it stands.

And then you just sum up, so that's enough for now...

12:52 PM  
Blogger sailorman said...

This sentence may sum it up:
This stuff is hearsayish and maybe speculative, so to a certain extent I can't even blame you for scoffing. It is also perfectly plausible and probably understudied.

Now, I wonder if you recognize this argument? You will see it used by proponents of almost every "alternative" concept from creationism to homeopathy to parapsychology. It's called the "it's plausible, so we should accept it until disproven" or the "negative proof" argument.

And it's wrong.

It's NOT plausible, given the effect of hospitals on historical neonatal death rates, that hospitals kill more than they save. It is POSSIBLE. But it is not PLAUSIBLE. Similarly, the claim that a midwife is as able--or more able--in handling birthing emergencies than an equivalently experienced board certified OB is possible--but not really plausible.

There is a reason why science works the way it does: If you start saying "seems good, let's assume it's true until you DISprove it" you run into a lot of problems. One of those problems is that it's muh harder to disprove something than to prove it.

It's unfortunate, but medical researchers don't bother to study things that doctors are dismissive about.

? Ignoring the apparent tautology, the reality is that "alternative" medicine IS studied by modern science.

Why? Because if you were the doctor who proved homeopathy "worked", you'd be famous. If you proved it worked and figured out HOW, you'd probably win a Nobel. Nothing makes you fame and fortune faster than successfully proving a new theory.

And nobody outside the medical profession has access to the facilities or the raw numbers of patients to do studies comparable to those done inside it.

This is simply not true.

Even if they did, what medical journal would publish a study by a bunch of midwives?

A WELL-DONE study would have absolutely no problems being published. See the "fame and fortune" concept above. A biased or poorly-done study would have little chance of being published.

So wherever doctors are habitually skeptical, the data is usually lacking because they're too skeptical to bother investigating. And then the lack of data is cited as support for the skepticism, etc.

This is simply how science works.

But there we are; the complexity and layered multitasking of our hormones and developmental signals are by no means inadequate to the task of using vaginal birth as a developmental landmark, and a lot of people suspect it does function that way.

You may be right! Go study it. If you can. Another reason science doesn't address things is that some things are too damn difficult to study. It has proven very difficult to find out the "cause" of autism, for example.

I would note that the existence of complexity is in NO WAY an indicator that there's some "cause" or "need" for that complexity. I can't bring myself to give the fullblown explanation in an avolutionary sense here.

So given any "possibility" which we don't know about, science tends to assume "nope". YOU seems to be assuming "sure!" for some of them--but not all! Do you accept mental telepathy? X=ray vision? There's a lot about the body we don't know; that doesn't give you license to assume that (insert your favorite thing here) is real.

But technophiles, in the grand modernist tradition that comes down to us really from the Enlightenment, are always awfully quick to think we can just artificially compensate for anything that comes up.

Technophiles? What does that have to do with anything?

We believe we can drive species to extinction and suffer no unexpected consequences; we believe we can feed crops on invented fertilizers without rotation and have those crops be nutritionally equal to those raised in undepleted soil; we believe we can replace mother's milk.

Actually: the extinction comment would be anathema to most scientists; the crop comment depends entirely on your goals (fertilizer, what nutrition) and science acknowledges the benefits of crop rotation; and as milk is just a compound like anything else, why can't it be replaced, in theory?

And we are too ready to assume that we can skip the actual birth without harm or loss to the baby or the mother. The sin is the same the whole way round--an astounding readiness to believe we've thought of everything.

No, no, you're getting it all wrong. Scientists NEVER think they know it all. We learn new things every day; that's why we do science. It is generally those who think they can easily describe the "limitations" of science who claim to have some sort of overriding knowledge.

And yet nobody has ever created a working arcology. We still miss things. As a general rule--and an unsatisfyingly non-statistical one, I understand--I believe there is a presumptive value to leaving well enough alone unless intervention is needed.

You are entitled to that rule. However, it's not necessarily a great general rule for medical use.

To the letter of the law, I imagine you'd all agree with that. But the more accustomed you are to doing caesarians, the quicker you are to conclude that one is needed. (c-sections just an example, same goes for other interventions.)

This may be true, though partly for other reasons than you think. The more you do, the safer they are (you're better at it). Which makes the "do/not do" calculus change as the risk changes.
Of course, this also applies to midwives. Perhaps once you are successful in a birth problem you are less likely to seek help the next time, and you assume you have improved skills. In both cases, people suffer if the doctor/midwife is wrong.

...it accomplishes little to brandish terms like "logical" and "scientific," so overused in internet arguments. These are simply not the monolithic and verifiable qualities they're cracked up to be.

Well, they are if you're a scientist. Though I suspect you might not like using them if you're not.

Logic is logic; in this application is requires coming to a conclusion based on a set of facts and premises. Logic also requires some sort of consistency. So if you're willing to believe hormonal claims based on anecdotal evidence or a "feeling", you need to be able to explain why you don't believe claims contrary to your position, such as the ones at the beginning of the post. If you can't explain that you have a logic problem. And so on.

Science is indeed a process. But it's also a frame of mind, which for centuries has been formed on the "show me" principle:
You want to change the bases of current scientific belief, whcih have been formed on the backs of decades or centuries or research? You need to do it with research, and your scientific proof needs to be able to carry the weight.

If you want to claim that only 0.0001% of babies are properly C-sectioned, you need to prove it. Similarly, if I want to claim that 100% of babies should be C-sectioned, I need to prove it too.

So no, investigations are not the sole things which can be "scientific". Beliefs can be based on results of studies (scientific) ro on emotions (not scientific), for example.

12:54 PM  
Blogger Amy Tuteur, MD said...

Robin Tell:

definitions

intrapartum death rate - rate of deaths during labor

perinatal death rate - intrapartum death rate + death rate immediately following delivery

neonatal death rate - perinatal death rate + deaths during the first 28 days of life

"I do of course mean to remind you again about Sarah's earlier question on the Farm study"

I erroneously stated initially that the Farm Study included only deaths in labor and that the sample group included deaths in the first 28 days of life. If I had been correct, the Farm Study's results would have been even worse than what we have been discussing. As it is, a death rate of 9.6 is bad enough. The average neonatal mortality rate for white women during the same time period was 8.3/1000.

"But I also gather the current rate in the US is up over 20%. Am I wrong? What would you say causes this?"

I would say that this is caused in large measure by the fact that the American public insists that all babies delivered by obstetricians must be perfect. Obstetricians pay anywhere from $50,000 to $150,000 in malpractice insurance every year to cover legal claims. Almost 100% of obsetricians are sued. They win the vast majority of cases (probably over 90%), but no one wants to be sued at all (not to mention that no obstetrician wants to be responsible for harming a baby). The primary claim of most obstetrical lawsuits is that the baby should have been delivered by C-section or should have been delivered by C-section earlier.

"Then you go through a little statfest about improvements between 1900 and 1950. This sort of fare goes over well at commencement speeches, but as a study, it's got an awful damned lot of variables... You don't figure there were trends in the mothers' baseline health, in diet, in hygienic practices (cheerfully co-opted by midwives), or in transportation during those years?"

I never claimed this was a study. As far as baseline health improvement, improvement in nutrition and improved hygienic practice are concerned, they are all medical discoveries. They certainly weren't discovered by midwives.

The causes of the precipitous drop in mortality during these years appears to be due to several specific medical developments: the discovery of antibiotics, the introduction of anesthesia, blood transfusions, improvement in the diagnosis and treatment of eclampsia and pre-eclampsia and the introduction of neonatal resucitation. That's why hospitals became and continue to be the safest place to have a baby.

"So the quick little fact check I'd want to do there, just to be careful, is whether women who begin laboring at home, call their OBs and make their way to the hospital, only to show up with a fetus that died en route, are counted as intrapartum deaths for the hospital crew, or excluded."

They are counted in the intrapartume and neonatal death rates.

"Do you mean to say, just to be clear, that these were "preventable" because under no circumstances would you allow a woman to carry a fetus to 42 weeks? And if so, are there established statistics showing that pregnancies past a certain duration begin to show more deaths?"

Yes, that's what I'm saying. The neonatal death rate at 42 weeks is 2-3 times higher than at 40 weeks. The longer a pregnancy goes beyond 42 weeks, the higher the neonatal mortality rate.

3:19 PM  
Anonymous maribeth, cnm said...

Dr. Amy’s critiques of the studies demonstrating the safety of homebirth are fatally flawed. Furthermore, her comments of “let’s just stick to the facts of the argument please” are hypocritical.

First, from the British Journal of Medicine: “At first sight this (home birth statistics) seem to endorse the view that hospital is the safest place to deliver. But 97% of these perinatal deaths at home were recorded in women who were actually booked for a hospital delivery or had no prearranged plan for delivery. The perinatal outcome in planned home births was better than for all women giving birth in the region--a result in line with Swiss and Dutch findings”. Somehow Dr. Amy considers European studies beneath the American audience… which I will never understand nor accept.

Do we all understand why studies demonstrating the “gold standard” of research in homebirth are difficult, if not impossible, to achieve? From the BMJ: “A randomised controlled trial would help to resolve the controversy over the relative safety of home and hospital birth, but conditions for a "fair" trial are difficult to achieve. Such a study would require large numbers because of the low frequency of adverse events, and the necessary environment of experienced home deliveries has virtually disappeared”. Would YOU be willing to have your birth randomized to home or hospital delivery? I know I would not.

Dr. Amy and other hospital birth advocates repeatedly refuse to acknowledge that only they, and not the expert organizations, claim hospital birth to be safer than home birth. So I invite you all to enter the challenge posed by Jock Doubleday. He has a legally binding contract which agrees to pay $50,000 usd to the first person who can use a study to show that hospital birth is safer than home birth. Guess what – no one has won so far. Go on and try why don’t you? www.spontaneouscreation.org

So, let us take the most recent, and well-done study by Johnson and Furniss in 2000. First of all, Dr. Amy states: “As far as the BMJ study is concerned, it also suffers from serious problems rendering it essentially useless”. This is nothing but blatant, unsupported propoganda. The BMJ is an excellent, respected, peer-reviewed, evidence-based clinical journal. If a study got in there, trust that it has withstood all criteria of research rigor. This is the Nth time that Dr. Amy claims to be more correct than an expert body – and yet refuses to acknowlege the inanity of this. This study would have been published by an American OB source, if the journals weren’t too busy asking ACOG to stop stealing the bed covers.

Dr. Amy goes on to say of the Johnson/Furniss study: “It is based on self reports by midwives. Would you base a study on the safety of hospital births on self reports by doctors?”. Which would certainly be a valid point, if the study did not specifically state that 10% of all records were randomly pulled for validation of data and not ONE discrepancy was found.

Dr. Amy then says: “Second, when you do the calculations, the actual death rates are: 2.6/1000 singleton births / 2.8/1000 twin births / 25/1000 breech births”. Now, if this conversation was about the homebirth safety of twins or breeches at home, I would concur. But I thought we were discussing the safety of healthy, low-risk women births at home as compared to the hospital. I agree that neither twins nor breeches are low-risk, and that data shows the best outcomes for each when in hospital. And, contrary to Dr. Amy’s words, the study states that “The intrapartum and neonatal mortality was 1.7 deaths per 1000 low risk intended home births after planned breeches and twins (not considered low risk) were excluded”. So go ahead and compare this to Dr. Amy’s quoted statistic of 7/1000. The safer option seems obvious.

Dr. Amy intends to include the women presenting in labor without fetal heart tones within the intrapartum death rate, when actually, this is considered a fetal death and is NOT considered in any American intrapartum death statistics. These are not deaths that specifically happen in transport of either the mother to the hospital or the midwife to the home. Likely, most deaths occurred well before the onset of labor. This is an inherent risk of pregnancy, is not affected in any way by place of birth, and affects even the lowest-risk women.

On top of that, Dr. Amy often harps on homebirths serving only socially low-risk women (hence her frequent reference to “white women during the same time period”). Well, the Johnson and Furniss study clarified that “Women who started birth at home were on average older, of a lower socioeconomic status…. than women having full gestation, vertex, singleton hospital births in the United States in 2000”. So whoops, there goes that assertion. In fact, it’s a very important point, which deserves to be heard: OB doctors only care about midwives taking the white, insured clients. They are frequent participants in policy-making for midwives to care for indigent (read: underinsured) populations. CNMs do 90% of the deliveries in the Indian Health Service, an incredibly high-risk population. Now, what does that say about ethics? Is maternal/ fetal outcome really the yardstick being used here folks?

Dr. Amy’s statistical analyses seem based more on exaggeration and the convenience of no other posters having access to the full text studies than on reality. Likewise, she has yet to respond to the challenge that while somehow neither the Cochrane Database nor the World Health Organization assert hospital birth to be safer than homebirth, SHE is really the one to listen to.

Later, Dr. Amy says that a meta-analysis of European studies on the safety of homebirth is not a real study. Get real! The authors included ALL quality studies in the meta-analysis, there was no picking and choosing. Meta-analysis, though I know Dr. Amy knows this, means “super study”. Entire national health policies have been built around this paper, yet it’s not good enough for Dr. Amy. Xenophobia if I ever saw it. Talk about picking and choosing…

Dr. Amy then says that she feels 10%, and possibly less, of deliveries should be accomplished by c/section. So, how does that compare to the 28% national rate last reported in the US? It has been proven (and re-proven) that maternal morbidity and mortality is increased four-fold in cesarean delivery as compared to vaginal birth. So, if you consider that, in that 18+% unnecessary c/section rate, some hundreds of thousands of c/sections, with a four-fold increase in morbidity and mortality, must be undertaken to save one maternal or fetal life for non-c/s related causes? And morbidity is no small factor. You guys seem to want to analyze it exclusively by the measure of morbidity. Screw them nasty iatrogenic infections, screw them devastating complications of anesthesia, screw them problems of neonatal transition!

Home birth is safer than hospital birth for healthy, low-risk women in the presence of a professional birth attendant.

11:49 PM  
Anonymous maribeth, cnm said...

Meant to say in that last paragraph, exclusively by the yardstick of mortality.

11:54 PM  
Blogger Amy Tuteur, MD said...

Maribeth, CNM:

"First, from the British Journal of Medicine: “At first sight this (home birth statistics) seem to endorse the view that hospital is the safest place to deliver...."

I don't see this in the BMJ paper. Can you tell me what page it is on?

"A randomised controlled trial would help to resolve the controversy over the relative safety of home and hospital birth ..."

I'm not sure why you are including this quote. It proves MY point that this study is inferior, not your point that we should accept the results.

"“Second, when you do the calculations, the actual death rates are: 2.6/1000 singleton births / 2.8/1000 twin births / 25/1000 breech births”. Now, if this conversation was about the homebirth safety of twins or breeches at home, I would concur."

That may be what the discussion is about, but it is not what the paper is about. The paper is about outcomes of planned homebirths. I think the midwives who attempted to deliver twins and breech at home were criminally negligent, but the midwives evidentally didn't understand the risk. That speaks to the quality of their judgment: poor.

"In fact, it’s a very important point, which deserves to be heard: OB doctors only care about midwives taking the white, insured clients."

Now that's funny. Homebirth is all about the 4 W's: white, well educated, wealthy and Western. Homebirth advocates seem to assume that their Euro-centric notions of self-actualization, empowerment and the conception of pain as enobling are shared by everyone.

I don't understand why homebirth advocates never think to ask themselves why women from other cultures and non-European countries are uninterested in homebirth midwifery. I guess that the reasoning of white, well educated women is supposed to be privileged above that of non-white women.

As I said before, your conspiracy theory about obstetricians needing more patients is flat out wrong (and you provide no evidence for it either), but it is hardly the fault of obstetricians that homebirth midwifery is all about white women with insurance!

"Home birth is safer than hospital birth for healthy, low-risk women in the presence of a professional birth attendant."

You may think so, but you certainly haven't offered any proof. Besides, let's be honest here: you wouldn't change your mind under any circumstances. Homebirth advocacy is about faith, not fact.

9:49 AM  
Anonymous maribeth, cnm said...

Dr. Amy, the first quote is from the editorial of that issue.

The fact that the study is not randomized, well, duh. Neither of course are the studies demonstrating the “safety” of hospital birth. For self-evident reasons previously discussed.

Your post is similarly non-responsive in the pattern of prior ones. It’s as if the valid points don’t exist. As if your assertion at the end is no less true of yourself. So tell us, are you going to try the Jock Doubleday challenge?

I am not, and never was, arguing that breech or twin birth homebirth are safer than hospital birth. Sorry if unclear on that point.

In talking about the racial and socioeconomic population of women choosing homebirth, you’re right (for now). However, more states are beginning to pay Medicaid to out of hospital birth midwives, which will open the door for more women of color and poor women. Good news! My point about OBs not caring that midwives serve indigent and rural women applies to CNMs and hospital birth.

I never had a theory that OBs need more patients. I do have a theory that midwives threaten their pocket books and power trips. But, let’s agree to leave that be, as it’s not particularly germane to the discussion, which surely our host is tiring of.

I don’t understand your point about other cultures not wanting homebirth? Of course, in the developing world, most women DO birth at home. Now, I’m not saying that’s ideal, as the parameters of safety (qualified attendant, adequate supplies, hygienic space, availability of transport) are usually non-existent. I've worked internationally in Safe Motherhood programs and am well informed in that arena.

I strongly disagree that the safety of homebirth has not been proven. I think the fact that your critiques of studies crumble under pressure is very telling. If it’s good enough for the WHO, it’s good enough for me. And below are sources which reported, based upon the Johnson Furniss study, that home birth is a safe option. Great news!

OBGYNworld.com
WebMD.com
Reuter
Fox News
MSNBC
CBC.ca (Canadian source)
Yahoo News
Forbes

And here are some further studies demonstrating the safety of homebirth. Again, these are the data upon which the Cochrane Database, the WHO, and entire national policies in Europe base their recommendation that homebirth is at least as safe as hospital birth. Likewise, in contrast to ACOG (who has a vested interest), the American Public Health association introduced a resolution in 2001 aiming to increase access to out of hospital birth, attended by professional midwives.

If you want me to post the hospital studies which show similar M&M numbers (with much more intervention) I will gladly do so. (As Dr. Amy’s long list never seem to have made it to the posts).

Prospective regional study of planned home births
Davies J, Hey E, Reid W, Young G.
BMJ 1996;313:1302-5.

The Northern Region's Perinatal Mortality Survey Coordinating Group. Collaborative survey of perinatal loss in planned and unplanned home births
BMJ 1996;313:1306-9.

Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands.
Wiegers TA, Keirse MJNC, van der Zee J, Berghs GAH.,
BMJ 1996;313:1309-13.

Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome.
Ackermann-Liebrich U, Voegeli T, Gunter-Witt K, Kunz I, Zullig M, Schindler C, Maurer M, Zurich Study Team
BMJ No 7068 Volume 313

Place of birth
Luke Zander, Geoffrey Chamberlain.
BMJ 1999;318:721-723 ( 13 March )

Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia [full-text article]
P.A. Janssen, S.K. Lee, E.M. Ryan, D.J. Etches, D.F. Farquharson, D. Peacock, M.C. Klein
CMAJ 2002:166(3)

Are home births safe?
Régis Blais
CMAJ 2002;166(3):335-6

Safest birth attendants: recent Dutch evidence
Marjorie Tew, S M I Damstra-Wijmenga
Midwifery (1991) 7, 55-63

Time of birth and the risk of neonatal death.
Gould JB, Qin C, Chavez G.
Obstet Gynecol. 2005 Aug;106(2):352-8.

12:37 PM  
Anonymous maribeth, cnm said...

A peek into evidence of the risks of hospital birth:

In a study of ten hospitals in the greater Chicago area, reported in 2000, the maternal mortality rate there was twice as high as reported by the CDC. Furthermore, on investigation of each case, these Chicago obstetricians found that 37 percent of the deaths were preventable. In the preventable cases, mistakes by doctors and nurses were determined to be the cause of death more than 80 percent of the time. Unfortunately, as is nearly always the case, the study made no attempt to determine how many of the deaths were related to obstetric interventions such as induction of labor, epidural block, and cesarean section.

A. Panting-Kemp, et al., "Maternal Deaths in an Urban Perinatal Network: 1992-1998," Amer J Obst Gyn 183 (2000): 1207-12.

12:40 PM  
Blogger Robin Tell said...

Quickly: my apologies for falling silent, daily life has interfered, but I will be back. (Though Maribeth is covering much ground better than I ever could, at the moment.)

2:12 PM  
Blogger Amy Tuteur, MD said...

Ok, Maribeth, tell us what the studies showed. You have read them, right? Otherwise, how would you know that they support your case? Or are you just throwing them out there to confuse the issue?

I will point out, though, that if other people thought those studies were definitive, they would not quote the other 3 first. Since we already know that the 3 papers most widely quoted as supporting homebirth actually have perinatal mortality rates higher than expected, you shouldn't get your hopes up that these are going to support your case.

Most importantly, the three most widely quoted papers show precisely what you would expect to find in a homebirth study:

most babies will do fine; no assistance of any kind will be needed

some babies will get into trouble during labor and the moms will be transferred to the hospital where obstetricians and neonatologists will save the babies' lives

some babies will be born with unanticipated anomalies, or there will be a cord accident or abruption and those babies will die for lack of appropriate medical care.

This is what prospective parents have to keep in mind. In the vast majority of cases, nothing is going to go wrong and anyone can deliver the baby. Yet there is ALWAYS as small chance that an emergency will occur and the baby will die because the people the baby needs (obstetricians, anesthesiologist and especially neonatologists) are not present.

No one is arguing that homebirth midwives cause these deaths. It's just that homebirth midwives cannot prevent them. If you want to gamble that one of these unusual circumstances won't happen to you, that's fine. If it doesn't happen (and most likely it won't; the odds are less than 1%) everything will be fine. However, if it does happen, your baby will die. Simple as that.

Homebirth will not and cannot be safe until we improve our ability to diagnose these rare problems before labor begins.

4:05 PM  
Anonymous maribeth, cnm said...

Again Dr. Amy specifically avoids answering questions and responding to important points, while the rest of us respond to hers, muddying the water as a debate technique.

6:06 PM  
Anonymous frectis said...

Homebirth will not and cannot be safe until we improve our ability to diagnose these rare problems before labor begins.

Do you have some idea that we are practicing in caves with no access to technology, labs, and referral whether it be collaborative or consultatory? 95% of my clients have an ultrasound (or more) during pregnancy and 100% of them have regular ACOG recommended labs drawn. I know with certainty my clients (that is mother and baby) are healthy prior to the onset of labor and do not take the risk of anything falling outside normal parameters on faith that everything will work out in my favor. If they are not low risk prior to labor or their status changes during labor, they're your patient. I don't rely on star patterns and tea leaves to assess and maintain health, nor am I a midwife who believes in home birth at all costs.

8:33 PM  
Blogger Amy Tuteur, MD said...

Frectis:

"I know with certainty my clients (that is mother and baby) are healthy prior to the onset of labor ..."

No, you don't, and that is precisely my point. You cannot know with certainty that the baby does not have a congenital anomaly. You cannot know with certainty that there will not be a cord accident. You cannot know with certainty that there will not be an abruption in labor. You cannot know because NO ONE can know that.

If it could be determined with certainty which babies will experience these events, then homebirth would most likely be safe. Until then, it can never be safer than delivering in a hospital.

10:01 PM  
Blogger Amy Tuteur, MD said...

Maribeth, CNM

"Again Dr. Amy specifically avoids ..."

I guess that means that you haven't read the papers you invoked to support your position.

10:08 PM  
Blogger Amy Tuteur, MD said...

Maribeth, CNM

I just finished reading all of the 9 papers you mentioned.

The Zander paper and the Blais paper are not studies, they are opinion pieces.

The Gould paper does not involve homebirth.

The Davis study included only 250 women. Obviously, when you are studying a phenomenon that is measured per thousand, 250 is far too small to be statistically significant.

The Northern Region study has a perinatal mortality rate of 4.8/1000 and then proceeds to compare it to hospital births that include high risk patients.

Ackermann-Liebrich study has less than 500 women in each group and attempts to compare the home birth group to a hospital group which contained high risk patients.

Wiegers study showed a homebirth death rate of 3.5/1000 and compared to a hospital rate of 2.9/1000. They hid this in a "perinatal index" that included over 20 different factors like episiotomy, etc. Only the "perinatal index" of the two groups was equivalent, not the death rate. In addition the hospital group was a higher risk group.

Tew compares midwives to all hospital births including high risk.

So now we know why no one reputable quotes these papers. They are all poorly done, or not statistically significant, or compare homebirth to hospital groups that contain high risk women.

11:07 PM  
Anonymous FRECTIS said...

No, you don't, and that is precisely my point.

Thanks to technology, laboratory studies, and a tight list of parameters to work with for risk assessment, I do know who is a healthy candidate for home birth prior to the onset of labor.

You cannot know with certainty that the baby does not have a congenital anomaly.

Wait... isn't one aspect of ultrasound used for the detection of congenital anomalies? If not, why am I referring to these consultants? Why do I send my AMA women to genetic screening consultants if I am not trying to assess risk and detect problems? It sounds like I might have a better shot with a crystal ball it seems you're saying.

You cannot know with certainty that there will not be a cord accident. You cannot know with certainty that there will not be an abruption in labor.

Now, now. These natural accidents have nothing to do with planning a home birth. Why bother to bring them up?

11:51 PM  
Anonymous colleen said...

Three papers presented. All three show that more babies died at home than in the hospital. Furthermore, based on the information presented by the studies' authors, most if not all of these babies died of preventable causes.

Confronted with this, many people are trying to change the topic to the hospital experience, to whether obstetricians are good or bad, or anything else but the matter at hand.


Speaking for myself, the topic of hospital experience isn't meant as a refutation that babies die of preventable causes in some home births. Rather, I'd like to see fewer preventable perinatal deaths, period. As far as relevance to discussion goes, the original post was about a death after home birth with an uncertified midwife; all of the comments are somewhat off of _that_ topic. :)

In any case, safety is not the only aspect of the decisions people make about where to have their babies. So it seems like if you believe that hospital births are safer, considering ways to make hospital births a less traumatic experience would have a very real, positive effect on perinatal mortality.

1:50 AM  
Anonymous maribeth, cnm said...

I have made a counter point to Dr. Amy’s critique of the Johnson Furniss study showing an actual mortality rate of 1.7:1000, a four-fold decrease compared to similar, low-risk hospital births. Thus, this first study shows homebirth to be at least as safe as (if not safer than) hospital birth.

Regarding the Murphy Fullerton study, Dr. Amy claims that the two who presented in labor without fetal heart tones should be included as an intrapartal death rather than a fetal death, and hints that possibly the midwives were lying about when the deaths actually occurred. She suggests the authors decided to leave out these numbers in an effort to improve the outcome statistics. Besides being slanderous to both the midwives and authors, it’s unfair. First of all, as reported in the study, random sampling showed a 100% agreement for major outcome variables (this is the second study for which Dr. Amy has erroneously tried to malign the validity of midwives’ data). 100% agreement of reports in a prospective study is significantly more reliable than normal sampling error. Her point is again rendered invalid.

Dr. Amy says IUFDs should be counted because the women ”intended to deliver at home” (as if intention killed the babies) and labored at home prior to the midwife arrival. Likewise, of course, women who intend to deliver at the hospital first labor at home. But Dr. Amy does not require that women presenting to the hospital without fetal heart tones be put into the intrapartum death rate of planned hospital births. So let’s compare apples with apples.

We’re back to the intrapartal and neonatal mortality rate of 1.8 / 1000 home births, much lower than hospital statistics. She tries to cast doubt on that number by then arguing that two of the births were “entirely preventable” because they were both 42+ weeks gestation with the presence of meconium-staining. No matter that it is well accepted that many deaths in hospital (both fetal, maternal and neonatal) are “entirely preventable”. See my recent post for more on that. But anyway, if we were to induce ALL women at say, 40 or 41 weeks, Dr. Amy seems to be saying that mortality would be decreased. Something she does not know. So, is that 18% unnecessary c/section rate with a 4 times greater likelihood of maternal morbidity and mortality factored into that equation?

I’m still interested to hear Dr. Amy’s response why a meta-analysis cannot be included in our discussion. When in fact, the Cochrane Review is just one big meta-analysis.

Interesting too that in Dr. Amy’s last response to me, outlining other home birth studies, she quotes statistics uncorrected for prematurity and congenital anomalies, even though the real homebirth statistics, with corrections, are in the papers. (And yes, I have read them).

An example of Dr. Amy’s magic: Regarding the Northern Region Perinatal Mortality Survey Coordinating Group’s study of 558,691 births over a 13 year time period, she states: “The Northern Region study has a perinatal mortality rate of 4.8/1000 and then proceeds to compare it to hospital births that include high risk patients.” When in fact, the study clearly explains most of the mortalities were unintentional (precipitous), and unattended home birth: “Perinatal loss to the 64 women who booked for hospital delivery but delivered outside and to the 67 women who delivered outside hospital without ever making arrangements to receive professional care during labour accounted for the high perinatal mortality (134 deaths in 3466 deliveries) among all births outside hospital”. The study goes on to say that "only three of 134 deaths were associated with planned home birth. Over three quarters of the perinatal deaths associated with planned home birth occurred in hospital. Perinatal mortality in the few (<1%) pregnancies in which home birth had been planned was less than half the average for all births, and few of these deaths were associated with substandard care".

Does Dr. Amy’s attempt to skew data, repeatedly, show a pattern and an unprofessional bias in trying to sway opinion? I think so.

Small studies are included because together they form the composite upon which valuable information can be drawn. These are, of course, the studies upon which the WHO and national policies are set in support of homebirth.

Do forgive me, the Gould paper was indeed included inadvertently. This was meant to be included in my list of the risks, including mortality, of hospital birth. Well, this paper demonstrates an even higher than average risk of death for babies born at nighttime. Why? Because the alleged “benefits” of hospital birth – OR teams, anesthesia, pediatrician and neonatologist care, etc – are no longer available. Only in modern obstetrics is this paper an impetus for more inductions and augmentations, which is how it’s been used several times lately.

Dr. Amy has provided a wealth of quotes that can be used to justify why healthy, low-risk women should work hard to avoid the average OB. Here’s another: “If you want to gamble that one of these unusual circumstances won't happen to you, that's fine. If it doesn't happen (and most likely it won't; the odds are less than 1%) everything will be fine. However, if it does happen, your baby will die. Simple as that.”

She is now purporting about a 1% death rate for all babies! All this fear, how COULD she see the studies without such dreadful bias, how could she treat a laboring woman as anything BUT a disaster waiting to happen? And when that happens – interventions, mistakes, iatrogenic complications happen, resulting in increased morbidity and mortality, a HELL of a lot more frequently than unpreventable OB emergencies like a cord prolapse or an abruption happen to healthy, low-risk women.

1:57 AM  
Anonymous maribeth, cnm said...

There's a point, slightly off topic, that I've been meaning to get back to. It was so rude it warrants response.

Regarding the Fullerton Murphy study of 29 US nurse-midwifery practices attending homebirths from 94-95, Dr. Amy wrote:

"There were 1318 women enrolled in the study, the pre-labor stillbirth rate was 7.6/1000. The baseline IUFD rate (for all women, not just low risk) is 5.1/1000, this is pretty remarkable. It is 50% greater than the population as a whole. It raises the possibility the the prenatal care in the midwifery group was substandard."

Now, first off, we see the problem of Dr. Amy saying "doubled" for a rate from 5.1 to 7.6. More magic.

You would think that Dr. Amy, who has worked for long times with as many as 20 certified nurse-midwives, would have some basic respect for my profession. But the quote above seems to demonstrate otherwise.

So that everyone knows, professional, nurse-midwifery care has been proven SAFE. It's obviously a whole 'nother topic, so we don't need to discuss it further.

The slightly higher than average stillbirth rate in the study above occured because 32% of the enrolled study participants were either Old Order Amish or Mennonite. This is the population that I serve. Our families face an enormous burden of genetic disease. No test, no procedure, no doctor can save most of these babies, a significant portion of whom die before term.

2:19 AM  
Blogger Amy Tuteur, MD said...

Frectis:

"Now, now. These natural accidents [cord accident, abruption] have nothing to do with planning a home birth. Why bother to bring them up?"

Why? They account for a substantial number of deaths at homebirths, that's why. Furthermore, these are preventable deaths in the hospital setting. They are exactly the kind of complications that demonstrate why homebirth will never be safer than hospital birth.

Colleen:

"if you believe that hospital births are safer, considering ways to make hospital births a less traumatic experience would have a very real, positive effect on perinatal mortality."

I agree 100%.

Maribeth, CNM:

You need to check out a basic statistics book. I don't mean this in a pejorative way; it's just that you don't appear to know about some basic principles of statistics. It puts you at an unfair disadvantage to me in analyzing the actual papers.

Specifically, you need to read up on the characteristics of a study that is statistically valid compared to one that is not. You don't seem to understand that when I say a study is not statistically valid, I am not stating my personal opinion: I am saying that the study does not meet the criteria defined by statisticians for a valid study.

So, for example:

1. Self-reporting violates one of the most basic principles of a scientific study. In certain settings, self-reporting cannot be avoided, but in the case of birth, there are multiple other sources (birth certificates, hospital records).

The authors of those studies know this, and in the Murphy Fullerton study they attempt to answer the criticism in advance. Basically they say that they checked up on 10% of the self reports and all those panned out. They then extrapolate to assume that 100% of the self reports were correct.

2. You don't get to define your own terms, you need to stick to the established definitions. An IUFD is a death that occurs before the onset of labor and an intrapartum death occurs in labor (and is part of the perinatal and neonatal mortality rate). You can't take an intrapartum death and put it into the IUFD category. You can try to argue that it was not ascribable to home birth but that is a different argument.

3."I’m still interested to hear Dr. Amy’s response why a meta-analysis cannot be included in our discussion."

Again, you seem to think that this is my personal opinion. Statistically, a meta-analysis is inferior to an actual study, for obvious reasons. The author chooses the studies that will be included and excluded, thereby biasing the data. Moreover, aggregating data from lousy studies does not make the resulting meta-analysis more valid than the original lousy data.

4. "Interesting too that in Dr. Amy’s last response to me, outlining other home birth studies, she quotes statistics uncorrected for prematurity and congenital anomalies, even though the real homebirth statistics, with corrections, are in the papers."

Again, this is not my personal opinion. In order for the study to be statistically valid you aren't allowed to exclude these data. Moreover (and I think that this should be obvious), if you try to exclude those data, you MUST remove the same categories from the hospital group.

5."The study [Northern Region] goes on to say that "only three of 134 deaths were associated with planned home birth. Over three quarters of the perinatal deaths associated with planned home birth occurred in hospital."

This study is particularly egregious in the way it slices and dices the data to obscure the outcomes. I'm not suprised that you are confused by it.

If you look carefully at the study, you will see that it says that 14 deaths occured in the planned homebirth group of 2888 (for a perinatal death rate of 4.8/1000). The other 120 deaths occured in women who accidentally delivered outside the hospital. The primary conclusion of the study is that planned homebirth had a lower death rate than accidental homebirth. Well, that's hardly an impressive endorsement of homebirth.

While only 3 of the 14 deaths in the homebirth group occured at home, the rest occured in the hospital after the homebirth patients were transferred there. Hence these deaths MUST be included in the homebirth group.

6. "Small studies are included because together they form the composite upon which valuable information can be drawn."

No, according the rules of statistics, those studies are not valid, and lumping them together does not improve validity.

Finally:

"interventions, mistakes, iatrogenic complications happen, resulting in increased morbidity and mortality, a HELL of a lot more frequently than unpreventable OB emergencies like a cord prolapse or an abruption happen to healthy, low-risk women."

That's your opinion. You haven't presented a single study of hospital and homebirth that shows that.

And as far as the "rude" comment is concerned where you say:

"Now, first off, we see the problem of Dr. Amy saying "doubled" for a rate from 5.1 to 7.6. More magic."

Go back and read it again. I did not say the IUFD rate doubled, I said it increased by 50%. Doubling would mean increasing by 100%.

Bottom line: all of the studies you quote are as lousy and statistically invalid as I said they were. Just pick up a basic statistics textbook and you will see that this is because they do not follow the rules of statistics.

10:38 AM  
Anonymous maribeth, cnm said...

Dr. Amy, regarding your last paragraph - your clarification does not change the rudeness of the comment nor the fact that your lack of understanding of the high stillbirth rate showed either an incomplete reading of the data or an intentional act to pretend the clarification of the data was not there. As you have done with other studies.

The statistical rules you cover have nothing to do with my critique that you are using statistics to your convenience (see several posts in this thread last week for more such allegations, along with my own). You repeatedly pick and choose numbers out of them to suit your case.

First of all - In 2001, data from the National Center for Health Statistics show a US national average fetal mortality rate of 6.5 deaths per 1000 births, not 5.1 as you quoted.

Where have you found evidence that women who present to care (at either home, hospital or a routine prenatal visit) without FHTs are classified as intrapartum deaths rather than fetal deaths?

For the what, third time? You know as well as I that a controlled randomized study cannot be done to compare home vs. hospital births. Stop acting as though the studies are inferior because they cannot meet that criteria, as of course neither can hospital births.

A 10% agreement rate from random sampling of the homebirth reports is an appropriate statistical measure. You well know that 100% of birth certificates are not pulled to obtain a national statistic. It's more like, what, 1.34% or something? Include sampling error in that then too. We ALL know statistics need to be extrapolated, Dr. Amy.

I'm pretty sure that you are asking for the studies of similar low-risk hospital births because you do not know them. You have never once quoted the mortality rate for low-risk hospital births. Therefore, of course, it's understandable that you do not know that those numbers are indeed controlled for issues like prematurity and congenital anomalies. The intrapartum and neonatal death rates are equal as compared to healthy low-risk women birthing out of hospital with qualified attendents.

Dr. Amy, surely everyone is tiring of this back and forth. I am. I agree to disagree with you on the safety of homebirth. I ask other individuals not to listen to Dr. Amy (saying homebirth is safe) and not to me or even expert organizations like the World Health Organization and the American Public Health Association (which say that homebirth is as safe as hospital birth). Do the research yourself. Give birth where, and with whom, you feel most comfortable and safe. Do you want to be able to blame a doctor if something goes wrong, a reason Dr. Amy endorses hospital birth over home? Go to the hospital. Do you believe that you are a partner in your own health care and that hospital is for sick people? Consider staying at home. Is there a freestanding birth center in your area? Consider that, but don't be fooled by birth centers attached to hospitals, as they are just hospitals with pretty packages. No place of birth will ever be right for every family, but one of them is just right for yours.

12:46 PM  
Anonymous FRECTIS said...

Why? They account for a substantial number of deaths at homebirths, that's why. Furthermore, these are preventable deaths in the hospital setting. They are exactly the kind of complications that demonstrate why homebirth will never be safer than hospital birth.

Amy, how will the hospital and an obstetrician prevent a cord prolapse or abruption for my planned home birth client who happens to be in yoga class, standing on line at the grocery, or flying in an airplane at the time? What has home birth got to do with it? These accidents don't only happen to home birth clients and they are certainly not intrapartum issues. You're starting to sound really silly by asserting the intention of home birth has some sort of effect on outcomes.

Here's an anecdotal story (retold from her medical record) about my current client whose baby was SAVED by the obstetrician who was caring for her: She was admitted for her planned induction for her second baby. When it came time to AROM her, there was something up aside the head. In order to diagnose the thing, the examiner yanked on it. Oh, it was a cord and now it's prolapsed! And now she's a VBAC. But you are right, the doctor and facilities saved her baby's life. And you're also right, it was preventable.

1:05 PM  
Blogger Amy Tuteur, MD said...

Maribeth, CNM:

I am more than willing to let people read what we have written and then decide. I have answered you point for point, and the only reason I have not addressed more of your points is that we would go on and on and on. Don't be confused, though; that doesn't mean I couldn't do so, easily.

Furthermore, you seem to think that this is somehow about me, and I guess it would make it easier for you if it were just about me. However, I am only conveying what statisticians, obstetricians and other scientists would tell you.

We've sliced and diced the data a zillion ways and this is what we have found:

There is not a single paper that shows homebirth is safer than hospital birth.

The deaths in the homebirth setting are often due to unpredictable, catastrophic problems that could never be treated at home.

As the proportion of US deliveries in hospitals rose, the maternal and neonatal death rate fell.

From my point of view, the most important thing that we have shown is that the notion that birth is, in and of itself, a safe phase of life is flatly false. Birth is one of the most dangerous times of life for mother, and especially for baby. This has been true since the beginning of time, and it remains true today. The only difference now is that obstetricians and neonatalogists have great success in preventing and treating these deadly complications (and midwives copy them).

As I have said quite a few times, because homebirth advocacy is based on a flatly (and obviously) false premise, it is not surprising that its conclusions are also false.

1:20 PM  
Anonymous maribeth, cnm said...

Dr. Amy, by no means did I think it was about you, personally. I know you were acting at point-woman.

Question: how do you rectify the fact that the expert organizations (inclusive of statisticians, obstetricians, global health policy makers, and so on), reading the same studies you claim to show higher death rates at home, disagree with your conclusion?

Even the entire state of California now has public policy stating homebirth is as safe an option as hospital birth:

SB 1479 ~ Amendment to the Licensed Midwifery Practice Act of 1993 APPROVED BY GOVERNOR SEPTEMBER 1, 2000

~INTRODUCED BY Senator Liz Figueroa ~ Co-authors: Senators Ray Haynes and John Vasconcellos
Co-authors: Assembly Members Audie Bock and Kerry Mazzoni

An act relating to midwifery

Section 4 ~ THE LEGISLATURE FINDS AND DECLARES THAT:

(a) Childbirth is a normal process of the human body and not a disease.
(b) Every woman has a right to choose her birth setting from the full range of safe options available in her community.
(c) The midwifery model of care emphasizes a commitment to informed choice, continuity of individualized care, and sensitivity to the emotional and spiritual aspects of childbearing, and includes monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle; providing the mother with individualized education, counseling, prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support; minimizing technological interventions; and identifying and referring women who require obstetrical attention.
(d) Numerous studies have associated professional midwifery care with safety, good outcomes, and cost-effectiveness in the United States and in other countries. California studies suggest that low-risk women who choose a natural childbirth approach in an out-of-hospital setting will experience as low a perinatal mortality as low-risk women who choose a hospital birth under management of an obstetrician, including unfavorable results for transfer from the home to the hospital.
(e) The midwifery model of care is an important option within comprehensive health care for women and their families and should be a choice made available to all women who are appropriate for and interested in home birth.

And finally, I've asked three times and am really curious for an answer: are you going to take the Jock Doubleday challenge? You seem confident enough in your conclusions to try to do so. Good luck!

2:50 PM  
Anonymous maribeth, cnm said...

PS -- Thank you Neonatal Doc for letting us play in your sandbox :)

2:54 PM  
Blogger Amy Tuteur, MD said...

Maribeth, CNM:

Different organizations have different policies depending on what level of risk they think is acceptable. That is completely independent of the scientific evidence.

You are free to draw your own conclusions from what we have discussed. You may have a higher willingness to accept risk than I do. However, there is no scientific evidence that shows homebirth to be as safe as hospital birth.

"And finally, I've asked three times and am really curious for an answer: are you going to take the Jock Doubleday challenge?"

This is science, Maribeth, not a game show. I'm not interested in winning; I am interested in the truth.

3:50 PM  
Anonymous maribeth, cnm said...

To be fair, expert organizations do not endorse the safety of homebirth on some individual definition of risk. It's based on critical analysis of the safety of homebirth versus the safety of hospital birth for healthy low-risk women with a qualified birth attendant, by outcome measures of the very same studies we've discussed.

4:13 PM  
Blogger sailorman said...

maribeth, I hope you don't find honesty insulting. If so, the Web is not for you.

I would make a couple of suggestions:
1) You need to learn how statistics work. It is impossible to teach you statistics in the middle of an argument. Your points, which claim to 'reply on' statistics, are simply wrong.

2) You need to stop acting like we are idiots. When you quote articles "in support" of a point, which turn out to be entirely irrelevant (see above posts) you look like a fraud. Citing Jock Doublespeak doesn't help.

Anyway....

Remember those "choices" I posted earlier? Thay're still valid. If you protest the home birth is "as safe", you need to eithter
1) Claim there are NO situations in which--no matter what the intentions--a death can be prevented in the hospital but not at home. We all know this is wrong and logically so:
-Some number of problems cannot be predicted prior to birth/labor.
-Of those conditions, some can be addressed in a hospital and not at home.
-Of those, some infants will die at home, but NOT die in the hospital.

What you are proposing seems to be a corruption of statistics. Yes: home birth is just as safe as hospitals, if you only count the babies who survive home birth, and push all the problems home births out of the category. It's the "no true Scotsman" logical fallacy; Google it if you want.


And in that vein, you said:
"Furthermore, on investigation of each case, these Chicago obstetricians found that 37 percent of the deaths were preventable."

This is completely meaningless in the absence of a comparative number, which you do not provide.

Back to statistics. Having performed meta-analyses, i can tell you that to "combine many smaller studies to find a larger overall result" is almost NEVER acceptable. It is ONLY really relevant in ver carefully designed tests which have an extraordinary similarity (and these do not). This meta-analysis is simply poor statistics.

Incidentally, re Jonk Doubleday: This "challenge" is purely a political tool to "convince" suckers. Jock's behavior re vaccines has shown him to either be a fraud, or someone who carefully crafts a challenge which is unwinnable. For example, I have personally read blogs of doctors who have tried to take his challenge, and he's found ways to 'disqualify' them--surprise!

You might find an interesting summary of this here:
http://www.ratbags.com/rsoles/comment/boguschallenges.htm

And you might see an example of how these "challenges" are generally rigged here:
http://www.ratbags.com/rsoles/comment/boguschallenges.htm

If you think his home birth "challenge" is really valid, why don't you post the full text here (I can't find it online). I'll be happy to show you why (like the vaccine challenge) it's a fraud.

Or, how 'bout this: I'll start my own challenge: I can give you $10,000 if you can conclusively prove beyond any doubt, subject to a scientific board review, EITHER OF THESE: 1) that every baby who died of a "preventable" death during a hospital delivery, would not have died at a home birth; OR; 2) that every baby who died in a home birth would have also dies had the birth taken place in a hospital.

Good luck in the challenge.

12:30 PM  
Anonymous maribeth, CNM said...

Sailor man, your formula for the definition of safety of homebirth is just that – YOUR definition. You cannot take one measure and call it the whole yardstick. Nobody ever claimed that every birth, regardless of setting, is preventable (nor someone's fault). Nobody ever claimed that some home birth deaths could not have been saved in the hospital or that likewise some deaths related to medical error or inappropriate use of intervention in the hospital could never have occurred at home.

I reiterate: you underestimate the risk of normal birth in the hospital and seem to over-estimate the benefit. You’re basically saying: never have a baby at home because (as one example) 'IF you have a cord prolapse your baby is more likely to die and if that's true then homebirth is unsafe'. But, at home (as one example) you’re about 7 times less likely to have a c/section, and risk death related to complications of anesthesia and hemorrhage from surgical trauma. You can't measure benefit without also measuring risk (for either place of birth) - and that's what I think your formula is lacking.

Whether you like it or not, whether you agree with it or not, my 'fraudulent' interpretations of the data are the very same as national and global public health organizations. Read the WHO policy piece on place of birth. Read the CA legislation. Read the APHA statement. Read the AIMS information. Go talk with the Ministries of Health of many countries. All have concluded that studies comparing potential risks and potential benefits of home versus hospital birth demonstrate equal safety.

I’m on call 24:7 and at this point, need to say, go argue it with the WHO if you think I'm so wrong. I enjoyed and appreciated this dialogue, but am not going to debate further. Too many lovely homeborne babies to welcome.

12:41 AM  
Anonymous Anonymous said...

Quite frankly, I'd never have my child at home. I don't care how small the chance is that something could be wrong with my baby...I wouldn't risk it.

It just isn't worth it.

2:28 PM  
Anonymous Tricia Cahill said...

I know I'm awfully late to the discussion, but I just wanted to thank Neonatal Doc for being a voice of reason and sticking up for those of us who are a little tired of being not-so-subtley sneered at by the earth-mama crowd for not choosing to have our babies at home.

I know they claim they're not really being judgmental, but they always manage to get a hurtful little dig in here and there and try to make you feel like you're not a real woman for not giving birth on your bathroom floor in front of a bunch of spectators.

My children were born at our local hospital, which was one of the forerunners in the "homey" atmosphere movement. We weren't strapped to beds or monitors (unless it was necessary), we were allowed to move about and walk around or get on our hands and knees if we wanted. Most of the horror scenarios these prarie-muffins cook up are either ancient history or occur in over-crowded, mediocre, inner-city hospitals, anyway.

I don't see how these holier-than-thous can make all the judgment calls they make based on their own one or two experiences. Unless they've experienced every single woman's delivery experience, they just don't know what's best or better. Frankly, they don't know anything about me or my deliveries at all.

I resent this crowd always insinuating that I'm not a real woman or a good mother because I didn't make the choices they made. You're bad if you had your baby in a hospital, you're bad if you don't breastfeed them for years and years, you're bad if this, you're bad if that, and they're all perfectperfectperfect and better than you and holier and going straight to heaven, blahblahblah.

It gets really old really fast, and a lot of us are sick of their superiority and their selfish, rude, hurtful opinions.

If people want to have their babies in the swimming pool or on the floor of their apartment or whereever, they pretty much have that right. But I have a right to make the decisions I feel are safest and best for my child and myself, too, without being told I'm someone less or someone bad for doing it.

And I am apalled and horrified by the woman who says she's a midwife over on that nasty woman's blog and says she knocks things on the floor and gets in the way so she can make the birth go the way she wants it to go instead of the actual medical personnel. That's criminal and dangerous and she ought to be reported. If these women will go so far as to enter hospital situations and sabotage them, endangering the lives of the mother and child, in order to promote this supposedly better way to have your baby, then you know something is seriously wrong.

8:01 AM  
Anonymous FRECTIS said...

And I am apalled and horrified by the woman who says she's a midwife over on that nasty woman's blog and says she knocks things on the floor and gets in the way so she can make the birth go the way she wants it to go instead of the actual medical personnel.

What nasty woman's blog would that be?

2:44 PM  
Anonymous JeanneBelle said...

"these prarie-muffins"

Hahahaha, now that is seriously funny to me.

That said, you're insane! It's us homebirthers that get all the flack from people - you have NO idea. Poor you is in the cultural majority, you have the support of your parents, the bag lady at the grocery store, and ignorant neonatologists too. Your bunch are hardly candidates for an oppressed group, jeesh.

And PS - if you chose not to breastfeed, knowing all the evidence these days, you ARE bad. If you can live with that, fine, I could care less. But don't kid yourself that formula is just as good.

8:56 PM  
Anonymous Tricia Cahill said...

I said 'breastfeed for years and years', not just 'breastfeed'.

See? You can't even read, and you want me to believe that dropping your baby on your dirty floor like some ignorant woman living in a third-world dump is the better option?

9:07 PM  
Blogger Jamie said...

Frectis, I think I'm the "nasty woman" in question, and Tricia was writing about Alicia's comment on my blog about teaching residents at her hospital not to cut episiotomies hastily. Tricia, I'm sorry my posts here left such a bad taste in your mouth. Truly, as far as I'm concerned you are welcome to the choices that work best for your family with regard to birth and breastfeeding. I understand that all kinds of families make all kinds of decisions, for reasons that are almost never any of my business.

While I'm apologizing, I'd also like to say to Dr. Amy that I'm sorry for the rude tone of a few of my comments. I stand by their content, but I could have made the points without being snippy.

If anyone here is interested, I posted again on my own blog about the homebirth choice, in two parts. (Neonatal Doc, if you are uncomfortable with people finding links to pro-homebirth material from your blog, please go ahead and edit this comment as well as the one up above that links to my blog. Thanks again for letting this conversation happen here.)

2:21 PM  
Blogger Amy Tuteur, MD said...

Jamie:

I saw your post and followed your links. I understand the attractiveness of making the homebirth debate about my opinion vs. your opinion because it tends to blur the safety issue. The debate then looks like my opinion (subject to my biases) against your opinion.

I have a suggestion, though. Why not submit the data to a statistician or an epidemiologist who has not previously studied the issue? That could be extremely helpful to others who are reading the debate but cannot follow the statistical intricacies. If you are truly confident that the data shows that homebirth is not more dangerous for babies than hospital birth, I would guess that you would welcome independent confirmation of this fact. It would certainly go a long way toward strengthening your argument.

10:48 AM  
Anonymous Anonymous said...

Amy Tuteur, MD said...
Frectis:

"Now, now. These natural accidents [cord accident, abruption] have nothing to do with planning a home birth. Why bother to bring them up?"

Amy Tuteur, MD said...

"Why? They account for a substantial number of deaths at homebirths, that's why. Furthermore, these are preventable deaths in the hospital setting. "

Oh really? Cord prolapse is preventable in the hospital setting? I'd venture to guess cord prolapse is not only preventable, but also more common in the hospital setting due to the higher incidence of AROM.

8:12 PM  
Blogger Amy Tuteur, MD said...

"Cord prolapse is preventable in the hospital setting?"

I think you misunderstood what I wrote. I said that death from cord prolapse is preventable in a hospital setting, but not in a homebirth setting.

If you'd like to continue the debate, you can head over to a new forum I created called Homebirth Debate. Neonatal Doc has generously hosted over 160 posts on this one topic. I thought it might be time to create a dedicated place for debate on this issue.

8:47 PM  
Blogger Navelgazing Midwife said...

*whew*

I couldn't even read everything, but wanted to add a short note.

I've midwife'd *several* nurses and doctor's wives at homebirths. Two NICU nurses and an L&D nurse in particular *because* they know what happens in hospital births. Including mistakes, humiliation, manipulation, and lack of privacy and individuality.

It isn't just about a woman's experience. It's about her protecting her baby and that should be rewarded. I am in school working towards a Master's in Psychology - aiming to be the first Midwife-Therapist in the US - choosing to go back to school *because* so many of my clients have had traumatic birth experiences in the hospital. Not unpleasant. Traumatic. Birth abusive. A new term has been coined (not by me) - Birth rape - and far too many women are screaming birth rape. Eventually, the hospital folks will hear it, too.

I work hard to be a go-between for women considering an unassisted birth (UC - unassisted childbirth) and I believe that MANY of the horrific births spoke of are actually UCs, not Licensed and Certified Professional Midwife-attended births.

I carry every single thing in the back of my car that a birth center has behind its doors (IV, abx, pit, meth, Vit K, e-mycin for baby, ambu-bag for mom and baby, O2, etc.). The difference is I schlep the stuff to my client's home versus their schlepping mid-late labor.

It is not a homebirth at all costs; it is a healthy mother and baby at all costs - cesarean included.

My birth career started 23 years ago in the hospital then moved to birth center births and now I midwife in homebirths, but doula in hospital births (and NEVER speak *for* my clients... but support them emotionally as they birth in a location that isn't the most spiritually friendly).

I'm sure no one will read this since I will be comment #163 and I started skimming at about #82 or so... but just wanted to say a couple of things.

8:34 AM  
Anonymous Tricia Cahill said...

I understand that all kinds of families make all kinds of decisions, for reasons that are almost never any of my business.

Lose the qualifier. Other people's decisions about their families are never any of your business, period.

9:53 AM  
Anonymous Anonymous said...

Iatrogenic. Get a dictionary and read the definition.

I've been planning to homebirth since I was young and I'd like to thank the author of this blog and the first respondent for showing me that homebirth is definitely and completely the way to go.

10:42 AM  
Anonymous Anonymous said...

"I am a neonatologist in an urban area of the midwest. The more I practice and study medicine, the less I know."

This is probably the most true thing neonatal doc has written here.

11:57 AM  
Anonymous Anonymous said...

So how, Neonatal Doc, do you explain the fact that in the countries with the lowest infant mortality rates, are the highest number of midwives and the highest number of midwife-attended homebirths?!

And to the one that stated "birth is dagerous" yeah- when you have it in the hospital where most things that can go wrong are iatrogenically- caused! Birth is safe- interventions are risky!

1:45 PM  
Anonymous Anonymous said...

I don't know what you've been reading- but you wrote, "the odds of having an adverse event at home (particularly with your first child) are so much higher than they are in a hospital..."

So much higher? The latest large prospective study form the BMJ states that for low risk primips homebirth can be considered AS SAFE as hospital births with better outcomes and for low-risk multips, homebirth is SAFER than a hospital birth. Read it for yourself at http://bmj.bmjjournals.com/cgi/content/full/330/7505/1416?ehom

1:53 PM  
Anonymous melissa said...

An anon said "Quite frankly, I'd never have my child at home. I don't care how small the chance is that something could be wrong with my baby...I wouldn't risk it.

It just isn't worth it."


Yeah... I would never risk going to a hospital to deliver a baby... It is a risk that I would never take...

I believe in all of the studies that show that women in countries with more homebirths have better outcomes for mom and child.

I wlove my children too uch to risk their lives in the hands of an OB...

6:56 PM  
Anonymous melissa said...

neonataldoc said:
"The deaths in the homebirth setting are often due to unpredictable, catastrophic problems that could never be treated at home."

I would rather something unpredicable happen at home then going to the hospital and putting my child in danger because of the policies and routine interventions that happen there.
I truly believe that doctors cause many of the problems and then can put on their "god" mask when they "save" the mom and baby...
Inductions, meds, breaking the water for no reason, putting time limits on labour, not letting women progress naturally, "tying" women down with monitors, IV's etc, making women lay in the most unnatural position for giving birth etc... all of these can lead to heart decelerations, stress in mom and baby, epis can stop labour, making a woman push before her body does so naturally makes the use of further interventions and problems more likely, cutting the cord prematurely deprives the baby of blood and oxygen, cord traction can lead to pph etc...
I don't have the energy to fight against hospital policy and knife happy docs with a god complex. I had to do it once... I refuse to do it ever again...
I fought for 12 hours against a "neccessary, unavoidable, your baby and you will die if it is not done" only to have the baby born unassisted and without pushing in my hospital room while everyone was hudling around with a hospital lawers to sign away my rights...

I would never risk my life and my childs life like that again!

7:15 PM  
Blogger neonataldoc said...

To those of you who have thanked me for hosting this and "letting us play in your sandbox" (great expression), you're welcome. Try to be nice, though, people. Reasonable people can have differences of opinion.

7:52 PM  
Anonymous Anonymous said...

I had a home birth. it turned into an emergency transfer of baby 1 hour after he was born. I was dilated to 7cm for 12 hours, yes you heard correctly 12 HOURS. If i had been in a hospital I would have had either pit or a section for "failure to progress". Once my water broke I went for a 7 to 10 in 10 minutes and pushed once before he was out. the baby was transfered because he was retracting and the assesment determined him to be 35 week instead of the 37 weeks we thought. a DOCTOR assured me at my ultrasound how far along i was. the baby was in the NOCU for 6 days.

Because I was at home I was able to hold my baby and bond. i was able to hold the oxygen mask to the baby as we had skin to skin contact. at the hospital he would have been wisked away before my husband OR i would have been about to look at him.

Because I was at home I had a drug free VAGINAL birth. I know i would have been sectioned for failure to progress at a hospital.

Because I was at home I was able to establish a bond and breastfeed my son withing minutes of his birth.

I would have another home birth if I ever get pregnant again and I will use the same midwife. I would never trust a MEDwife (CNM) with me or my child much less an OB.

8:04 PM  
Anonymous maribeth, CNM said...

Hey! Just popping back to check on things. I absolutely agree that there are MEDwives, but don't paint all CNMs with that same brush. A lot of us are out here doing really great homebirth too ya know.

8:46 PM  
Anonymous maribeth, CNM said...

I think this thread is officially dead, but I needed a safe, uncensored place to post something. A warning if you follow the link to Dr. Amy's discussion on the homebirth of safety: she has now begun deleting any comments that she does not like, or is using some standard I can't understand. I'm not even talking about heated or 'controversial' posts! NOT PLAYING FAIR.

5:41 PM  
Anonymous Anonymous said...

Its funny that everyone thinks homebirth is so dangerous, when scientific studies have shown that homebirth is safer than hospital births. Its sad that a woman lost her child. Not every midwife is perfect, not every OB is perfect, not every birth is perfect.

And yes, the birth experience IS important. Thats like saying "So what if you were raped!? Youre fine now, get over it!" Birth is a huge part of a woman's life and the experience needs to be protected and savored.

The fact is that homebirth is still safer than hospital birth and women absolutely have every right to make that decision on their own after reading and educating themselves. It is their responsibility to take their births and their childrens lives into their own hands and make that decision themselves. I wouldn't have my baby anywhere but at home. I would take a long long time to choose a competent midwife and (in my case) doula(s) and put my confidence in them and rely on their confidence in me, and birth my baby safely at home. If problems arose, the midwife would know what to do and how to do it. Im sure you know that birth is naturally unpredictable, and midwifes, women, and babies are only human.

Its funny, though. I suggest you truly do some unbiased (snort) research on homebirth before you start spouting crap. That would be like me spouting crap about the insane cesarean rate and infant mortality rate in the US as opposed to other less fortunate countries in which midwives are utilized, or different stories of babies who died in the hands of medical staff. There are many, many more of THOSE.

2:26 AM  
Blogger Dr John Crippen said...

Hi guys

This difficult issue has been well covered here.

In the UK, the Secretary of State for Health has just announced that doctors are to be "instructed" to offer women home deliveries conducted by midwives.

The will, if it happens, lead to an immediate increase in maternal death and morbitiy and neonatal death and morbidity.

Unlike the USA, we have large number of welll established midwives who purport to be able to practice without supervision by a doctor.

If this happens in the UK, watch the experience closely.


John

11:22 AM  
Blogger Dr John Crippen said...

Home deliveries in the UK are covered in NHS BLOG DOCTOR at:

http://nhsblogdoc.blogspot.com/2006/05/home-delivery-lunacy.html


John

11:23 AM  
Blogger rgdoc said...

RGDOC
low risk pregnancy is a diagnosis in retrospect .....
unfortunately till medcine reaches a point when we can predict no risk intra/post partum ......home birth is a gamble. Welcome to informed choice!!
working in Uk(London) i can say with the recent 'proclamations' of the health secretary here ; we will see poor outcomes rising.....
while i was working in a west london hospital, a patient who was a previous c-section wanted a water birth at home and asked me my opinion ...... not happy with my opinion she said 'u come from india -dont the vast majority deliver at home or in the bushes so to speak ?'

i said we also have a maternal deaths and neonatal mortality and intrapartum still births....
having seen women in india brought in labour with dead babies and bleeding to death post partum and we were unable to save them -i find it so strange that given the choice of a safe hospital who in their right minds will choose not to have it .....
In India the women dont deliver at home out of choice they do so because they dont have a local hospital......midwives in India only work in the peripheries ..there is no such thing as doulas(for the unintitaed this is a 1000 pounds-currency not weight- birth and delivery motivator; not a midwive...popular among the rich and 'elite'...the midwives in the villages are so experienced and astute that their referrals mean all hands on deck.
They have no ego hassles to refer to a hospital 'cos they understand the required endpoint of a pregnancy a healthy mother and healthy baby.....
want developing or third world practices then accept the complications..... welcome to informed choice .....

hind sight has no value for the mother/family with a poor outcome in the pregnancy...

and for those 'anonymous' people still using anecdotes of succesful home births remember to plan their next holiday week in the fistula hospital in ethipoiaa visit -- will cure all illusions and grandiose ideas of safety and whale music and candles in 'low risk' pregnancy.
THE PLURAL OF ANECDOTES IS ANECDOTES NOT 'DATA'

6:45 PM  
Blogger rgdoc said...

sorry about the typos in above post.

6:51 PM  
Blogger Highland Midwife said...

As I read these posts I am saddened by the bias, fear, short-sightedness, and often hypocricy of seemingly well-meaning people who lose all manner of reason when you mention "home birth". Their eyes glaze over and they seem to drop 50 IQ points.

A quick review of the sordid history of "modern medicine" will put the bias against midwives and home birth into glaring perpective for you.

For example: Midwives are criticized for babies who need resuscitation, when it is the medical associations who lobby to have laws passed to forbid the midwives from such simple safety measures as carrying oxygen! One could implode from such a hypocritical stance. Lightning should strike them.

In my state, midwives are very highly trained. After passing our CPM and state exams, some of us have challenged the ACNM exam and passed with top scores. We carry oxygen and resuscitators, no big deal. We carry pitocin, mag sulf, epinephrine, etc., (also no big deal, this is not some mysterious knowledge that only modern dark-age doctors have the brains to understand), administer IV antibiotics for Group B strep and immunoglobin for Hep B, monitor fetal heart rates throughout labor, test and screen diligently for risk factors (both prenatal and intrapartum), and when it is needed we can do everything else that is done by allopathic caregivers on a maternity ward, except we do NOT stick needles into a mother's spine for an epidural, prevent her from moving around and being comfortable (which has a proven detrimental effect on the process of labor - what a surprise), unnecessarily stress her out, and set her up for an appalling 30% C-section rate! The same safety net is there, the same medical advantages, only we are experts at knowing when NOT to use it, when interventions will only create more problems (and most complications are created by interventions!), and when to change what the mother is or is not doing to head off problems before they need to be "fixed" instead of after they have developed. We are also very conservative and careful, and quick to refer when there is a need.

Homebirths in our state have a far better outcome record than the hospital births. Homebirths even in states where the midwives are prevented by law from giving any modern care still have good outcomes (equal to hospitals) in study after study, so where are your FACTS? You will call good birth stories "anecdotal", yet that is exactly what your bad-outcome stories are, which fly in the face of the statistics. The needless traumas to mothers and babies that take place daily in hospitals would read like horrors from the Spanish Inquisition, so should we start posing those? If we did, no one would feel very safe with a hospital birth, yet you want to create an element of fear toward home birth based not on facts but on the very rules that you have forced upon midwives.

So, if a baby died from lack of oxygen at a home birth in your state, then shame on your lawmakers for not having the midwives carry O2 like we do! You should be more concerned about that 30% C-section rate, and the fact that you are not speaks volumes about your motives.

Stop acting so childish about the location of the birth, and lobby your legislature for better training for the midwives who will be serving those who want to birth at home, and for laws which allow those dedicated traditional caregivers to use all of the simple life-saving tools at their disposal, and for which they should be extremely well-trained, so that mothers who want something better than institutional births for their families will have a genuine choice from several safe options.

Or is it all about the money?

2:33 PM  
Anonymous Anonymous said...

Dear Dr Crippen,
re your comments...either at the homebirths I attend women are dropping like flies and dying at my feet (in which case you would think I would have plenty of experience to 'practice' my emergency procedures) OR the women are safely birthed of their babies to everyone else's pleasure (obviously not yours... )Which is it ? you cannot have it all ways?!

Eleanor Peck
Independent Midwife

2:48 PM  
Blogger Dr John Crippen said...

In the UK, the secretary of state for health, Patricial Hewitt is instructing (yes, instructing) doctors to offer all women a midwife run home delivery.

A midwife had a home delivery of her fourth baby at the age of 37.

There was a prolapsed cord. It took 57 minutes to get this mother to a hospital operating theatre. The baby died after three days on a ventilator.

Staggeringly, STAGGERINGLY, this midwife still believes in home deliveries and advocates them in a national forum. She states that the baby would have died even if she had had it in a hospital.

Full report here:

http://nhsblogdoc.blogspot.com/2006/05/home-birth-tragedy.html

Unblievable.

The pro home birthers never produce evidence. To them it is all emotional stories.

As has been said before:

The plueral of ANECDOTE is ANECDOTES not DATA


John

10:16 AM  
Anonymous Anonymous said...

'and when it is needed we can do everything else that is done by allopathic caregivers on a maternity ward, except we do NOT stick needles into a mother's spine for an epidural'

Oh God, another bloody 'pain is good, you need to suffer fro it to be natural' zealot. And who said childbirth is so touchy feely anyway? Except for those who have a vested interest in the process? I have two kids and my wife certainly di not want 'a wonderful experience'. She wanted a normal baby.

11:01 AM  
Anonymous maribeth, CNM said...

Dr. Crippen, have you never seen babies of prolapsed cords die in hospital?

11:51 AM  
Anonymous maribeth, CNM said...

And PS - aren't you fighting anecdotes with... anecdotes?

11:53 AM  
Anonymous Anonymous said...

In 10 years of obstetrics I've delivered 9 babies with cord prolapse. 8 babies had excellent outcomes following rapid forceps of CS, one had CP despite a rapid CS. Most were low-risk multips. So yes, it can make a difference being in hospital. To argue that it doesn't is just ABSURD. There are many advantages to homebirth but not accepting the downsides won't help your argument.

6:27 PM  
Anonymous Robin Tell said...

Well, this thread is getting a bit old--a sudden spike in the number of anonymous posters, ongoing posters pretty much wrapping up, and a raft of new posters brandishing well-worn stereotypes as if these hadn't been addressed more than once on this page. The discussion remains a great little nutshell resource on the subject, thanks again to our host for providing it, but I'm going to bow to the mood of things as well as to my own circumstances and let the few things I'd been itching to rebut go under the bridge. Others have said the important things better.

Just wanted to check in one last time to say: my furious baby daughter Nadia was born yesterday here in the living room without benefit of monitors or whalesongs. After a gestation of 37 weeks, and well over a month of perfect positioning, she decided to come down breech. This caused not only no trouble, but hardly a pause; the only fuss was needing to get my wife out of the rented tub and over to a bed, which didn't take but a moment (but, coming as it did after Nadia was rumping, it did occasion my wife's only "I can't do it" of the day). Something less than three minutes elapsed from the time the baby rumped to the time she was fully delivered. She lay there for a minute squinting at people, kind of purple; the midwives gave her oxygen for about fifteen seconds, after which she pinked right up and has stayed very ruddy (she's 5 pounds 11 ounces, not much fat).

So, mostly I'm just mooning over her like any new dad, but as far as this discussion goes it does weigh in a bit. Yes, of course, this is an anecdote, and I don't mean to position it as anything else. But I do think it's a welcome counterpoint to the steady stream of horror stories from the insitutional side, which are also anecdotes.

And for our topic, the point is this: in a hospital, or even in a hospital-supervised birthing center, the mere fact of breech presentation would have led virtually any obstetrician in the US to insist flatly on turning the whole business into major abdominal surgery. Even remarkably progressive doctors like Dr. Amy, who did not in her practice adhere to the stay-on-your-back habits so widely prevalent in the business, would have been pretty absolutist about extracting my little girl surgically because they wouldn't have trusted my wife to get her out.

And all the while, nothing would have impaired my wife's powers more than the resident authority figures acting distrustful and apprehensive about her. Fear, negativity--that makes the cervix cinch up tight, right round a baby's neck.

As it was, she was told she could do it, and the baby came out like butter. Like a pop gun. I almost want to say she made it look easy. Baby's perfect and unhurt, my wife got away with a little labial split about like a badly chapped lip, and some sore muscles like she'd been hiking. That is the difference attitude makes--in a case like this, it's all the difference. The whole shebang.

You want to write that off as being about "the experience"? Well, heck, I guess it is that. But it is also very much a crucial question of safety. Experience is safety. That's what we bet on and we were right. We're hanging out at home this weekend, heating up leftovers and admiring our daughter, no stitches necessary.

With that I sign off. Thanks to various participants for this resource--I will continue to point people here.

12:25 AM  
Blogger Chava said...

If you look at Ina May Gaskins most recent book, you can find birth stats from the Farm from 1970 - 2000. It includes 13 neonatal deaths out of 2028 births. 5 "lethal anomalies", 2 placental abruptions (one of which happend after transer to hospital d/t protracted labor), 2 prolapsed cords (one of which occured as the first sign of labor) 1 crib death, 1 premie that died in 1972 after a hospital birth and 2 deaths from probable infection.

One point of interest, is that the stats consist of anyone who received prenatal care at the Farm and planned to deliver at home - even if they ended up a planned hospital birth.

3:04 AM  
Blogger Chava said...

Ah - and one further point. I recently read that a portion of the decrease in neonatal mortality is d/t improved prenatal diagnosis and therapeutic abortion. This often does not apply to homebirth populations as they often reject not only amnio, but often routine u/s as well.

3:09 AM  
Anonymous English Mother-To-Be said...

I am expecting our first baby here in England, and am amazed by most of what I read about the care of pregnant women in the States. Here most antenatal care is done by NHS midwives, not by obstetricians. If, as I hope will happen, I give birth at home, an NHS community midwife will attend me. Should I change my mind and give birth in hospital, most of my care will still come from an NHS midwife. Unless something goes wrong, I will meet an obstetrician just a tiny handful of times. That seems to me a much better use of resources - the highly trained obstetrician can concentrate on mothers and babies who desperately need their skilled attention.

There has been so much posturing and argument over statistics on this thread that interesting points have been lost.

What I would still like to know is - what is the evidence about the impact of place of birth on the baby in a low-risk pregnancy?

And why is it that the United States still has such a shocking perinatal mortality rate when compared to Northern European countries? It seems to me that there are some lessons to be learnt.

6:49 AM  
Blogger rgdoc said...

http://www.pubmedcentral.gov/articlerender.fcgi?tool=pubmed&pubmedid=15961814

good article ... choice and outcomes...
why are the advocates of home birth ready to use and quote articles on good outcomes, but see a doctors' bias when large publications suggest a tangible risk? the risks that parents should be aware of - however small.
remember CHANCE HAS NO MEMORY!!--yes i am an alarmist but when there is one mother and one baby/fetus in the index pregnancy...information helps..

4:27 PM  
Blogger stockingup99 said...

Please read Henci Goer Obstetric Myths vs Research Realities. It sites numerous studies and explains why hospital interventions cause bad outcomes. Even the routine IV is show to increase C sections.

I read the whole thread. I have birthed out of the hosptial, because of the trauma I experienced with my first two births. He continued to cut the episiotomy as I was pointing out that he agreed I would prefer to tear. Informed consent? How 'bout the nurse who bristled when I asked her what the pill she was asking me to take was. She expected me to just take it without knowing what it was.

I am still convinced that homebirths are safer. Pregnancy is not an illness.

2:55 PM  
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6:57 AM  
Anonymous Anonymous said...

What an interesting discussion this has been! I hope it remains up to help those of us who have been trawling the internet looking for homebirth information.

What's made me sad, though, is the bordering-on-misogynist condescension that seems to drip from so many of the anti-homebirthers' posts (largely, I'm sorry to say, by MDs). The notion that women choose homebirth because they're emotional little moonchildren who don't understand statistics is insulting. With attitudes like that, is it any wonder that so many women want to stay away from hospitals?

Personally, I haven't decided yet what I'll do -- I'm very risk-averse, so chances are I will use a hospital-affiliated birthing center at least -- preferably a hospital with a top-notch neonatal unit! But this whole discussion has been very helpful and I'd like to thank all the parties involved. Double thanks to those of you who managed to stay polite.

12:43 AM  
Anonymous Lillet said...

WOW.

I think the best lesson to take away from this conversation is:

Do your research
Know yourself and what is going to be right for you
If you are considering hospital birth, have some serious conversations with your doctor(s) about how you would like to proceed in various scenarios.

Myself, I am hoping to labor in the St. Lukes/ Roosevelt hospital birthing center. Sounds like the best of all possible worlds to me.

3:52 PM  
Anonymous Anonymous said...

I'm curious if any unassisted homebirth parents have ever been charged with negligence in a case where the baby died but would clearly have been lived in a hospital setting. Anyone know of any caselaw?

2:10 AM  
Blogger Chris said...

As someone making the decision of where to give birth right now I have to say the case for hospital birth is not nearly as clear as you are suggesting. I started out "knowing" that I would only consider having my much wanted and long awaited baby in a major teaching hospital with a level III NICU. Then, as a trained scientist with several doctors in the extended family, I did what I do before anyone in my family undergoes a major medical procedure: my own independent review of the professional literature to figure out for myself what the best standard of care is. The answer: it is far from clear that standard practices in most U.S. hospitals actually correspond to the best standard of care!

In the end, I've concluded that hospital birth appears to safer then homebirth IF your hospital meets the following requirements:

1. your obstetrician does not induce labor or opt for a c-section in the absence of real medical necessity;

2. your obstetrician gives you honest advance information about the risks of medical procedures such as epidurals and pitocin drips so that you can make a rational cost-benefit analysis regarding these procedures;

3. the hospital provides real support for low risk women wishing to avoid epidurals and pitocin - interventions that have their place when things go wrong, but introduce unnecessary excess risks to both infant and mother in normal, uncomplicated deliveries.

Well, suffice it to say that I'm still looking for that hospital! And in the interim I am seriously considering giving birth in an independent birth center based on the growing body of evidence for better overall maternal and neonatal outcomes as opposed to hospitals.

So don't automatically condemn mothers who shun a hospital setting as selfish women in pursuit of a 'birth experience.' I understand where you're coming from on this, but a more productive way to get women back into the hospital is to address the reasons they left in the first place. One of them being that too many obgyns speak to pregnant women as if they were two-year olds. I still haven't gotten over the obgyn who told me I 'had to' go off a medication because of a 1 in 1000 risk of minor respiratory distress (no recorded incidence of fatality) and then scoffed at me for even asking about the risks of medically unecessary elective c-section ... which turned out to be a 1.72 in 1000 chance of a DEAD baby. What possible logic is there for that other than a total failure to examine his customary practices in light of the best current evidence? I lost all respect and trust for this man after that incident. And though I went off the med (better safe than sorry), I also decided to do everything possible to prepare myself for labor ahead of time and take active steps to avoid a c-section. Including, of course, not delivering at that hospital!

Bottom line: there is ample evidence that American obgyns need to clean up their act -- not least our dismal infant and maternal mortality rates compared to other developed nations. As a woman with scientific training and no pro-homebirth prejudices I can tell you that standard practices in maternity wards across this country are shockingly far from what the best evidence on proper standard of care suggests they should be. I find this extremely frustrating. And I would be overjoyed if all the obgyns who scream and holler about the dangers of home birth were equally energetic in making their own work places safer for mothers and newborns.

4:16 PM  
Anonymous Anonymous said...

I'm not against homebirths. I think mothers should birth where they choose.

However, I'm tired of homebirth Nazis.

2:47 PM  
Blogger Vol Abroad said...

I am expecting my first child in England. I live across the street from a neonatal centre of excellence (there are hospital parking spaces as far from the entrance as my front door is) Am I considering a home birth? Yes I am.

Why? I find the hospital depressing and scary. I don't want intervention if I don't need it. The hospital seems dirty (I've been treated for a minor emergency in a room littered with medical waste by a student doctor I had to reassure and talk through the procedure). The midwives go on and on about financial trouble and layoffs and how if I have a hospital birth I'll have to share a midwife, but if I have a homebirth I'll have two - one for me and one at the final stages for my baby. I feel pretty sure that I'm not going to get the care of an obstetrician even if in hospital.

Also, I'm American and the thought of being on a nasty, noisy, crowded NHS ward after the trauma of labor scares the crap out of me. Call me selfish - but I have a long history of depression and I'm scared of post partum depression, too - and I know that insitutional care will probably only make it worse. I have high anxiety every time I step into the hospital. I don't trust the midwives and I'd rather be on home turf where I feel a bit more powerful.

I will also be hiring a doula whose instructions will be to demand hospitalisation and intervention if I say I want it even if the midwife thinks I should continue with the home birth.

I know that I will have trouble labouring well in hospital - but I won't be able to get domino care (where midwives attend early labor at home and later stages happen in hospital). Opting for a home birth with the choice of getting to a specialist hospital quickly and easily seems the only way that I'll be able to minimise risk to my mental and physical health.

7:54 AM  
Anonymous Anonymous said...

I couldn't agree more. You said it better than I could have!

1:19 AM  

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