midwives...do you think UC is as safe as a homebirth?

[caedmyn]

I'm trying to work some things out in my own mind...not looking to start a debate! Didn't want to post this in the UC forum since I'm sure there will be opinions against UC.

I'd like to know what homebirth midwives think about UC compared to a trained midwife attended homebirth. Specifically, do you think a low risk birth by a mom who is pretty well-educated about birth & related complications and prepared for things like PPH, is as safe as a midwife attended homebirth? If not, why not?

[nikirj]

To be quite blunt: no.

I think that UC is a valid choice and I support the women who choose it.

But as safe as a birth would be with a trained MW there? No. A 1-2:100 chance of coming against a situation you can't handle might not seem too bad to you, but when I see that many women in a year or two, the thought of 1-2 moms or babies dying is overwhelmingly awful. I can indeed think of two situations where (no exaggeration at all) mom or baby would have died without trained help and gear there. A couple more where mom or baby would have been fine during a UC if the family had transferred to a hospital in a timely manner, or where I believe family members would have been able to handle a situation, but where the presence of trained MWs meant that a transfer wasn't necessary.

If you are comfortable with the smallish odds of something bad happening during your UC, that's fine, and I support womens' rights to choose the way they want to birth. But no, I don't think it's as safe as a birth with a trained professional there. I don't think most women choose to UC because they feel it will be *safer* than having a midwife there; there are many different reasons to UC, I just don't think that's one of them.

I had an accidental UC this last time around (read about it here: http://lifeatnikis.blogspot.com/2010...rth-story.html if you like) and my knowledge was completely useless to me. On a similar vein, you can know all you want about PPH but if you don't have the second-line drugs and are passing out, it's not going to matter. Or if you have a shoulder dystocia and you have exhausted position changes without it resolving, you aren't going to be able to reach in and turn a shoulder. I know there is a school of thought that says that these things are less likely in a UC; I think they are also unlikely in the extremely low-intervention model many MWs here believe in, but they do still happen. The worst hemorrhage I've ever seen was the next best thing to a UC up until that point; we'd done VERY little at that birth.

ETA: I wanted to add that "UC is acceptably safe" and "UC is *as safe as* MW attended homebirth" are two different things. The first I believe, the second I don't.

[MidwifeErika]

Originally Posted by nikirj

To be quite blunt: no.

I think that UC is a valid choice and I support the women who choose it.



ETA: I wanted to add that "UC is acceptably safe" and "UC is *as safe as* MW attended homebirth" are two different things. The first I believe, the second I don't.

I agree with all of the above.

I guess a UC could be just as safe as a MW attended homebirth if you are in the percentage of women who have no problems at all, but it would be much more dangerous if you were in the percentage of women who do have a complication.

I still support women to birth in the way that they want and am not opposed to UC, but I do feel that MW attended homebirth is safer.

[MsBlack]

I agree with the others. I've had 4 UC attempts, 3 successful and 1 transfer for probably-necessary csec. And really, it was the best option available at the time, given the lack of hb mws and things they would almost certainly have needed to do for me/baby if I'd birthed vaginally--being a mw would not have done me any good in that complicated birth. It was enough though, to help me know I really should transfer care.

I totally support UC as a choice! But between the transfers that occur for help that a hb mw could well have given at home, and the more complicated/dangerous things that also sometimes occur--where a mw knows soonest when med help will be needed, and usually can provide 'interim help' til med assistance is there--well, I can't say I believe that UC is as safe attended hb. And I don't think the stats show that, either--though of course we don't really have (in the US) good stats on attended hb or UC.

[loveneverfails]

Not a midwife, but I did come across a study from the late 70s in South Carolina that actually did include planned unassisted home birth as a category, and found that it had neonatal mortality rates 10 times higher than planned midwife assisted home birth. Unplanned unassisted was 40 times higher than planned midwife assisted, if I'm remembering correctly. The neonatal mortality rates for the midwives and hospital based OBs were pretty well within the ranges that we're used to seeing. And the planned unassisted birth population looked a lot like the planned UC community

I can look up the reference if you'd like. I will admit to being very very very wary of unassisted birth, because I almost planned one with my 3rd child, decided to call my midwife to come because she was like a friend to me at that point and I didn't want to hurt her feelings, and had a picture perfect labor with a shoulder dystocia out of nowhere resulting in a baby with an initial apgar of 0. I don't want to scare you and UC is a choice that every woman should have the right to make for herself and her baby, but that scenario does happen even in low risk people. Without my midwife's skills and resuscitation equipment, I don't want to think about what would have happened.

[Otterella]

My issue with UC is that you're forcing yourself into a choiceless choice. IF anything goes wrong, you're forced to choose between staying at home and dealing with it yourself or going to the hospital. There's a list a mile long of small minor complications that can happen in an otherwise uneventful birth that DO require knowledgeable attention. These can be handled easily and respectfully by a competent midwife. If someone can be comfortable knowing they will have to go to the hospital for them, then they can UC with confidence. I knew I would not be comfortable going to the hospital for anything less than a life-threatening medical emergency. When I lost over a pint of blood after an uneventful birth, my midwife was able to handle my PPH very effectively and respectfully. If I had been UC, my only choice would have been to go to the hospital to treat it.

[Romana]

I consider UC to be a valid choice and I support informed, educated, prepared women choosing it. I would not undermine a woman's right to have an unassisted birth.

That said, it is unquestionably less safe than attended homebirth, which in the United States, is also pretty unquestionably less safe than hospital birth.

Safety alone does not validate or invalidate those choices. It's just a matter of understanding and choosing risks and benefits. As long as a woman understands what she's choosing (and in the case of UC, in my opinion her partner needs to be on-board as well), I am supportive of that choice. It's not my place to dictate how women choose to have their babies, be it by UC or by maternal request elective c-section (I also support a woman's right to choose a c-section without medical necessity).

ETA: Also, honestly, I feel the strong allure of UC. I totally understand the desire, even compulsion for one. I feel it, very strongly. But my rational brain interjects. I want that person with skills and expertise, and the equipment and drugs, in case things don't go perfectly. I think that if I knew less about birth, I might choose to UC, but knowing what I do . . . it is not a choice I would make, no matter how alluring it feels.

I'm not a midwife.

[CherryBomb]

Originally Posted by loveneverfails

Not a midwife, but I did come across a study from the late 70s in South Carolina that actually did include planned unassisted home birth as a category, and found that it had neonatal mortality rates 10 times higher than planned midwife assisted home birth.

There was a similar study done in Indiana using the Amish (who often have planned UC) that showed pretty similar results, iirc. Though I think the neonatal mortality rate was compared against hospital birth and was more like 15 times higher.

[caedmyn]

Originally Posted by Otterella

My issue with UC is that you're forcing yourself into a choiceless choice. IF anything goes wrong, you're forced to choose between staying at home and dealing with it yourself or going to the hospital. There's a list a mile long of small minor complications that can happen in an otherwise uneventful birth that DO require knowledgeable attention. These can be handled easily and respectfully by a competent midwife. If someone can be comfortable knowing they will have to go to the hospital for them, then they can UC with confidence. I knew I would not be comfortable going to the hospital for anything less than a life-threatening medical emergency. When I lost over a pint of blood after an uneventful birth, my midwife was able to handle my PPH very effectively and respectfully. If I had been UC, my only choice would have been to go to the hospital to treat it.

That really isn't true. I think many, maybe most minor complications could be handled during a UC if you are well-educated and prepared. Many of the things that a midwife does for a PPH can be done without a midwife present as well, such as herbs, homeopathy, nursing, uterine massage, that sort of thing. Certainly there are some complications that could likely be successfully handled at home if a midwife were present, that would require transfer if you were UC'ing, but to say that any complication would require a transfer is far from accurate.

[caedmyn]

Originally Posted by nikirj

ETA: I wanted to add that "UC is acceptably safe" and "UC is *as safe as* MW attended homebirth" are two different things. The first I believe, the second I don't.

I guess that's what I'm going to have to decide, given the lack of acceptable homebirth midwives around here...whether acceptably safe but not as safe as a homebirth is within my comfort level.

[caedmyn]

Originally Posted by CherryBomb

There was a similar study done in Indiana using the Amish (who often have planned UC) that showed pretty similar results, iirc. Though I think the neonatal mortality rate was compared against hospital birth and was more like 15 times higher.

That seems really high! I do wonder, though, how many of those deaths were from non-low-risk pregnancies/births, and how many of the parents were well-educated about birth and prepared for emergencies. I definitely do think some go into UC with little or no preparation, or are very reluctant to transfer in situations where it seems clearly indicated, or think intuition will diagnose or take care of any problems, or in higher risk situations that would likely risk them out of a homebirth.

[nikirj]

Originally Posted by Romana

That said, it is unquestionably less safe than attended homebirth, which in the United States, is also pretty unquestionably less safe than hospital birth.

This is not true. See the CPM2000 study and the Washington DOH report. Of the studies done in the US, a bare few poorly designed studies have shown higher mortality in planned midwife-attended homebirths, the rest have shown similar mortality in home vs hospital with injury and intervention less likely for homebirths.

[cileag]

Originally Posted by caedmyn

That really isn't true. I think many, maybe most minor complications could be handled during a UC if you are well-educated and prepared. Many of the things that a midwife does for a PPH can be done without a midwife present as well, such as herbs, homeopathy, nursing, uterine massage, that sort of thing. Certainly there are some complications that could likely be successfully handled at home if a midwife were present, that would require transfer if you were UC'ing, but to say that any complication would require a transfer is far from accurate.

I'm an L and D nurse, not a midwife, but the issue that I have is that you're right in that many of the things are not terribly tricky to implement, however making the decision to do it, AND having someone who is responsible to do it is kind of a big deal to me. You as the laboring woman, might not be able to --then again, maybe you will be totally 100% with it--- and so it falls on your husband (or this other OB RN) to do those things, which is a lot to ask of a lay person, even an educated one. And I'm not one to dwell on it, but feeling 100% comfortable with the outcome if something did happen and you weren't able to assist or were too stressed/exhausted/panicky to respond appropriately is something you need to at least work through.

[caedmyn]

Originally Posted by cileag

And I'm not one to dwell on it, but feeling 100% comfortable with the outcome if something did happen and you weren't able to assist or were too stressed/exhausted/panicky to respond appropriately is something you need to at least work through.

That's why I would prefer a midwife-attended birth. I'm just trying to work through all my thoughts and see if I can get comfortable with the idea of UC, and if not, if there's a way to find a midwife who's acceptable to both DH and I.

[TyrantOfTheWeek]

What about unassisted, but not unattended? I asked my midwife about this and she said she has been asked a few times to leave the room, go outside, or whatever. That way, you are doing it yourself, but a trained hand is immediately available. Seems like a rational compromise to me.

[Pirogi]

Originally Posted by Romana

That said, it is unquestionably less safe than attended homebirth, which in the United States, is also pretty unquestionably less safe than hospital birth.

Can you please share how you arrived at the conclusion that attended homebirth is unquestionably less safe than hospital birth?

[AlexisT]

Originally Posted by TyrantOfTheWeek

What about unassisted, but not unattended? I asked my midwife about this and she said she has been asked a few times to leave the room, go outside, or whatever. That way, you are doing it yourself, but a trained hand is immediately available. Seems like a rational compromise to me.

It may be rational for you, but not for many midwives. They're being asked to accept responsibility for a situation while taking away part of their ability to affect the outcome. What if there's a serious problem, and you don't realize it, and by the time you do it's too late? The midwife will be the one held responsible for the outcome because she was there.

[loveneverfails]

I looked up the study for you, because I was pretty sure it addressed your concern regarding "but are these moms who are having planned UCs low risk?"

Here's the abstract:

Home Delivery and Neonatal Mortality in North Carolina

Claude A. Burnett III, MD, MPH; James A. Jones, MPH; Judith Rooks, CNM, MS, MPH; Chong Hwa Chen, MS; Carl W. Tyler, Jr, MD; C. Arden Miller, MD

JAMA. 1980;244(24):2741-2745.


Abstract


Neonatal mortality is examined by place and circumstances of delivery in North Carolina during 1974 through 1976 with attention given to home delivery. Planned home deliveries by lay-midwives resulted in three neonatal deaths per 1,000 live births; planned home deliveries without a lay-midwife, 30 neonatal deaths per 1,000 live births; and unplanned home deliveries, 120 neonatal deaths per 1,000 live births. The women whose babies were delivered by lay-midwives were screened in county health departments and found to be medically at low risk of complication, despite having demographic characteristics associated with high-risk of neonatal mortality. Conversely, the women delivered at home without known prenatal screening or a trained attendant had low-risk demographic characteristics but experienced a high rate of neonatal mortality. Planning, prenatal screening, and attendant training were important in differentiating the risk of neonatal mortality in this uncontrolled, observational study. "

The entire study can be read here

[freestylemama]

Originally Posted by TyrantOfTheWeek

What about unassisted, but not unattended? I asked my midwife about this and she said she has been asked a few times to leave the room, go outside, or whatever. That way, you are doing it yourself, but a trained hand is immediately available. Seems like a rational compromise to me.

I totally agree. I had a beautiful midwife assisted birth. One of the midwives took pictures and the other knit right until my daughter came out. I was checked once and they intermittently used a Doppler to check baby's heart rate. Most of the time they sat back and let us do our thing. Once they offered me a mirror to see her hair . My husband caught her and we have this great picture of her actually coming out into the water (I stood up in the tub). I think their motto was if they did their job right, we would leave thinking we could have done it ourselves. I'm totally grateful that they were there though because we got amazing pictures and I was sewn up because I tore. I'm also grateful for them because it was so reassuring to know that if something bad happened, it wasn't up to us to make difficult choices.

I wish more people had wonderful options for undisturbed attended births.

ETA: I guess this isn't the same as them leaving the room though.

[caedmyn]

Originally Posted by TyrantOfTheWeek

What about unassisted, but not unattended? I asked my midwife about this and she said she has been asked a few times to leave the room, go outside, or whatever. That way, you are doing it yourself, but a trained hand is immediately available. Seems like a rational compromise to me.

Honestly, I'm not particularly attracted to the idea of UC. I prefer and have had very hands-off births, where the midwife doesn't really do anything until after baby is born, but I do prefer an attendant. UC is just something that's being considered because A) the three area midwives are no longer options due to either personality conflicts or potential safety issues, and B) DH doesn't see the point in paying a midwife to "do nothing" as he sees it. So unless an out-of-area midwife moves here by fall or we can figure out a way for the apprentice midwife to attend with a different preceptor, I'm out of midwife options. Going to the hospital for a low risk birth is not an option, so I'm left with UC.