April 3, 2006

"It was the most cozy, lovely, lush experience."

That's a description of childbirth, accomplished at home, by candlelight, with the help of a midwife. It's pretty when it's pretty, but what if the baby dies, and it wouldn't have died in the hospital? Indiana is prosecuting a midwife:
Stacey A. Tovino, who teaches at the Health Law and Policy Institute at the University of Houston Law Center and has written on midwifery and the law, said prosecutions of midwives almost always started with a tragedy.

"No one complains until a baby dies or a mom dies," Professor Tovino said. But once the issue arises, she said, legislatures often become involved as well, with doctors and midwives engaging in a bitter struggle over the proper regulation of midwives, one driven by a mix of motives that are difficult to disentangle....

"Midwifery is an autonomous profession," [a midwife, Mary Helen] Ayres said. "It's an art and a science that predates the medical model of care. Midwifery sees birth as normal and basically safe.

"It's made safer by reliance on the woman's power," she continued. "The medical model assumes the woman is passive and her body needs to be acted upon. Every birth is presented as a potential disaster from which every woman needs to be protected and potentially rescued."
Every birth is a potential disaster! So is every car trip. Lots of us assume we will be lucky, especially when the odds are in our favor. That's why when we lose we say "Why me?" We rarely think to say "Why not me?" The question is whether the state ought to save us -- and our children -- from our relentless optimism.

84 comments:

Drethelin said...

I personally think the wiser choice is a hospital, but I also think it should be up to the parents.

James R Ament said...

"The question is whether the state ought to save us -- and our children -- from our relentless optimism."

In a word, NO.

MadisonMan said...

No mention is made of the cause of death. Would a hospital birth have made a difference here?

Why would they publish a story with such a gaping hole?

My two were born in a hospital, but with a midwife for the second.

Truly said...

I think it's interesting that the midwives cast the debate in terms of the ancient traditions of home birthing v. male doctors and their clinical, dehumanized notions of medicine. Is something better simply because it's older, particularly when superior medical treatment is available? After all, we're not Druids.

Personally, the gross-out factor is pretty compelling. Would you sleep in a bed where someone had given birth? I hope they threw out that mattress...and the box springs, just to be safe.

Also, "midwiffery" (as it's pronounced) is a funny world.

Truly said...

Er, "word." Sorry.

Patrick said...

"No one complains until a baby dies or a mom dies," Professor Tovino said.

Interesting quote, since no one involved in the case is complaining. The parents do not blame the midwife for the child’s death and she is not being charged in connection with the child’s death. This is not a standard-of-care case.

Instead, this case is about two things:

1) Under Indiana law it is legal to have a home birth and it is also legal to practice as a licensed midwife; however, doctors and nurses by-and-large choose not to perform home births and Indiana does not provide a licensing process for non-nurse midwives or recognize (as many other states do) national certifications for midwives.

The Indiana House several times has passed a bill to license midwives, but it has not been allowed out of committee in the Senate (the Health committee chairwoman is a nurse and very opposed to midwives).

2) Prior to the prosecution of Jennifer Williams, there were a couple of deaths from untrained midwives delivering high-risk babies (e.g. two months premature) and the parents not obtaining appropriate medical care for the child after it was born.. There are a lot of religious issues connected with the other deaths and since Indiana does not license midwives, there is no way to distinguish between trained and untrained practitioners. I am having trouble posting a link, but if you search for “Doris Mae White” it will pull up one of the cases.

SteveR said...

People choose to not use medical services all the time, whether the child who is at risk matters, I would say yes and that should be a factor. But not everyone feels that way.

MadisonMan said...

(the Health committee chairwoman is a nurse and very opposed to midwives)

I really enjoy the little tidbits one learns in a blog.

grass said...

Lots of studies show that for a normal pregnancy, birth at home is as safe, or even safer than a hospital. Countries where this practice is used often have some of the lowest infant mortality rates. Some good stats on this are in Sheila Kitzinger's books - she's an anthropologist who has done research on this.

grass said...

Obviously meant to add developed countries where homebirth with a trained midwife is used have lower mortality rates, not just any home birth!

CB said...

Childbirth is certainly normal, but it's a bit ironic to claim that it's basically safe while criticising modern health care. Childbirth is now basically safe, but primarily because of modern health care. (Though I'm guessing there's probably a debate there)

patrick--
You say that no one involved in the case is complaining; remember that one person involved is dead & it's hard to complain when you're dead. (I'm assuming that when you say no one is complaining, you mean it's therefore not the state's business)

John Henry said...

Obviously meant to add developed countries where homebirth with a trained midwife is used have lower mortality rates, not just any home birth!

There is a real problem comparing infant mortality rates between countries. This is because different countries have different ways of reporting a "live birth"

In the US, any infant who takes asingle breath before expiring is a live birth and their death counts in infant mortality rates.

In France, Germany and other countries, it is not a live birth until the baby is registered. This normally occurs 3-5 days after actual birth. An infant who dies in that period does not get included in infant mortality rates.

In Russia, low birthweight/premature babies who die before reaching a certain weight are not counted.

In other words, I would be VERY careful in drawing any conclusions from comparing infant mortality rates.

My other point is that if it were only the mother involved, I have no problems with whatever medical or non-medical practices they choose to indulge.

In this case, there is a baby who has no say in the decicision. It is a fully legitimate function of the state to protect that infant's life. This may mean protection against the mother's ignorance or negligence.

So as a liberal/lbertarian,I have no problem with requiring medically trained personnel at birth.

John Henry

Ross said...

My mother is certified nurse-midwife (master's from Columbia U.) who practices in hospitals with full medical backup in cases of complications, which of course are relatively frequent in childbirth.

Her opinion as a feminist who believes in empowering women is that anyone who has a birth at home is an idiot, and the "lay midwives" (as she calls them) who help them are in over their head and grossly irresponsible.

And if somebody dies when you are practicing medicine without a license (as opposed to being a cab-driver who had no choice but to help with the delivery), you deserve to be prosecuted. The Times stressed that the midwife "is not charged with causing or contributing to Oliver's death." Well, sure, that's hard to prove. The prosecutors took the easy case.

Sad, very sad, all around.

(Oh, a good friend of mine has two healthy young children who were delivered in her living room. Everyone was delighted with the experience. Everybody has a story.)

dbp said...

Dear Professor Althouse,

I can't say if mortality rates are the same for home-birth of an uncomplicated pregnancy v. hospital birth. It certainly makes sense though since hospitals are notorious for their nasty antibiotic resistant bugs and my impression is that complications are fairly rare in routine pregnancies.

My wife had our first two children in a hospital with midwives and we were happy with the experience. Our third daughter was born at home, but not on purpose. Other than the terror of actually having to perform the delivery myself, the third birth experience was far better than the first two. The quiet privacy and familiarity of our own home and the lack of idiot orderlies constantly bursting in made for a memorable and moving experience.

If it is the case that the risks are the same for home-birth v. hospital birth, then there is a good arguement for home-birth.

Best regards,

dbp

PatCA said...

"It's made safer by reliance on the woman's power."

Invoking the "it's okay because a woman is superior" rule again.

Eye Doc said...

The state should not save you from your "relentless optimism". However, midwifery is illegal in IN unless the midwife is a physician or nurse with the proper qualifications, and this midwife deserves to be prosecuted. Had the parents chosen a midwife who had the legal qualifications to be a midwife in that state I would have nothing really to say about any of this.

And one issue that I haven't seen discussed is how this midwife represented herself to the parents in the first place. I'd have to believe that she didn't tell them she was not a legal midwife, or I'd think the parents would be in some legal jeopardy as well.

Jennifer said...

Should the state save us from our relentless optimism? I guess the question is where should the state draw the line. It allows pregnant women to get in a car as often as they like despite the fact that two-thirds of pregnancy trauma is the result of car accidents.

I wonder if more babies would be saved by disallowing pregnant women from the use of a car than would be saved by disallowing home births.

I wanted to have my second child at home. Not because of the cozy, lovely, lush experience, but because the hospital where I had to give birth had killed off and permanently disabled a jarring number of babies and mothers in the six months before my due date. Killed off, mind you. Actually caused the deaths and disabilities through the stupid mistakes of its own staff.

However, as a military dependent, I didn't get to make the choice.

Although this is beside the point, those of you who advocate for government managed centralized healthcare might want to consider this anecdote.

MrsWhatsit said...

I have friends whose baby died during a home birth from causes that probably would not have resulted in death had the birth taken place in a hospital. The state prosecuted the unlicensed midwife, against the wishes of the parents. That process horribly complicated their grief, which was already bad enough. Their marriage did not survive the experience. It was a nightmare, and enough to put me and everyone who knew them off home birth once and for all.

eye doc, on your question about the parents' knowledge -- my friends, at least, were fully aware of their midwife's unlicensed status. They wanted a home birth, disagreed with the state's position on license requirements for midwives, and took the risk. There were no legal consequences to them, but their identity was made public in the course of the proceedings against the midwife, and their judgment was called into question -- so it was all quite painful.

I am not normally a fan of the state interfering in decisions of this kind but I agree with the commenter who pointed out that there is a baby involved in this decision who does not get a voice. In this case, it seems to me, reasonable state regulation may be justifiable.

Bruce Hayden said...

One reason I believe in hospital deliveries is that you never know. One kid I know went into distress during her delivery. It was, of course, picked up immediately on the fetal monitor, and was solved by giving her mother oxygen. If that had not worked, they were ready for a C-section. But in most home deliveries, it would have gone unnoticed, and the baby born with potentially some brain damage. Most likely not noticable, but there.

Then, upon birth, a complication was discovered than ended up with her in the infant ICU for a day or two. Two pediatricians were there immediately. Yes, she could have been rushed to the hospital, but this was much, much, better.

So, how many home deliveries do end up with some minor damage to the babies that is not readily detected? I know another kid who was delivered at home by midwife, and has the emotional maturity of a kid 4 or so years younger. It could be fetal-alcholol syndrome, or it could be an undetected problem with the birthing - something that would routinely have been detected in a hospital.

HaloJonesFan said...

During that entire article, I kept thinking of the scene in "Airplane!" that parodies the public-access cable talk show, with the female 'guest' saying "If this country were run by vegetarian women, instead of flesh-eating men..."

(accompanied by a sign-language translator, who gives up halfway through and just starts making "jerk-off" motions...)

Patrick said...

CB patrick--
You say that no one involved in the case is complaining; remember that one person involved is dead & it's hard to complain when you're dead. (I'm assuming that when you say no one is complaining, you mean it's therefore not the state's business)


As I said in my original comment, this is not a standard-of-care case. Neither the parents nor the state is complaining about the care given. You can read my comment for the context this remark was made in. This quote sums up what the case is about, if you are interested:

“After an investigation, Williams was found to have acted appropriately both in the delivery and her response to the emergency; but she was later arrested for practicing medicine without a license. . . .

“I acted completely appropriately,” Williams says. “The charges are not about the baby, or because of anything I did or didn’t do at the birth, but because the state of Indiana requires midwives to be licensed, but does not provide a way for that to happen.” . . .

http://www.nuvo.net/archive/2006/01/25/desperate_midwives.html

Freeman Hunt said...

Having a baby is a pretty big deal. I can't imagine not wanting the full resources of a hospital at your disposal in case complications should arise.

That said, having a baby is not, in itself, a complication. Giving birth or assisting someone who is giving birth is not practicing medicine.

I'd keep the state out of it.

gj said...

Had the parents chosen a midwife who had the legal qualifications to be a midwife in that state I would have nothing really to say about any of this.

Eye Doc, the problem is that the state only licenses Nurse Midwives, and as the article states, Nurse Midwives generally do not provide home births.

I have a cousin who lives in Indiana and had her second child at home. Her first child was born in a hospital, and was taken away from her moments after it was born. It was an hour before she knew whether her child was dead or alive. It turned out that it was fine, and had just been taken for a standard exam, but no one was available to tell her that. She had what was probably the worst hour of her life because of the medical profession treated her baby like a tumor that needed to have a biopsy run on it.

She didn't want that to happen with her second child. She knew about the law but she disagreed with it on principle, and so she was willing to work with someone who was flouting it.

Tara said...

How many women and newborns are harmed by having the birthing process in hospitals? I imagine it would vary from hospital to hospital and the *actual* quality of care and resources available. It doesn't make sense for me to make this decision at a state-wide level unless there can be some really tight quality assurance in hospitals that really shows a lower rate of complications for women who are forced to give birth in hospitals versus women who are allowed to choose to give birth at home.

Patrick said...

Ross: My mother is certified nurse-midwife (master's from Columbia U.) who practices in hospitals with full medical backup in cases of complications, which of course are relatively frequent in childbirth.

Not to question your mother, but maybe her perception of the frequency of “complications” is influenced by practicing in a hospital. A study following 5418 women (98% from the U.S. the rest from Canada) who planned to deliver with a midwife at home found:

“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.”

(go to www.bmj.com and search for Daviss as author), summary of intervention rates at:

http://www.cfmidwifery.org/pdf/CPM2000.pdf

A lot of the “complications” in hospital births are self-created. Inducing labor (approximately 20% of low risk U.S. hospital births) leads to substantially more complications than if labor is started naturally.

http://www.expectantmothersguide.com/library/pittsburgh/EPGinduction.htm (discussing Belgian study of 15,000 births) found:

“The women with induced labors used significantly more pain medication and had more cesarean births due to both fetal distress and stalled labors. That group also had more forceps and vacuum births and had more babies admitted to intensive care.”

These are big studies tracking thousands of births and they don’t demonstrate a lot of medical advantages to giving birth in the traditional “hospital” way. On the other hand, using lots of unnecessary procedures and interventions is a good way to shield the doctors and hospitals from legal liability if something does go wrong

Patrick said...

I think it should be noted that the midwife being prosecuted in Indiana could legally practice in more than 30 states based on the certification she already has (provided she applied for the particular state's license). Indiana chooses not to recognize this certification (or, more appropriately, the chairwoman of the Senate Health committee chooses not to recognize it).

This not so much a case about standards-of-care as about market regulation, which Indiana is within its rights to do, but where is the research supporting hospital births? Anecdotes are nice, but when the research doesn't support a position rational people should take a step back and reconsider.

One of the benefits of federalism is that states are allowed to experiment. Most states have chosen differently from Indiana without suffering undue negative consequences. If horrible consequences follow from allowing Certified Professional Midwives to deliver babies at home, shouldn't these consequences already be occurring in the many states that legally allow this to occur?

Andy said...

This is just an anecdote.

Our daughter (19 days old today!) was delivered by a pair of nurse-midwives, in a hospital environment, with an assist from a nurse specialized in fetal monitoring.

I consider this to have been the best of both worlds. Had we delivered at home, our daughter likely would not have survived - her cord was true-knotted. Had we delivered with a traditional doctor, we likely would have ended up with a caesarean - my wife's water broke 24 hours before labor really started.

The politics of how easy it is to get licensed as a midwife aside, midwives need to be medical professionals, and should be trained and licensed accordingly.

sailordave said...

Sorry, my son's birth was not any less magical or special because he was born in a hospital instead of at home. It's not the location that makes a birth special!

I think some of the fears of hospitals expressed here may be exaggerated or old. My son was born a little less than a year ago, and our hospital was a really nice environment with labor rooms that looked like a luxury hotel. There were not orderlies running in and out or any form of chaos; it was a very smooth and nicely handled process. I realize not all hospitals were like this in the past, but, it is a big trend right now for hospitals to build special birthing centers that are much nicer and much more sensitive to patient concerns than in the past. Our selection of a hospital felt like a college recruiting visit: a tour of the facilities, reception with the doctors, prepatory classes, etc. If you aren't stuck with an HMO or government care, please, shop around!

Oh, and my son came out not breathing, without any particular birth trauma or previous signs. With a home birth, he would not be alive. He spent a couple days in the NICU and he has been just fine ever since. He and his being alive are infinitely more special than any romantic delusion about how nice it is to have a home birth.

p.s. Do the parents above who aren't complaining about the quality of care when a child dies have any medical, nursing, or midwifery training enabling them to assess the quality of care? I wouldn't necessarily take their word for it.

gj said...

If we're going to rely on well-documented research then, as Patrick points out, for low-risk pregnancies home birth is at least as safe as hospital birth.

If we're going to rely on anecdotes, here's one about a woman who entered a hospital to give birth and was subsequently transferred to another hospital where both her arms and both her legs were amputated without her prior knowledge or consent. Speaking about her baby boy, she said,

"I want to pick him up. He wants me to pick him up. I can't. I want to, but I can't. Woke up from surgery and I had no arms and no legs. No one told me anything. My arms and legs were just gone."

Apparently her limbs were amputated because of a very bad infection, but the details are not clear because the hospitals have refused to give the woman access to her medical records. As of the writing of the article, she still did not know what had happened.

So all of you who like spending time in hospitals, go for it. But I'll continue to support people who want to have their babies at home.

knoxgirl said...

Trying to either "empower" or "pamper" yourself by experiencing childbirth without all available medical technology at hand, is dangerously, stupidly self-indulgent, to my mind.

Sure, most childbirths come off without a hitch, but why take that sort of risk?

I think if the midwife is being prosecuted, the parents should too, though I'm sure they're suffering horribly for their decision already...

knoxgirl said...

"a woman who entered a hospital to give birth and was subsequently transferred to another hospital where both her arms and both her legs were amputated"

Oh, gimme a break.

Ann Althouse said...

gj: That's horrible. I note that it happened in Florida. Personally, I would dread medical care in Florida, based on my family's experience. Doctors can do some terrible things. It's true! But staying away from them can be even more devastating. The trick is to find good doctors and good hospitals!

I must say that when I had my second Caesarean, I went into a state of hypotension, and I never learned how serious it was, but I was in a situation where I was wondering if I was dying. I wasn't allowed to move, and medical personnel were walking about talking about my condition in a way that I couldn't quite understand. Afterwards, I had the question, so was I sort of dying back there? But they never gave me a straight answer. The fact is, I didn't die, so what's the good of knowing?

Jennifer said...

Trying to either "empower" or "pamper" yourself by experiencing childbirth without all available medical technology at hand, is dangerously, stupidly self-indulgent, to my mind.

Knoxgirl: I think you're probably right that some women are pampering themselves by giving birth at home. But, I think there are many women who believe that its a safer and healthier option.

I think the research posted in the comments here bears out their belief.

I think its clear that some people would have been much better off steering clear of a hospital. Others should not have given birth at home.

I'm not sure its stupid and self-indulgent to weigh the particulars of your own situation to make a decision.

gj said...

Knoxgirl, according to the Centers for Disease Control, "In hospitals alone, [Healthcare-associated infections] account for an estimated 2 million infections, 90,000 deaths, and $4.5 billion in excess health care costs annually."

Don't get me wrong, I'll be the first to go to the hospital when I need the services they provide. But hospitals also have their downsides, and shouldn't be used more than they're needed.

(more here)

Maxine Weiss said...

Most insurance does not cover labor and delivery. Hospital births are very expensive.

Still, I think it depends on the age of the mother since older mothers are at greater risk for complications.

Women are having babies at an older age today, and probably need the services of traditional obstetrics more than, when the average age of childbirth was a woman in her 20s....and a midwife would suffice for that back then.

Peace, Maxine

Sara said...

Truly said: Personally, the gross-out factor is pretty compelling. Would you sleep in a bed where someone had given birth? I hope they threw out that mattress...and the box springs, just to be safe.

No fear! This mattress can be saved!

What you do is: you put sheets on your bed. Then, you cover those sheets with a flannel-backed vinyl tablecloth. On top of that you put on a set of old sheets.

After you have the baby, when you're ready to clean up, you hop in the shower. Your midwife takes the top layer of sheets off the bed, and throws the tablecloth in the trash. When you come back from the shower, you're nice and clean, and so is your bed.

On their way out, the midwives throw your sheets and towels in the laundry, and they usually turn out just fine.

Of course, most people having homebirths don't actually have their babies in the bed. People have them in the tub, on birthing stools, on their hands and knees, even standing up.

Ann Althouse said...

"People have them in the tub, on birthing stools, on their hands and knees, even standing up."

Oh, good lord! How about standing on their head? Is this really the time to be showing off?

Sara said...

Showing off? No.

It's just that it's hard to have a baby lying on your back. You have to push AGAINST gravity. (That would also be an argument against having a baby while standing on your head.)

The baby comes out much easier if you're more upright when you're giving birth.

Aspasia M. said...

I'm a cautious person, so I'll be going to the hospital to give birth. Luckily, my local hospital not only has a good reputation, but has recently re-done the birthing rooms. There's even whirlpools in the birthing room.

In our health care system a woman usually works closely with a midwife who is present throughout the labor. A nurse is also in the room. The OB/GYN comes into the room for the birth when the baby is ready to be born. (Or the doctor comes if something is going wrong.)

I also understand people's caution about unnecessary medical intervention. It's scary when forcepts (or a vaccum birth) causes head injuries. But I'd rather be at a site with readily available medical equiptment in case of an emergency.

I do think that the state should pay for labor and deliveries for uninsured women. People may stay at home because it is expensive to give birth in a hospital if they don't have health care.

HaloJonesFan said...

Ann: No, showing off would be giving birth on a trapeze. Use centrifugal force to assist the birth!

My opinion of most home-birthing, based on little personal research but a lot of anecdotal evidence, is that it's more of a Momzilla thing than anything else. This woman is so desperate to be at the center of a big dramatic event that she'll create a set piece, with herself as the lead actress and the baby as a prop.

Aspasia M. said...

No, showing off would be giving birth on a trapeze. Use centrifugal force to assist the birth!

And the baby could bounce into the world!

Holojonesfan,

I don't know - in any labor everybody is pretty focused on the woman. I mean - people want to take PICTURES & Tape videos of things that I know I don't want recorded.

knoxgirl said...

"...many women who believe that its a safer and healthier option. I think the research posted in the comments here bears out their belief."

If the hospital(s) you are restricted to are butchers, by all means, have the baby at home! But I seriously doubt this is the norm. Trying to scare women with gorey, if true, stories about hospitals is just wrong.

Having a baby is not a complication---nor should it be a political act of woman power! -- like a lot of feminists want to make it.

Ann Althouse said...

What a vaginal birth does to a baby's head -- if you did anything like that to your child after it was born -- with your hands, I mean, not your vagina -- it would be horrific child abuse. You can say it's "natural" -- but it's an extreme thing to do to a baby and it can cause permanent damage. To treat it as a spiritual experience for the adults is creepy.

But those who are doing home births to save money -- I really feel sorry for them.

Those who are impressed by posh "birthing rooms." You do realize the reason hospitals dump so much money into this? They know it influences women choosing their insurance plans. You're then stuck with the rest of the hospital. But they know you'll notice this.

Jennifer said...

If the hospital(s) you are restricted to are butchers, by all means, have the baby at home! But I seriously doubt this is the norm. Trying to scare women with gorey, if true, stories about hospitals is just wrong.

I think you're being a wee bit obtuse here. The research I was referring to was the posted evidence in this thread that home births don't result in a higher rate of injury or death than hospital births.

Trying to guilt women into using hospitals by calling them stupid and self-indulgent is no less wrong than scaring them with gory stories.

Those who are impressed by posh "birthing rooms." You do realize the reason hospitals dump so much money into this? They know it influences women choosing their insurance plans.

Ann: Exactly! And we fall for it, don't we?

For the same reason, hospitals for those of us who don't have a choice don't bother with the luxury. I still had to do the stupid exam room, labor room, recovery room progression. And I got to share my recovery room for two days with another couple and their child. Good times!

Jennifer said...

Knoxgirl: I should clarify that I wouldn't have thought I would consider home birth for myself either. It's not something that would have been my "style".

I just think its a kneejerk reaction to summarily dismiss the option for other people based on your own preferences when evidence supports their decision.

knoxgirl said...

Jennifer:

I'm not trying to guilt anybody! There are real risks involved.

1. If your childbirth goes smoothly and you're at the hospital, chances are overwhelmingly good that you and the baby will be safe. Same with home birth.

2. If your childbirth does NOT go smoothly, at the hospital there are medical personnel and equipment to address the issue. At home, there is nothing but 911.

I cannot find the evidence in this thread you are referring to?

Anyway, FWIW, if we had universal health care, I'd be the first one having babies at home, believe me.

Sara said...

ann althouse wrote: What a vaginal birth does to a baby's head -- if you did anything like that to your child after it was born -- with your hands, I mean, not your vagina -- it would be horrific child abuse. You can say it's "natural" -- but it's an extreme thing to do to a baby and it can cause permanent damage.

Are you trying to be a troll on your own blog?

raisa said...

Knoxgirl:

The evidence you are looking for is in Patrick's post at 12:58 p.m. yesterday. He references large-scale studies showing that for low-risk births, homebirth is just as safe as hospital birth.

How is it possible that homebirth is just as safe, given that hospitals, as you say, are equipped to handle complications?

The only answer consistent with the study data is that there are ways in which homebirth midwives handle birth better than hospitals and are safer than hospitals. Not that they handle every aspect of birth better, but that they handle some aspect of births better, but enough to balance any safety benefits provided by hospitals.

And of course a big advantage of midwives is that they provide the same record of safety with significantly fewer interventions. For example, the British Medical Journal study Patrick pointed out found that the c-section rate for low-risk attempted homebirths was about 4%, compared to about 20% for the comparable hospital population. Lowering interventions shortens recovery time and hospital stays and significantly lowers costs.

I understand having the feeling that having a baby at home is risky. But for low risk pregnancies, that feeling is not supported by the evidence. The fact is, a baby is just as likely to die or have complications in the hospital as at home.

P.S. What does universal health care have to do with your home birth choices?

Aspasia M. said...

What does universal health care have to do with your home birth choices?

I suggested that the state should pay for uninsured women to give birth in a hospital with appropriate medical care. I also suggested that the economic costs could encourage people to choose home births.

Giving birth in a hospital is expensive if one does not have insurance. So, I suggested that the state ought to pay for those without means.

For example, if Indiana is going to criminalize home births, then IN should pay for hospital births for the uninsured.

Ann Althouse said...

Re me being my own troll...

Interesting idea!

I do act a little different in my comments persona.

knoxgirl said...
This comment has been removed by a blog administrator.
knoxgirl said...

(sorry...)

raisa,

I've yet to meet anyone expressing the interest or desire to have their baby at home who says it's for "safety reasons" ...but ok!

I'm sure if you're "low-risk" then it is indeed relatively safe to have your baby at home. But the key word is "risk". As in, "still risky."

I was actually expressing agreement with Jennifer in my comment about universal health care....

kel kel said...

as a midwifery student studying to be a homebirth midwife, i made it through about half of these comments before not being able to stand it anymore. so, a couple of things...

first of all, anyone who is wondering about the safety of homebirth where babies are being delivered by lay midwives (midwives without nursing degrees), please take the time to read this. i'll give you a hint...
"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."
http://bmj.bmjjournals.com/cgi/content/full/330/7505/1416?ehom

second of all, to me, what is more disturbing is the cesarean section rates in this country which are now up to 1/3 of all births. These are not necessary and are based majorly on the doctor's failure to have patience with the birthing process or the need to get home for dinner. so, my question is why would someone want care from someone who barely has the time for them?

Midwives provide an environment that is all about patience and self-awareness and informed choice. that is truly what midwifery is all about. it is about allowing women to reclaim their right to choose what is best for them given all of the information.

knoxgirl said...

so, my question is why would someone want care from someone who barely has the time for them?

I *can* see this point of view. Doctors are VERY into inducing labor these days. I always thought the high rate of c-sections was attributed to doctors getting nervous about being sued when complications arose.

raisa said...


Knox girl wrote: I'm sure if you're "low-risk" then it is indeed relatively safe to have your baby at home. But the key word is "risk". As in, "still risky."


Entirely eliminating risk in birth, as well as in life, is impossible. But if you're a low-risk woman, data show you're not increasing your risk by having the baby at home.

If it feels riskier to have a baby at home, that's because there is a cultural message that homebirth is dangerous -- a message that is not consistent with current medical research.

Oh, and I had a baby at home partially for safety reasons. Every woman on my street seemed to be having a c-section, and I really did not want that. I was afraid of surgery, I didn't want a scar, and I wanted to be able to hold my baby immediately.

I always thought the high rate of c-sections was attributed to doctors getting nervous about being sued when complications arose.

There are lots of reasons why the c-section rate is so high.

Picture this: you are an obstetrician. You have a crazy call schedule. You get paid more for for doing a c-section than for a vaginal birth, even though a vaginal birth may drag on for hours and hours, and a c-section is over and done with in an hour tops. Furthermore, you have crazy high malpractice insurance rates, which will only get higher if you get sued. You know that you are much more likely to get sued for failing to perform a c-section than performing an unnecessary one. You might even get a discount on your malpractice insurance if your c-section rate is high enough.

It is 4:00 in the afternoon and you have one woman in labor, with no signs of being done anytime soon. You are tired and there is a playoff game on at 7:00.

You sincerely believe everything is going fine with the woman's labor, but you have the slightest twinge that something might be wrong. What are you going to do?

Might you do something different if it were noon, you feeling awake, and you had somebody else laboring who would prevent you from going home, anyway?

Obstetricians are only human. And they are under a lot of stress. They're mostly going to do their best to make sound medical judgments.

But when there's ambiguity about what is the right decision, is there wonder they consistently err on the side of more interventions? No. And that's why intervention rates in obstetrics are sky-rocketing, without a concomitant improvement in outcomes (which have remained stalled for two decades).

The embattled status of the obstetric profession does no service to women or babies.

knoxgirl said...

Raisa,

"The embattled status of the obstetric profession does no service to women or babies."

I remember hearing a piece on NPR about how there weren't enough OBs in Nevada--maybe it was just Vegas, not sure--to deliver all the babies, and there were pregnant women who had no doctor to go to, because of malpractice insurance rates there.... yikes

gj said...

In Massachusetts, insurance pays for hospital births but not for home births. I believe the situation is similar in most states. So when someone has health insurance but wants a home birth, at least in Mass, it costs them about $3,000 out of pocket.

By the way, my wife just delivered a very healthy baby boy, at home, yesterday. Arrival time was 2:55 pm, weight 7 pounds 3 ounces. Mother and child are doing well. After the birth we made a $100 contribution to the Mass Midwives Alliance.

raisa said...

gj,

Congratulations! I hope mom and baby are doing well.

I agree that if you have insurance, homebirth is usually more expensive.

But for people who don't have insurance, homebirth can be cheaper. Here in Indiana we have a large Amish community. The Amish don't get insurance for religious reasons, and they prefer homebirth to save money. Both of the midwives mentioned in the New York Times article have large Amish practices.

faith gibson said...

NY Times story on Indiana prosecution of home birth midwife RE: The question is whether the state ought to save us -- and our children -- from our relentless optimism.

I started my professional life relentlessly optimistic about the benefits of hospital-based medical care for normal childbirth. I was an L&D nurse in a big busy hospital and it was a fact of everyday life that complications could and did suddenly occur. My opinion about planned home birth mirrored all the derogatory comments read here and elsewhere – mainly that it was “only for idiots”. However, working for two decades in the hospital-based obstetrical system relentlessly stripped me of optimism about ‘modern’ obstetrics. The public’s perception about medicalized childbirth in hospitals is wrong. It is TV obstetrics and not real life.

After just a few years in a high-volume L&D I began to see the connection between obstetrical interventions routinely applied to healthy laboring woman (70% of all pregnancies) and a steep increase in the need for additional interventions, unexpected complications, operative deliveries and breathing difficulties for the baby. Immobilizing a laboring woman in bed in anti-gravitational positions, hooked up to IVs and electronic fetal monitors, is not a biologically-effective way to facilitate normal childbirth.

I remember only to well racing down the hall with a stretcher, frantically trying to get a patient with a ruptured uterus to the operating room before she died. Eventually an emergency hysterectomy was necessary to save her life. As a young and inexperienced nurse, I initially thought this disaster proved that the biology of normal childbirth was dangerously defective. Afterward the older nurses talked about this ‘accident’ of childbirth, privately admitting among themselves that the Pitocin electively used to speed up her labor is what caused her uterus to rupture. I saw similar situations in which it was the baby who suffered permanent disability. However, all the families would ever learn was that the mother or baby was the victim of a life-threatening obstetrical emergency and that the quick response of the medical team had saved their life. Even though these emergencies were a known side-effect of obstetrical intervention, no acknowledgment of that important fact was made to the family.

I began to wonder if other things that we all took for granted were also causing iatrogenic complications. By paying close attention I soon noticed a direct correlation between the use of drugs and anesthesia and the need for assisted delivery (episiotomy, forceps or Cesarean section). I saw a direct correlation between the use of Pitocin to speed up labor, fetal distress in the baby and excessive maternal bleeding or even hemorrhage after the birth. I also saw a big spike in babies who had trouble breathing when their moms had narcotics during labor or other interventions such prolonged pushing (due to anesthesia) and /or delivery by forceps or C-section. All of these personal observations were also acknowledged in the drug company inserts or confirmed in the scientific literature.

My efforts to change the hospital culture failed miserably so I eventually cross-trained into community-based direct-entry midwifery. Counting my experience in both home and hospital, I have been present at approximately 3,500 births over the 40 years of my professional life. I can testify to the improved safety for both mothers and babies of physiological (vs. medical) management. Physiological management refers to care “in accord with, or characteristic of the normal functioning of a living organism”. This non-medical, non-interventive form of care depends on continuous one-to-one social support, ‘patience with nature’, the right use of gravity and a commitment not to disturb the natural process. Presently, physiological management is only available in an out-of-hospital setting and midwives are the only caregivers a mother can turn to for non-interventive maternity care. Planned home birth (PHB) always includes a skilled birth attendant and appropriate access to medical services when indicated or requested by the mother.

Midwifery as an organized body of knowledge preceded the modern discipline of medicine by more than 5,000 years. Midwifery principles recognized as effective and still valid in our own time were found among ancient Egyptian hieroglyphics dating back to 3,000 BC. Today, physiological management is the scientific backbone or evidence-based model of maternity care used world wide by midwives, except in the US where medicalized care eclipses all else. Physiological management is actually protective for both mothers and babies. Nationally certified direct-entry midwives (CPMs) using physiologic management in a domiciliary setting, reduced the episiotomy / operative delivery rate (and associated complications) from approximately 72% to approximately 5%, with an identical or even slightly improved perinatal mortality rate. It is efficacious -- that is, both safe and cost effective.

Nothing that modern allopathic medicine has to offer – no routine use of drugs or surgical procedures, no electronic devise such as continuous electronic fetal monitoring, no ‘preemptive strike’ such as universal hospitalization or the routine elective use of Cesarean section, has been able to create a system that is better or safer than the routine use physiological management for healthy childbearing women. However, these methods don’t belong to midwives per se. They belong to science and to society, to be used by anyone regardless of professional affiliation, including physicians.

One must question how the ancient and honorable tradition of midwifery came to be obliterated almost to the vanishing point by the medical profession and then claimed by the medical profession to be an illegal practice of medicine? What brought about the wide-spread but uncritical acceptance of an unscientific method such as interventionist obstetrics for healthy women? The medicalization of normal labor triggers a chain of inevitability that starts with the ‘domino-effect’, in which the unintended consequences of routine interventions make childbirth progressively more complex, eventually requiring the use of injurious interventions and sometimes progressing on to serious complications. When injury to mother or baby does occur, the biology of normal birth gets the blame. The complications of these obstetrical interventions are often cited as proof that “I would have died if I hadn’t given birth in the hospital”. This chain of inevitability, multiplied by forth years, has ended in an ever sky-rocking Cesarean section rate, which was a 30% for 2004 and is projected to be 34% by 2006. This is the disheartening background of most midwife/home birth prosecutions, which are inevitably based on medical politics instead of credible scientific evidence.

Like the midwife in the Indiana prosecution, I am a CPM, that is, a nationally certified professional midwife. CPMs are experienced direct-entry midwives who trained directly in midwifery instead of becoming a nurse first or becoming certified as a nurse-midwife. The statistics from the CPM study published in the British Medical Journal (June 2005), include those from my own home-based practice, as well as Indiana CPM Jennifer Williams and 500 other CPMs in the US and Canada. The BMJ study confirmed again the consensus of the scientific literature, which consistently identifies that planned home birth, when compared to hospital-based care for healthy women, is equally safe for the baby and reduces maternal interventions by as much as ten times.

Unlike the recently arrested Indiana midwife, I am also licensed in my state of California but only because mothers and midwives in our state spent 30 years fighting an uphill battle against organized medicine to get midwifery decriminalized. Finally, in 1993, the California Legislature passed the Licensed Midwifery Practice Act. The LMPA officially recognized that the greatest safety for healthy mothers with normal pregnancies is to provide them with access to professionally-trained and licensed midwives.

In my opinion, the relentless optimism that needs to be addressed in America is not false optimism about normal birth but the unfounded idea that the current obstetrical model is the most appropriate one for healthy childbearing women. Most important, everybody in society, even those who would never use a midwife or plan a home birth, benefits from preserving and promoting physiological management. In a perfect system, medical educators would learn and teach the principles of physiological management to medical students. Practicing physicians would utilize physiological management as the standard of care for healthy childbearing women. Hospital labor & delivery units would be primarily staffed by professional midwives, with incentives for current L&D nurses who wish to retrain as hospital-based midwives to do so at minimal expense to themselves. This would dramatically reduce rate of injurious interventions and the cost of maternity care while increasing good outcomes and satisfaction of families served.

In the meantime, community-based midwifery needs to be legal for both mothers and midwives. If the problem is the law, then the law needs to be changed, as it must be kept in mind that the basic purpose of medical practice legislation is consumer safety, not as a political tool for promoting a medical monopoly. Enforcing medical practice laws in a manner contradictory to common sense and the well being of the public is not in the interest of childbearing families or a civil society.

More info is posted at www.sciencebasedbirth.com. See ‘April 06 Info for Bloggers – midwife controversy’.

faith gibson said...

NY Times story on Indiana prosecution of home birth midwife RE: The question is whether the state ought to save us -- and our children -- from our relentless optimism.

I started my professional life relentlessly optimistic about the benefits of hospital-based medical care for normal childbirth. I was an L&D nurse in a big busy hospital and it was a fact of everyday life that complications could and did suddenly occur. My opinion about planned home birth mirrored all the derogatory comments read here and elsewhere – mainly that it was “only for idiots”. However, working for two decades in the hospital-based obstetrical system relentlessly stripped me of optimism about ‘modern’ obstetrics. The public’s perception about medicalized childbirth in hospitals is wrong. It is TV obstetrics and not real life.

After just a few years in a high-volume L&D I began to see the connection between obstetrical interventions routinely applied to healthy laboring woman (70% of all pregnancies) and a steep increase in the need for additional interventions, unexpected complications, operative deliveries and breathing difficulties for the baby. Immobilizing a laboring woman in bed in anti-gravitational positions, hooked up to IVs and electronic fetal monitors, is not a biologically-effective way to facilitate normal childbirth.

I remember only to well racing down the hall with a stretcher, frantically trying to get a patient with a ruptured uterus to the operating room before she died. Eventually an emergency hysterectomy was necessary to save her life. As a young and inexperienced nurse, I initially thought this disaster proved that the biology of normal childbirth was dangerously defective. Afterward the older nurses talked about this ‘accident’ of childbirth, privately admitting among themselves that the Pitocin electively used to speed up her labor is what caused her uterus to rupture. I saw similar situations in which it was the baby who suffered permanent disability. However, all the families would ever learn was that the mother or baby was the victim of a life-threatening obstetrical emergency and that the quick response of the medical team had saved their life. Even though these emergencies were a known side-effect of obstetrical intervention, no acknowledgment of that important fact was made to the family.

I began to wonder if other things that we all took for granted were also causing iatrogenic complications. By paying close attention I soon noticed a direct correlation between the use of drugs and anesthesia and the need for assisted delivery (episiotomy, forceps or Cesarean section). I saw a direct correlation between the use of Pitocin to speed up labor, fetal distress in the baby and excessive maternal bleeding or even hemorrhage after the birth. I also saw a big spike in babies who had trouble breathing when their moms had narcotics during labor or other interventions such prolonged pushing (due to anesthesia) and /or delivery by forceps or C-section. All of these personal observations were also acknowledged in the drug company inserts or confirmed in the scientific literature.

My efforts to change the hospital culture failed miserably so I eventually cross-trained into community-based direct-entry midwifery. Counting my experience in both home and hospital, I have been present at approximately 3,500 births over the 40 years of my professional life. I can testify to the improved safety for both mothers and babies of physiological (vs. medical) management. Physiological management refers to care “in accord with, or characteristic of the normal functioning of a living organism”. This non-medical, non-interventive form of care depends on continuous one-to-one social support, ‘patience with nature’, the right use of gravity and a commitment not to disturb the natural process. Presently, physiological management is only available in an out-of-hospital setting and midwives are the only caregivers a mother can turn to for non-interventive maternity care. Planned home birth (PHB) always includes a skilled birth attendant and appropriate access to medical services when indicated or requested by the mother.

Midwifery as an organized body of knowledge preceded the modern discipline of medicine by more than 5,000 years. Midwifery principles recognized as effective and still valid in our own time were found among ancient Egyptian hieroglyphics dating back to 3,000 BC. Today, physiological management is the scientific backbone or evidence-based model of maternity care used world wide by midwives, except in the US where medicalized care eclipses all else. Physiological management is actually protective for both mothers and babies. Nationally certified direct-entry midwives (CPMs) using physiologic management in a domiciliary setting, reduced the episiotomy / operative delivery rate (and associated complications) from approximately 72% to approximately 5%, with an identical or even slightly improved perinatal mortality rate. It is efficacious -- that is, both safe and cost effective.

Nothing that modern allopathic medicine has to offer – no routine use of drugs or surgical procedures, no electronic devise such as continuous electronic fetal monitoring, no ‘preemptive strike’ such as universal hospitalization or the routine elective use of Cesarean section, has been able to create a system that is better or safer than the routine use physiological management for healthy childbearing women. However, these methods don’t belong to midwives per se. They belong to science and to society, to be used by anyone regardless of professional affiliation, including physicians.

One must question how the ancient and honorable tradition of midwifery came to be obliterated almost to the vanishing point by the medical profession and then claimed by the medical profession to be an illegal practice of medicine? What brought about the wide-spread but uncritical acceptance of an unscientific method such as interventionist obstetrics for healthy women? The medicalization of normal labor triggers a chain of inevitability that starts with the ‘domino-effect’, in which the unintended consequences of routine interventions make childbirth progressively more complex, eventually requiring the use of injurious interventions and sometimes progressing on to serious complications. When injury to mother or baby does occur, the biology of normal birth gets the blame. The complications of these obstetrical interventions are often cited as proof that “I would have died if I hadn’t given birth in the hospital”. This chain of inevitability, multiplied by forth years, has ended in an ever sky-rocking Cesarean section rate, which was a 30% for 2004 and is projected to be 34% by 2006. This is the disheartening background of most midwife/home birth prosecutions, which are inevitably based on medical politics instead of credible scientific evidence.

Like the midwife in the Indiana prosecution, I am a CPM, that is, a nationally certified professional midwife. CPMs are experienced direct-entry midwives who trained directly in midwifery instead of becoming a nurse first or becoming certified as a nurse-midwife. The statistics from the CPM study published in the British Medical Journal (June 2005), include those from my own home-based practice, as well as Indiana CPM Jennifer Williams and 500 other CPMs in the US and Canada. The BMJ study confirmed again the consensus of the scientific literature, which consistently identifies that planned home birth, when compared to hospital-based care for healthy women, is equally safe for the baby and reduces maternal interventions by as much as ten times.

Unlike the recently arrested Indiana midwife, I am also licensed in my state of California but only because mothers and midwives in our state spent 30 years fighting an uphill battle against organized medicine to get midwifery decriminalized. Finally, in 1993, the California Legislature passed the Licensed Midwifery Practice Act. The LMPA officially recognized that the greatest safety for healthy mothers with normal pregnancies is to provide them with access to professionally-trained and licensed midwives.

In my opinion, the relentless optimism that needs to be addressed in America is not false optimism about normal birth but the unfounded idea that the current obstetrical model is the most appropriate one for healthy childbearing women. Most important, everybody in society, even those who would never use a midwife or plan a home birth, benefits from preserving and promoting physiological management. In a perfect system, medical educators would learn and teach the principles of physiological management to medical students. Practicing physicians would utilize physiological management as the standard of care for healthy childbearing women. Hospital labor & delivery units would be primarily staffed by professional midwives, with incentives for current L&D nurses who wish to retrain as hospital-based midwives to do so at minimal expense to themselves. This would dramatically reduce rate of injurious interventions and the cost of maternity care while increasing good outcomes and satisfaction of families served.

In the meantime, community-based midwifery needs to be legal for both mothers and midwives. If the problem is the law, then the law needs to be changed, as it must be kept in mind that the basic purpose of medical practice legislation is consumer safety, not as a political tool for promoting a medical monopoly. Enforcing medical practice laws in a manner contradictory to common sense and the well being of the public is not in the interest of childbearing families or a civil society.

More info is posted at www.sciencebasedbirth.com. See ‘April 06 Info for Bloggers – midwife controversy’.

elfanie said...

One reason I believe in hospital deliveries is that you never know. One kid I know went into distress during her delivery. It was, of course, picked up immediately on the fetal monitor, and was solved by giving her mother oxygen. If that had not worked, they were ready for a C-section. But in most home deliveries, it would have gone unnoticed, and the baby born with potentially some brain damage. Most likely not noticable, but there.


Ok...first off...you seem to think that homebirths are unmonitored. Homebirth midwives monitor the baby and DO catch the same "distress" that you are referring to.

secondly..you mention that it was "solved" by giving the mother oxygen. Bull. Homebirth midwives carry oxygen - but that in no way saved this baby, I assure you. If the mom's pulse ox was 98-100% (which it almost universally is), what benefit do you think putting oxygen on her did? nothing...just made the mother feel like they were doing something.

you said that if it didn't resolve they would have done a cesarean. Same thing with a homebirth. Something starts to look funky, you transport. Not a big deal.

You don't mention WHY the baby was in distress. Was mom being induced? (not happening at a homebirth) Was her water broken for her? (not happening routinely at a homebirth) Did she have anesthesia - an epidural? (not happening at a homebirth)

You say this baby was at risk...but how do you know that baby wasn't at risk BECAUSE of the hospital and the things we do to to them.
I see a lot of fear of homebirths based on the proverbial "what if"...but I also fear the "what if" of hospitals, since the #1 cause of complications is iatrogenic! We start messing with mom (inducing, strapping to monitors, restricting movement, restricting food/fluids, giving analgesics, giving anesthesia, breaking her water...) and then a complication occurs that wouldn't have otherwise.


THAT is what I think more people should find scary.

Cherrie said...

Thanks Faith, for a really well thought out post. I appreciate seeing all the accurate info you took the time to write down.

I think it's amazing how we all form such strong opinions on things we know so little about. We can't each be experts in everything, of course. And knowing this, we have to take somebody's word as the expert we choose to believe. Something like childbirth is so socialized, we tend to align our belief system with, say, our sister or neighbor, rather than take the time to educate ourselves. The evidence is out there, folks. But each of us has to choose to dig it up, read it, and then be able to critically examine what that means to us.

The fear about the baby's head being a 'battering ram' originated long ago when mothers were out cold when giving birth. It has long since been proven over and over again that a vaginal birth has many benifits for the baby in prepairing it for those first breaths, and life outside the uterus.

Home or hospital isn't the question so much as what 'style' care your provider is going to give you. Expectant management? Agressive treatment? Defensive Decisions? There are so many decisions in the many months of pregnancy and childbirth, each practitioner has their own paradigm from which they make decisions for your care. And each decision has a big impact on the safety of both mother and child. Each birthing woman and her family should take the time to educate themselves just enough to at LEAST know which style of management they want, and find a provider who'll give it to them.

faith gibson said...

I am impressed by the thoughtful, informed and informing responses to my April 4th comments. Usually I am talking to myself when addressing any aspect of this unpopular topic. I have to admit that this is the first time I’ve ever posted anything to a blog, as my handlers usually keep me chained up in the basement, nose to the grindstone, and won’t let me ‘waste’ time with such foolishness. But the NYT article on the Indiana midwife had a link to Ann Althouse’s blog and I clicked just to see what it was all about. Imagine my surprise! Cherrie and Elfanie’s replies are so good and worthy of being quoted. So I’m officially asking – may I quote you both?

The actual hot issue of the day is not the prosecuted midwife in Indiana but the draft report by the National Institute of Health subsequent to their “State-of-the-Science Conference on Cesarean Delivery on Maternal Request” (which they kindly reduced to ‘CSMR’ for the keyboard challenged). The conference was held March 27-29 in Bethesda. One of the most interesting aspects is that a government agency officially released a report at 5pm on March 29th, the last day and last minute of a conference. [www.consensus.nih.gov] Obviously, the report had already been written, which means the input of the participants was just a feel good move and window dressing for a predetermined agenda.

The NIH draft report concluded that mothers are demanding C-sections in greater numbers (good data says not true!), which ‘explains’ the 29% percent C-section rate for 2004 (and the projected 33% C-section rate for 2005!). The report went on to infer that there isn’t really any good data to determine if C-sections are better or worse than vaginal birth, but if you’re only planning one or two children, the odds are about even.

The illogical conclusion was that if you want to, go ahead and have all your babies by scheduled C-section (something about consumer convenience and giving mothers ‘control’ over their birth), never mind that it doubles maternal mortality and costs twice as much. Rumor has it that one of the things fueling this conference was a push for a CPT code (Current Procedural Terminology) for patient choice CS. This would permit them to hide a lot of poor obstetrical practices under the banner of women’s reproductive freedom and a woman’s ‘right to choose’. How poetic.

The NIH’s official conclusions are a great way to distract the American public from the real issue, which is physician fear of normal birth, spurred on by lack of education or experience in physiological management of spontaneous labor and birth, hospital policies that make physiologic process hard or impossible for either mother or physician to use in an institution, run away litigation, pressure on doctors from malpractice insurance carriers not to ‘allow’ mothers with VBAC, breech and twin pregnancy to deliver vaginally (docs get a ‘good driver’ discount if they agree) and astronomical malpractice premiums. This is all wrapped up in the notion that Cesareans (referred to as ‘vaginal by-pass surgery') are safer and better than normal birth (referred to as “delivery from below” – uck!). All these spurious ideas come to us courtesy of a dis-information campaign by many spokespersons within the obstetrical profession, who go on the Today show and NRP and assure us that vaginal birth is very bad for the mother’s pelvic floor (under anti-gravitational obstetrical management I agree!) and the baby and that “Cesarean is safer for the baby”.

Mind you, I’m not anti-obstetrician or anti-hospital. I have several physician friends that are obstetricians, even ones that are politically active in ACOG. They are all honest dedicated people. I am however ‘anti’ the politics of organized medicine, which includes methods of mass deception and the ill-informed idea that the best way to prevent complications is the “pre-emptive strike” -- routine use of potentially injurious interventions on healthy women and a form of malpractice insurance referred to by OBs as “when in doubt, cut it out”.

American mothers don’t have a “C-section deficiency”. The most important issue is not maternal choice Cesarean, it is how and why the mismanagement of normal birth has been systemized by the entire obstetrical profession to become the 20th century ‘standard of care’. Abandonment by the medical profession of physiological management in 1910 has brought us, in 2006, to the brink of the “tipping point”. For the lay public, post 9-11 political & economic overload, normal human inertia and the blind spot and prejudiced reporting that the media treats this topicwith, combined with the relentless lobbying pressure of ‘special interests’ groups and especially the loss of ‘institutional memory’ within the medical profession for normal birth management, has us tittering on the brink of a precipice. In some ways, the NIH document represents that exact point of the “tip-over” into no man’s land.

The NIH’s went off track because they started with the idea that the ‘normal’ CS rate is and should be one out of three or higher. Since no one can tell which one of the three patients will have a C-section and since the other two mothers will be subjected to so many injurious interventions that the rate of sequelae will be as high as it is for scheduled C-sections, then why shouldn’t we retool the behemoth of obstetrical care into a 9-5 M-F walk in C-section assembly line, which is already how its done in Mexico City (95% CS rate, with surgery scheduled at 15 minute intervals).

Throughout the entire 20th century, organized medicine has been free to build a relentlessly ambitious system to replace normal childbearing with a new and improved version, orchestrated by institutional medicine but never exposed to scientific methods. This unofficial medical experiment required that the principles of physiologic process be ridiculed and discredited and that infrastructure for physiological management dismantled. In the obstetrical model the integrity of childbirth is broken up into two separate sub-systems. Normal labor is conducted as a medical condition managed by nurses (no directly billable units, just routine hospital charges). Normal birth is renamed as the ‘delivery’ and given its own special professional status and economic base. Delivery is considered to be a surgical procedure that can only be ‘performed’ by a physician-surgeon in an institutional setting and which generates an itemized professional fee to be billed on top of normal hospital charges.

After 96 years of this new world order, physiological management has become invisible, a total non-entity (aside from the practice of community midwives) and was of course, missing-in-action in the 2006 NIH scheme of things. The federal government’s rubber stamp for maternal choice cesarean simply gives the obstetrical profession the green light to continue on with business as usual. That business is the death of normal birth via the total replacement of spontaneous vaginal birth with various forms of Pitocin accelerated labors and assisted vaginal delivery under epidural anesthesia and what they'd like us to think of as the Rolls Royce of OB care -- Cesarean surgery. The ultimate goal is the obstetrical dream machine – 9 to 5, Monday thru Friday walk-in assembly line C-section as the 21century standard of care.

The NIH panel did not report anything that is technically in conflict with "the literature" at the most base level of interpretation. Its faults, of which there are many, are subtle instead of simple and easily apparent. What that means is the scientific facts must be explained one by one; those explanations requires several sequential steps, which of course, means the listener has to care enough to pay attention long enough to get the point. The bottom line seems to be that nobody cares enough about this topic to find out the facts and/or knows enough about the issues to hold the obstetrical profession accountable. Like the popular perceptions of Enron and Arthur Anderson, we all just assume that ‘they’ know what they’re doing and of course, ‘they’ have our best interest at heart. I wish it were true.

Cherrie said...

What that means is the scientific facts must be explained one by one; those explanations requires several sequential steps, which of course, means the listener has to care enough to pay attention long enough to get the point. The bottom line seems to be that nobody cares enough about this topic to find out the facts and/or knows enough about the issues to hold the obstetrical profession accountable. Like the popular perceptions of Enron and Arthur Anderson, we all just assume that ‘they’ know what they’re doing and of course, ‘they’ have our best interest at heart.


E.X.A.C.T.L.Y!!!!

Ann Althouse said...

Faith: We discussed the NIH study here.

Thanks to all who are bringing the pro-midwife perspective.

Personally, I'm skeptical of everyone, not just midwives. Being pregnant is quite a predicament, and you need someone to help you out of that jam. I didn't like anyone I had to deal with. But the reality was, with modern nutrition, the babies' heads were completely out of proportion to the pelvis. I had no real choice.

Good luck to all. I don't have the answer myself, other than to say I'm glad I lived through the supposedly "natural" phenomenon of childbirth. Millions of my sisters did not.

C.Lybolt said...

I haven't read through all of the posts, but I do have some reactions. I am a midwifery student in Indiana, working to become a CPM. I made that choice after working in a hospital as a doula for several years. After seeing what the medical does to women and babies, I needed to become a midwife to offer an option. That said, the sad fact of life is that some babies die during birth and some women die. But if birth were this phenomenally dangerous process, which is only made safe by modern medical technology, how did we ever survive as a species to this point? 95 % of women and babies are within normal parameters and safe during pregnancy and birth. Also, if medicalization has made birthing so much safer in our modern country, why our statistics so abmyssal in comparison to other countries ? It is safer to have a baby in Cuba than it is in the States. Babies and mothers are hurt and die in hospital deliveries also, often from iatrogenic reasons. That big word means the damage was caused by the medical intervention or doctor. The greatest difference is that we accept the damage in the medical atmosphere and there is no prosecution or media reporting. Our inductions rates are somewhere between 50 and 75 %, or more. Our Ceasarean rate is over 30 %. Medicalization is not improving the state of women and newborns. For a number of standard of care practices, we have no signifacant long term research showing safety. Yet, we do have lots of research showing it does not improve outcomes. Electronic fetal monitoring is one of those modern technolgies. It is routinely used in hospitals when we know that the only difference in outcomes is an increase the incidence of casaearean section. There is absolutely no improvement in fetal outcomes, either in morbidity or mortality. Midwifery care is safe and research and hard data support that position. Midwifes are trained to trust normal and respond to abnormal and seek appropriate help. Midwives are also trained in neonatal resuscitation. During the posts, lots of people were stating that their baby needed resuscitation and would not have lived unless born in a hospital. Medical personal make it appear that way but that is not necessarily true. The more natural management of midwifery care, even with a true knot, provides a safety net allowing a woman's body and the baby to control the labor and birth and keep it safe. I've seen babies damaged by an impatient doctor hurrying a labor along with pitoccin and causing fetal distress because of a cord problem. The issue in Indiana is one of responsibility, shoiuld the state make our decisions or do we make our decisions as intelligent, rationale adults. We understand that not all women want a home birth and that is fine. But, for those who make the responsible decision to birth in the safety and privacy of their home, qualified and legal midwifes should be available. As midwives, we will continue to serve those women because that is our calling. We would prefer a licensure which allows peer review and regulation.

Cherrie said...

You know, one thing nobody has pointed out, is that unless a doctor has aquired extra training that they don't offer in medical school, s/he will NEVER have been present at the birth process from beginning to end. This means a doctor has no way of putting together the sequence of events that cause a complication at the birth itself. The 'warning sign' 5 hours before the birth, that a complication will occur.

A midwife is present from the onset of labor, until several hours after the birth. She's an expert in anticipating problems. She does not have to rely on a third hand report of a woman's labor, reported by a short-handed nurse, possibly over the phone, in the middle of the night, And with 12 other women in labor at the same time, without looking at a chart, to prescribe interventions for an individual labor. That's gotta be hard to do! No wonder so many iatrogenic problems! Got bladder problems? painful pelvic floor, scars and adhesions, Vaginal prolapse? Milk won't come in? Depressed? I'ts very possible that the forceps, episiotomy, c-section, pitocin caused that.

The midwife is right there the whole time. With all the necessary equipment (oxygen, suction, hemmorage drugs, a brain) that will deal with complications.

That's safe care! One on one, with a practitoner who knows you, and is with you during your whole labor. Midwives are experts at keeping labor/birth normal. And doctors are experts at saving the abnormal ones. I'm thankful to have a skilled physician and hospital near my home. And I'm very thankful to have the choice to hire an expert to come to my home, and oversee my entire labor, no matter how long it takes, for about the same out-of-pocket cost as a hospital birth.

Maureen Trovato said...

Wow, I am so encouraged by this blog and the midwives and midwives--in-training! We need your voices out here and I truly believe the "tipping point" is inevitable but also necessary because I can't help but think that this will be the moment the pendulum reaches it's outer limit. (However, that Mexico C-section stat is very disheartening. What is going on there?) I've been a childbirth educator since 1992 and a doula since 1999, and all the "anecdotal" experience of these women dedicated to the profession of midwifery needs to be heard by women everywhere. I and others in alliance with an organization called Birth Without Boundaries, are in a major struggle with our largest local hospital birth provider just to get them to become a Baby-Friendly Hospital...(WHO international certification process to promote breastfeeding) This will help babies, but barely addresses the needs of mothers giving birth before they start to breasfeed! When we offered a summary of the recent CIMS conference, (Coalition for Improving Maternity Services) and their effort to promote Mother-Friendly maternity care, this put our hospital reps over the edge! Our April meeting with them has been cancelled, however we're assured there will be a meeting in May. We'll see? I would also like to ask if I may quote some of you women for an article I'd like to get published in the local newspaper. There was a big hulabaloo here when some of us were arrested for trespassing on hospital property when we wanted to bring to the publics attention some of the hospitals practices concerning newborn infant care and how it often undermines successful breastfeeding. We must never stop exposing this modern birth machine for what it is!!!You have all expressed it SO WELL! I have five daughters! They are entitled to be cared for by caregivers who will respect them and the normal, natural process of thier births. They are also well aware that they themselves are responsible for their own health and well being and wouldn't dream of abdicating that responsibility to any institution "claiming" to have only "thier" best interests at heart. This is just a fallacy that the unknowing public is willing to buy into because they have gotten lazy about their own health care! I don't want to sound cynical but, if this current C-section trend doesn't stop this pendulum in it's tracks, I'm afraid I don't know what will. My 30 year old niece, first time mom, was just induced for post dates,(escaped the first week but surrendered the second week) to an induction that never got her passed 4 centimeters and she inevitably relented to a c-section. All this after she was fearmongered by a doctor who insisted she sign a paper relieving him of responsibility if she did not agree to an induction!!
THEN he decided to give her another week anyway because his schedule was too full!!!(She lives in Philadelphia)Please visit our website birthwithoutboundaries.com, we could really use your help in advancing our little part of the world toward more humane, peaceful, safe birth environments for ourselves and our daughters and on and on.

faith gibson said...

Ann, thank you for the kind words and the link to your blog on the NIH draft report. I wish I’d read it before my own post; I feel a bit foolish now.

I’d feel even worse if anything I said about the politics of physiological childbearing and the need to reform our national maternity policies that were interpreted by you or your readers as a criticism of your informed choices or birth-related medical necessities. Nor do I mean to ignore real dangers such as maternal mortality. My objection is only to the systemized and often non-consensual use of potentially dangerous drugs, interventions and operative delivery in the absence of a medical necessity, without first employing science-based physiological principles and without first obtaining true informed consent.

I do not mean to cast aspersions on any of the lovely women who require or desire medically appropriate interventions or make light of the ability of modern obstetrics to successfully treat life and limb-threatening complications. My eldest grandson was born by Cesarean. It never occurred to me to judge his mother (my beloved first daughter) based on an accident of biology or the route of delivery.

As a young married woman, I was diagnosed with Stein-Leventhal syndrome (polycystic ovaries). At that time the only treatment required major abdominal surgery. I was and still am eternally grateful to my wonderful OB doctor, who made such an astute diagnosis more than 40 years ago (before modern infertility technologies) and skillfully performed surgery that permitted me to have 3 lovely children and 2 grandchildren. I love obstetricians and continue to grieve that they no longer love me.

However, I also remember waking up in the recovery room after abdominal surgery, feeling like I had been kicked in the stomach by someone wearing a pair of ice skates, retching and desperately in pain. I pondered long and hard on what such intense pain and prolonged debilitation would be like as a new mother also trying to meet, get to know, breastfeed and care for a newborn. Thus was born my dedication to preventing *unnecessary* cesareans.

I have been an advocate for childbearing women since I was an 18 year old nursing student. I define that as meeting the mother’s practical needs with the right amount and right kind of care – timely, not too little, not too much. I was taught to baby the new mother so that she was empowered to mother the new baby. My entire professional life has been a quest to secure the right of healthy, mentally-competent women to have control over the manner and circumstance of their normal childbirth.

My father, my husband and more recently my son were all in the armed forces, fighting (and risk dying) for our democratic way of life. But despite my ability to vote for the politician of my choice, my mother, myself and now my daughters, did not / do not have the ability to say no to medically unnecessary obstetrical procedures we didn’t want or need. Obstetrical care is often provided on a basis similar to pediatric care, in which the adult experts make the fundamental decisions while the childlike patient is expected to be good and to be grateful.

I know of these realities because I was the labor room nurse who carried out the doctor’s orders and the hospital policies, whether or not the mother wanted or needed or even legally consented. This is still as immutable for the majority of childbearing women in America today as it is for woman living in third world countries who can be forced as children to submit to female circumcision and required as a married woman to submit to unwanted sexual encounters.

Only in America, if a pregnant woman in a hospital should object to a treatment perceived by the staff as ‘necessary’ or refuse to cooperate, the obstetrical version of unwelcome bodily invasion will be accompanied by threats to call a juvenal court judge for a court order. If the baby is already born, the non-compliant mother will be told that if she doesn’t quickly agree to the proposed medical procedure for her newborn, Child Protective Services will be contacted.

Occasionally this is justified for an acting-out teenager on crack cocaine or mentally ill adult woman, but ask around and you will find many reports of being coerced into treatments because mothers couldn’t hold out against the sustained professional pressure or they feared retaliation. The prestigious Maternity Center Association of NYC just published their second “Listening to Mothers Survey” conducted by Harris Interactive of 1,500 healthy women with a single fetus who gave birth in the last 12 months. Only 1 mother identified herself as voluntarily (with true informed consent) choosing an elective Cesarean, but 9% of women described being ‘talked into’ a cesarean which they didn’t believe was medically necessary and didn’t want. (www.maternitywise.org)

True mastery in normal childbirth services means bringing about a good outcome without introducing any unnecessary harm. Interventionist obstetrics is an “expert” system that has failed most in the very area it was supposed to have the most mastery and expertise -- "the optimal conduct of the many normal cases". This dysfunctional system creates an asymmetrical burden of that risks falls unfairly on the childbearing woman, in which the mother is exposed to the actual pain and potential harm of medical and surgical interventions in order to reduce the risk of litigation for the obstetrician and hospital.

As a mother myself, this breaks my heart. But one of the most intractable issues I face as a birth activist (second only to the vitriolic rhetoric of lobbyists) is that attempts to widen and deepen the public discourse on this topic inevitably triggers an avalanche of protests from (yes, you guessed it) other mothers. Usually these women needed or wanted medical interventions and feel that I am judging their use of medical procedures as unnecessary, and inferring that they are bad. Most people I talk to are also misinformed about physiological care, believing that it means NOT doing anything at all, denying the laboring woman access to effective pain management, putting the baby at risk because no one is monitoring its well-being, refusing to offer medical help if labor stalls or gravity fails to bring about a spontaneous birth.

This instantly negative reaction specifically applies to career women, many of whom are the movers and shakers in my political world -- women legislators, members of the medical board, attorneys, members of NOW, newspaper reporters, TV journalists, etc. This is a major, if not insurmountable, stumbling block to effective political action. America needs to question the fundamental premise of a surgical specialist routinely using a medically and surgically interventive model to provide care to healthy childbearing women with normal pregnancies (70%). There is real danger in permitting obstetrics to adopt Cesarean section as the 21st century standard of care. Already the new maternity unit at the Ann Harbor University Hospital (Michigan), scheduled to open in 2011, is replacing 50% of its LDR with ORs in anticipation of a 50% C-section rate by 2010. It is “build it and they will have no other choice”.

Heaven help us all if there were to be a dirty boom, bio-terrorism or a pandemic of the avian flu. Precious hospital services would have to be divided between the gravely injured or the contagious, critically ill AND providing customary but medically unnecessary high tech interventions to healthy pregnancy women because none of our OB doctors know how to physiologically manage a normal birth any more (the midwives will all be in jail). I Googled the words “obstetrical research on normal childbirth” on March 31, 2006. The search results said it all in a single digit: “Number of results: zero. Sorry, your search for Obstetrical Research on Normal Birth has found no results.”

So my question for you lovely women is what can I and other birth activist say or do that would not inadvertently insult the 99% of the childbearing public that did not have un-intervened with childbirth and among that cohort, the 30% who had a Cesarean? Unless we can avoid this pitfall, it will be impossible to would elevate the public discourse and reform our national maternity care policies.

A rehabilitated system would integrate the classic and scientifically sound principles of physiological management with the best advances in obstetrical medicine, to create a single, evidence-based standard for all healthy women used by all maternity care providers and in all birth settings -- family practice physicians, obstetricians, and professional midwives, providing care in hospitals, independent birth centers and homes.

But without rigorous public debate, we will never have maternity care that is safe, cost-effective, family-friendly, physiologically-sound and able to keep on keeping on, even during a Katrina-like civil disruption.

Any constructive feedback would be most welcome…. Faith ^O^

HaloJonesFan said...

The recent "Cesaerian Surge" is mostly due to legal reasons.

If a baby is born naturally, and there are complications, and those complications would have been avoided if the delivery were a C-section, then that doctor will be sued out of existence (and probably take a big chunk of the hospital with him.) And it doesn't even have to be the mother filing suit--any lawyer will be able to weigh in on the case!

So at the slightest twitch, the most minute delay of contraction, the smallest pause in the baby's heart rate, it's off to the OR. Yes, the C-section might introduce problems of its own, but those are considered 'normal' risks, rather than 'avoidable' risks.

Also, there's the fact that obstetrical treatment focuses on the child, and not the mother. The mother's wishes are irrelevant--she is an incubator. If something would make the child's experience slightly easier, then that happens, regardless of what the mother wants or needs or can handle. Which, again, leads us to a preference for C-section whenever possible--it's much less traumatic for the child, and in the delivery room that's the only thing anyone cares about.

Why does Cuba have a better rate? Well, let's see the statistics. If the statistics are cherry-picked, then there's your answer. Say, for example, the statistics only apply to hospital deliveries, which is the standard for America. Is it the standard for Cuba? If the high-risk deliveries happen outside of hospitals, then you'd get "better" statistics...

Sort of like all those people who only look at low-risk deliveries and pronounce home birthing to be "just as safe" as hospital births. Sure, but you can't just look at a part of the statistics! You have to look at all births, including high-risk births. Now the picture doesn't look so rosy.

Jennifer said...

Halojonesfan: I don't think anyone is advocating for home births in high risk situations. Given that, it doesn't make sense to lump high risk statistics in.

They wouldn't really figure in to the home birth numbers and they would drag down the hospital numbers. So, yes the picture would look less rosy - for hospital births. But it wouldn't be a fair comparison.

elfanie said...

Sort of like all those people who only look at low-risk deliveries and pronounce home birthing to be "just as safe" as hospital births. Sure, but you can't just look at a part of the statistics! You have to look at all births, including high-risk births. Now the picture doesn't look so rosy.



However....we aren't comparing apples to oranges when looking at homebirths and hospital births...which is what looking at ALL births would do.

We compare apples to apples....low risk moms at home vs. low risk moms at hospitals.

If we were to include high risk mothers, then hospital stats would PLUMMET and homebirths would look EVER so rosy! (because high risk births aren't being done at home)

HaloJonesFan said...

The assertion of home-birth people is not so much that low-risk deliveries could happen at home, as it is that ALL delieries SHOULD happen at home. If we could determine beforehand which births would and which births would not require intervention, then obviously home-birthing would be more acceptable. Is anyone saying that we can do this?

Perhaps I was wrong when I said "high-risk". I should have been saying "with complications". Regardless, you can't just ignore statistics that you don't like. I could just as easily set up a study that shows home-birthing as insanely dangerous, by looking at the outcomes of only high-risk births.

Jennifer said...

Halojonesfan: I don't think I've ever heard "home-birth people" advocate that every birth should happen at home. That's a really irresponsible position.

The studies quoted in this thread do not exclude births that had complications. They exclude high-risk pregnancies. Very very very very few women with high-risk pregnancies attempt a home birth. Thus, those numbers skew the hospital statistics and don't affect the home birth statistics. That's why they are excluded.

It is not a case of "ignoring statistics you don't like". Nor is it impossible to identify which pregnancies are likely to lead to complications in birth.

faith gibson said...

If the statistics are cherry-picked, then there's your answer….. Now the picture doesn't look so rosy.HaloJonesFans post:

I continue to be interested in how to talk about this topic in a way that does not inadvertently insult 99% of the childbearing public. So far, no one has responded to my question. However, I see the catch-22 aspect of my inquiry. If you believe that all the studies on planned home birth (PHB) are poorly done or cherry picked, that assumption would automatically prevent anyone from addressing my question.
I am particularly motivated to hear from women because the D.C. office of American College of Obstetricians and Gynecologists (ACOG) is currently gearing up to rebut the BMJ paper on PHB and (they hope) discredit its conclusions. ACOG has formed a national committee to develop a uniform policy on how best denigrate PHB and (they hope) eventually eliminate both home-based birth care and non-nurse midwifery (naturopathic doctors who attend PHB as well as direct-entry midwives).
Organized medicine already implemented this type of campaign once before, in1910. It resulted in a precipitous drop in the number of midwife-attended births from 60% to 13% in a single decade. Regardless of what one thinks of midwives and PHB, I’m assuming that most people would agree that a one-party political system, a one-church national religion or a total monopoly over other aspects of American life is not such a good thing.
None of you don’t know me from Adam’s house cat, but I’m not joking when I say that I know the scientific literature backwards and forwards So just for the sake of argument, I’m asking readers to be temporarily willing to believe me. I am one of a tiny handful of published historians on the practice and politics of midwifery and its interface with the medical profession, especially in 20th century American and the state of California.
I live about five minutes from the Stanford University campus and medical center and have logged about 3 calendar years in its medical library doing research on this topic. For the last 13 years I have also been a liaison between the Medical Board and California licensed midwives. To answer the Medical Board’s questions about the relative safety of PHB, I put together a 2-volumn set of the research on planned home birth as attended by midwives published since 1976. Together these two books weighs 71/2 pounds.
The consensus of the scientific literature over the last 30 years is always remarkable the same. For low and moderate risk women who give birth either at home or in a hospital, the perinatal mortality rate is between 1.9 and 2.3 per 1,000 or approximately one out of 500 normal births, *regardless of location or category of care provider*. All out-of-hospital statistics include outcomes for women or babies transferred to the hospital during labor or after the birth.
As for mothers, the medical and surgical intervention rate is between 3 and 10 times *less* for physiological management in free-standing birth centers and client homes than for hospital delivery. For example, the C-section rate in the BMJ study for PHB (including transfers to hospital) was *3.7%*. For a similar cohort of hospital birth, it was *19%*. PHB with an experienced midwife, in combination with access to appropriate obstetrical services for complications, is a responsible choice for healthy women who want a physiologically-managed labor and birth and do not plan on using labor stimulating drugs or pain medications.
Next I want to provide a basic fact about biology. It is a missing piece of the puzzle for most people.
The childbearing pelvis is shaped like a lower case letter ‘ j ’. If the mother is standing, the long stem of the ‘j’ tracks with her spine, then a 60-degree bend occurs as the curved foot sweeps the last few inches of the pelvic outlet and birth canal. For the baby to be born spontaneously, it must negotiate that 60-degree bend and be born going forward (not down as one might imagine). When a mother gives birth in an upright position, the baby is born going forward into her own hands or those of the birth attendant. Under these circumstances the weight of the baby is a force that aids in its own expulsion. In physiologic terms, this is known as the right use of gravity.
If the mother is laying down during the pushing stage of labor, the big triangular bone in the back of the pelvis (the sacrum) naturally encroaches somewhat on the pelvic outlet (the curved foot of the letter ‘ j ‘). The ability of the baby to negotiate this turn and get past this bone can be seriously limited by the mother’s own weight on her sacrum and the pressure from the mattress when she is lying down. If she gives birth while lying down in the lithotomy position, she must push the baby around that 60-degree bend and then push it up hill (towards the ceiling), against gravity. The baby’s size and weight work against its ability to be born under these anti-gravitational conditions.
If the baby is bigger than usual or the mother’s pelvis is smaller usual or her ability to push has been impaired by the effects of anesthesia, then it may be necessary to perform an episiotomy and use forceps or vacuum extraction to rescue the baby. If that doesn’t work, a Cesarean will become necessary. Episiotomy and instrument-assisted vaginal birth are both associated with pelvic floor/pelvis organ damage and maternal incontinence. Cesarean is associated with a number of intra-operative, post-op, delayed and downstream complications that don’t occur in spontaneous births under physiological management. The reason for using physiologically-based management it is to reduce the trauma to both mother and baby.
So I’m asking again if anyone out there can articulate for me what the road blocks are, at least as they see them, to having this type of conversation in a public forum without making women feel unduly anxious (or judged) and cutting off debate. Physiological management should not be about hospital vs. home, neither should it be a debate about pain management.
The ‘perfect’ solution is the ‘relocated home birth’ in which mothers can be in the hospital and still get science-based physiologically-based care under the primary management of a midwife or physician. Should the mother want or need drugs or interventions for any reason, primary care would be transferred to an specialist in obstetrics (now days a perinatologist), while the midwife continued to provide social and emotional support. It’s a win-win solution.

Jennifer said...

Faith: I don't know how you frame the debate without seeming to disparage those who choose differently. Babies and mothering are touchy subjects.

Just look at breastfeeding. Try to put out a factual message like "breast is best" and automatically you set anyone who chooses bottle on the defensive. But how else do you advocate for breastfeeding without pointing out its inherent advantages?

My only guess is to frame the debate in terms of new information that most of us don't have access to. Most people are unaware of the evidence supporting home births.

HaloJonesFan said...

I don't think that there are "roadblocks to having this conversation". Mostly because you're trying to have about six different conversations in one. What are you arguing about? Home birth? Standing birth? Midwifery versus nursing? Mechanically-assisted birth? A narrower range of C-section initiation criteria?

As far as PHB goes, I'd judge it by two statistics. (And I should have been asking about them all along, but I hadn't fully understood it until just now.)

First: What is the percentage (overall, PHB or in-hospital or wherever, any birth) of "low-risk" births that end up requiring intervention? Because that is where PHB falls down. We've used statistics to prove that births which don't require intervention...don't require intervention. The reason you'd go to a hospital is in the rare instance that the birth does require intervention. What happens when a low-risk home birth has complications? You send mother and baby to the hospital--adding that much time before treatment is possible.

Also, one big part of your argument in favor of PHB is the lower rate of medical intervention. But what are the criteria for medical intervention in the case of PHB? Are they less stringent than those in a hospital birth? As I've said earlier, if a hospital would call for a C-section but a PHB would just roll with it, that means that you aren't comparing statistics in a meaningful way.

If you're arguing that a clinical approach to childbirth is associated with a lot of un-necessary medical issues and may cause great pain to the mother, that I can agree with, but I'm not sure that is what the home-delivery debate is all about. The debate is typically framed, from both sides, as women wanting to do whatever they like and expecting their insurance to pay for it. They aren't saying "I think that the medical practice surrounding childbirth results in a needlessly traumatic experience, but I understand the need for having the resources of a hospital immediately available", they're saying "women should be allowed to do whatever they want".

Cherrie said...

A couple of us might know you from Adam's house cat, Faith. I, for one. And let me take this moment to publically thank you for all the years you've spent clearing the trail for women like myself, who had the option of picking up a few books and thinking for myself when I became pregnant. Then I had the further option of choosing a CPM in my midwifery legal state and having the most incredible birth, spending the next week sky high on my own opiates. Was I lucky? YES! I was lucky to have both the information AND practicing caregivers available in my area.

A couple requests have been posted to quote. Anyone has permission to quote me, but I'm just an ordinary girl, not terribly worthy of quoting. But I'd like to quote YOU Faith, if I may. That J discription is the best I've seen. And I'd love to get my hands on those two volumes you've put together.

Faith said:
So I’m asking again if anyone out there can articulate for me what the road blocks are, at least as they see them, to having this type of conversation in a public forum without making women feel unduly anxious (or judged) and cutting off debate.

I'm one of the 1% who didn't birth in a hospital, so I'll share what I've interpreted from those 99% around me.

First, I think women who've had a bad hospital experience have a psycological need to protect themselves from believing that it was all unnecessary. That would make them victims. Nobody wants to be a victim. And when a woman DOES admit to herself that she was victimized, she may struggle from post-tramatic stress disorder (diagnosed or not). How many women put aside their complaints after being told for the 12th time 'but at least you have a healthy baby!'
As if the alternative was the opposite. And we women do this to each other. Was anybody here told horror stories when you were pregnant?

Women also have a hard time trusting themselves. If our decisions are questioned by loved ones, we cave.

I honestly have no idea why women feel judged or pushed by 'natural birthers'. I know that on a number of occations I've had to cut a conversation short when the people I'm talking to get defensive. The thing is, how do I share what I know, from facts about what anesthesia does to the baby (which most hospital personel do NOT disclose), to what my natural hormones (resulting only from a completely unmedicated birth) did for me. I'm immediatly met with comments like, 'I'd like a natural birth, but I bled after the last one, being in the hosptial saved my life'. How can I present to this woman the fact that most hemmorages result from 'aggressive management of third stage', when they don't know what that means, and they think I'm making a comment about their personal circumstances. We have a language barrier, and I'm not a midwife, or a health care professional!

Somebody reciently pointed out that the language of the press release required in depth discription of each item, and people's attention spans just aren't that great. And they get confused too, and then give up listening.

halojonesfan is right, the topic seems too large, too encompassing. What ARE we discussing? From my perspective, you can't discuss one part separately. It's all tied up together.

And too often in these attempted discussions I come across as being anti-doctor or anti-hospital. But that's not it at all.

Faith uses the term physiologically managed care. That's an excellent discription, IF you know what it means. But lay people don't know the difference between it and medical management, and it's too difficult to describe in a casual conversation.

So my answer is; not enough information available to the average person. (although the info is there, it's interpreted as 'militant' or 'judgemental')
And, we have a language barrier.

Cherrie said...

halojonesfan said:
What is the percentage (overall, PHB or in-hospital or wherever, any birth) of "low-risk" births that end up requiring intervention?

The reason I find this impossible to answer is that 'intervention' is a collective term that means anything anybody does to change the course of the labor/birth.

some common interventions are: restricting food/drink, any kind of drug, rupturing the waters, directing the woman to lay in bed, strapping on a monitor or listening with a fetoscope.

Each intervention carries it's own set of risks/benifits and needs to be carried out on a basis that takes the INDIVIDUAL labor into account.

intervention isn't bad. it's the routine application of the intervention that leads to further problems in an individual labor/birth.

You can't have a hospital birth without interventions of one variety or another. I suppose it is theoretically possible, but not very probable to have one at home either.


halojonesfan said: The reason you'd go to a hospital is in the rare instance that the birth does require intervention. What happens when a low-risk home birth has complications? You send mother and baby to the hospital--adding that much time before treatment is possible.

Intervention happens in and out of hospital. Some interventions are so risky however that they can not happen out of hospital. c-section being an obvious one. Epidurals, for instance, can not be administered out of hospital because of very serious and life-threatning risks for both baby and mother accompany them.

I believe you may be asking how many PHBs need emergency transport? An emergency transport would be in case of an emergency (obviously) vs a transport that occurs because of a non-emergency situation. A non-emergency situation might be if a mother decides on an epidural, or baby is in a weird position and can't be born without further invasive help.

Many 'complications' can be delt with at home, with gentler methods. (and always the decision about what to do about a complication should be the mothers) Some can not. This is where we get into involved discussions about this situation, or that situation, and the statistics and evidence of care for each situation.

I don't know the statistics for emergency transport. I know they're low. Anybody here have a link, or stats available? I know the midwife I used had a 4% transfer rate total, and the emergency transfers were a small % of that.

halojonesfan said: Also, one big part of your argument in favor of PHB is the lower rate of medical intervention. But what are the criteria for medical intervention in the case of PHB? Are they less stringent than those in a hospital birth?


I'm not a medical professional, where's that apprentice who posted earlier? I believe the arguement is over the use of interventions in a hospital setting that are used strictly for cover-your-ass purposes. An intervention that may leave lasting harm to mother or baby in an individual case may be done anyway because it's 'standard of care'.

Each Out Of Hospital (OOH) midwife must have their own protocols, in which they have their own practice rules written down. That means they have to have written standards, I'll do x if y happens. I can't comment on how 'stringent' they are.


halojonesfan said: As I've said earlier, if a hospital would call for a C-section but a PHB would just roll with it, that means that you aren't comparing statistics in a meaningful way.

I think this is one reason it's difficult to use statistics alone for an arguement such as this. You can't untangle them to make logical sense. Just too many variables. An individual woman isn't simply a statistic. She's an individual and deserves to be treated that way. She deserves to be in charge of her own health care. She deserves a caregiver who will listen to her wishes and work with her as a partner in achieving that. She does not deserve to be subjected to completely unnecessary medical procedures, with all their accompanying risks to her health and well-being, just because it's hospital 'policy' or even 'standard of care'.

Cherrie said...

strapping on a monitor or listening with a fetoscope

oops, that would fall under 'survalence'. It's the decision that comes as a result of listening with a fetoscope that is the intervention.

My mistake.

HaloJonesFan said...

Cherrie: You're proving my point. Discussing statistics that "prove" home births are safer is useless, because the home-birth advocates don't use the same critera as hospital births. A proper study would have to look at home-births situation by situation and judge whether a hospital would have intervened(*). You can argue about whether or not the intervention was actually been necessary, but that isn't the argument that we're having.

As I've said earlier, I get the impression that most home-birth advocates aren't saying that home-birth is better, they're saying that the criteria for intervention should be relaxed, and that the birth process is needlessly clinical. That's fine, but it doesn't necessarily drive women towards home birth and midwifery.

(*) and I'd think that it was obvious, from the context of this discussion, what I mean by 'intervention'

Cherrie said...

halojonesfan said: You can argue about whether or not the intervention was actually been necessary, but that isn't the argument that we're having.

But I think that is the argument we're having. Lets take one example. If at home, a woman has a baby in an upright position, and because of her J shaped anatomy, baby comes without incident. In the hospital another woman who carries the same 'risk factors' (predetermined examination of her situation which anticipates complications during the birth process) lays in bed to give birth, and forceps are necessary because of gravity slowing the process, and baby's heart rate drops due to the strain of turning that 90 degree angle. The forceps require an epidural (with accompanying IV to keep blood pressure from plummeting), and an episiotomy, which then tears into the rectum upon insertion of the forceps. The epidural leaks just the tiniest amount resulting in a spinal headache that forces the woman to lie flat on her back for a week following birth. Any upright position, or even moving around too much causes an excrutiating headache. The episiotomy is sewn, but because of the extention into the rectum, bowel movements will be excrutiating for way longer than a week, and carries possibility of a fistula developing, where feces migrates into the vagina. The forceps create a tiny, yet perminant scar on the cheek of the baby. Later in life, the woman in at risk of developing bladder incontinence from the forceps damage, as well as a slight risk of vaginal prolapse, also from the forceps. The episiotomy, once healed, is always a source of pain and irratation, especially during sex.
Now, you tell me. Which birth was 'safer'?
It seems to me, that the argument hinges on home births being, as the BMJ study showed, 10 times safer for the mother, and just as safe for the baby. That's taking into account morbidity (that's my above example, damage that results from interventions) and mortality (death of either mother or baby). They take into account morbidity and mortality resulting from both necessary, and unnecessary interventions. No distinction can be made for purposes of a study, on if the intervention is necessary or not. The reason we then claim that home birth is as safe (mortality) or safer (morbidity) at home, is because fewer interventions with their lasting effects happen at home.
If the majority of interventions in a hospital were necessary, why wouldn't women at home be suffering from lack of these interventions? Because in the majority of cases, when a complication occurs, a midwife who has been at hundreds of labors from start to finish, has learned many non-surgical ways to resolve the complication. And because a hosptial, if it becomes necessary, is hopefully right around the corner.
halojonesfan said: As I've said earlier, I get the impression that most home-birth advocates aren't saying that home-birth is better, they're saying that the criteria for intervention should be relaxed, and that the birth process is needlessly clinical. That's fine, but it doesn't necessarily drive women towards home birth and midwifery.

I agree with your point on this. The first birth in my example could have happened in a hospital. Why doesn't it happen very often? Yet it's not as simple as saying the criteria should be 'relaxed'. Because the forceps really were necessary in the hospital to get the baby out safely. The point is, the envionment in the hospital makes interventions such as forceps necessary more often. Something about being in your home makes it less necessary. A study can't possibly determine what it is that makes it this way. The studys are saying that births that happen in the home are as safe, or in some situations, safer than births at the hospital. Therefore, I believe home birth should be a legal option in every state. Faith thought the ideal would be to bring midwives into the hospital setting, where women could get OOH care, while in a hospital. I think the ideal would be to remove the antagonistic barriers between OOH and H birth. I think Holland is a great example of just such a system. 30% of births occur in the home, it's the womans choice where to birth. If a H becomes necessary, she, and her caregivers transport to the H, and her caregivers continue care there. Statistics show that Holland is the safest place in the world to have a baby.

faith gibson said...

Wow, I’m impressed. This is public discourse at its best. Everything I was going to say has been said eloquently by other knowledgeable and articulate souls.

HaloJonesFan said (and rightly so) that my original post was *not one* conversation but many. As pointed out by Cherrie, it is so hard to talk about just one circumscript aspect of this complex subject. But up front, I am NOT saying that “anything goes”. I am no more promoting irrational, “feel good” but potentially injurious choices by childbearing women than I am for the obstetrical profession.

The crux of my commentary is not even about midwives or home-based midwifery per se. This only gets into the fray because there is absolutely no place for physiological management in public consciousness or in mainstream obstetrics. Healthy childbearing women in the US are not suffering from an “obstetrical-intervention deficiency”; instead it is American obstetrics that suffers from a deficiency in its knowledge of and respect for and experience in physiological management. The powers-that-be wwould like to distract us from their unproven, unscientific practices (resulting in a 30% C-section rate!). So they turn the story around and make it about irresponsible midwives using false ideas about 'normal process' to lead gullible young women astray. Not true.

So here is the pearl of great price.

The main and the plain reading of the scientific literature brings one to the logical conclusion that physiological management is the safer and most cost-effective form of care for a healthy childbearing population. This leads us to the natural and compelling conclusion that our current intervention-based maternity care system must be reexamined and rehabilitated.

A newly formulated national maternity care policy would integrate the standard, science-based physiological principles with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. That standard must be based on criteria arrived at through an interdisciplinary process that includes the all the stakeholders.

In addition to obstetricians, public health experts and economists, the traditional discipline of midwifery as an independent profession and *the input of childbearing women and their families* must be integrated into the political process.

Once identified as the foremost standard for normal maternity care, the principles of physiological management would apply equally to all birth attendants – physician, obstetricians and midwives – and in all maternity care setting – hospital, home and independent birth centers. Physiological care ALWAYS defaults to medical care whenever medical and surgical interventions become the *more appropriate* treatment for a complication or are requested by the childbearing woman.

Reform of our national maternity policies is also vital to the ability of the US to maintain its place in a global economy. To meet the practical needs of childbearing families while remaining competitive in the world marketplace, the US must utilize the *same efficacious form of maternity care as the countries with the best, most cost-effective outcomes*.

Just from the standpoint of economics, that can never be a system based on escalating medical interventions and scheduled C-sections. Only an improved and cost-effective system can permit limited health care dollars to be properly used so as to meet the medical needs of the ill, injured and elderly. Effective and affordable maternity care based on scientific principle of physiological management is to the mutual benefit of mothers, babies, fathers, families and society in general.

As a practical matter, most normal births would actually be best managed (from the doctor's and the mother's standpoint) by the professional midwives that would normally staff the L&D unit. This saves OB doctors all those sleep-destroying middle of the night trips to the hospital for a simple delivery, thus allowing obstetricians to do what they do best and are trained for – treat the diseases and disorders of reproduction and complications of pregnancy and birth.

Were our national maternity care polices to reflect this change, the unbelievable tension and acrimony between midwifery and medicine would be naturally resolve itself, based on the genuine merit of both disciplines.

How could this happen? Actually, it is easy at the practical level but frankly unlikely at the political level. The answer is simply that ACOG itself acknowledges that physiological management is the appropriate standard for healthy women, that medical interventions should not be used “prophylactically” and instead be reserved for actual complications or if requested by the mother. The would instantly shift the landscape of our tort law in relationship to obstetrical "malpractice".

I have pasted in an operational definition of physiological management, since it is somewhat elusive in the minds of most people. Anyone who is also interest in how midwives apply these principles (at least as defined by the standard of care for members of the California College of Midwives), I have pasted in this link:
www.collegeofmidwives.org/Standards_postHearing_Feb2005/Standards_of_Care_Dec2005.pdf

Stedman’s Medical Dictionary definition of “physiological” – “…in accord with,
or characteristic of, the normal functioning of a living organism” (1995) ©

Physiologically-sound practices* include:

Continuity of care
Patience with nature
Social and emotional support
Mother- controlled environment
Provision for appropriate psychological privacy
Mother-directed activities, positions & postures for labor & birth
Full-time presence of the primary caregiver during active labor
Recognition of the sexual nature of spontaneous labor
Upright and mobile mother during active labor
Non-pharmaceutical pain management such as showers & deep water tubs
Judicious use of drugs, anesthesia, medical and surgical procedures when needed
Absence of arbitrary time limits as long reasonable progress, mom & babe OK
Vertical postures, pelvic mobility and the right use of gravity for pushing
Birth position by maternal choice unless medical factors require otherwise
Mother-directed pushing - no Valsalva Maneuver (prolonged breath-holding)
Physiological clamping of umbilical cord-- after circulation stopped (avg. 2 to 5 minutes)
Immediate possession and control of healthy newborn by mother and father
On-going & unified care and support of the mother-baby for postpartum
Access to appropriate social and psychological services for the 'second nine months' relative to breastfeeding advise, infant development, parenting and psychological adjustments to postpartum stresses, other children, spouse and employment outside the home, etc

**One does not have to be a midwife to appropriately use physiological (i.e. "midwifery") management.

Cherrie said...

One more comment about cherry picking statistics...
I wanted to clarify that for studies such as the BMJ study, all Planned Home Births (PHB) stay in one pool of statistics, wheather or not they transport and recieve the same interventions in the hospital. That's why 3% of PHBs were reported as having C-sections. Not because they had the C at home, but because the stats follow everybody planning a HB.

I think people are often confused at how statistics are gathered.