Thoughts on new study showing homebirth increases risk of nenonatal death? - Page 3

[GuildJenn]

Originally Posted by Veritaserum

Sure, but it's not exactly easy to get a low/no intervention birth in a hospital. If hospitals across the board adopted natural childbirth-friendly birth practices, we'd be in an entirely different situation.

It's not easy everywhere, I know. It's hard. . But I have to say that has not been an issue for me in my area.

[MsBlack]

Originally Posted by bailefeliz

There is a much needed move to establish transparency to all aspects of health care delivery, and hospitals are way ahead of OoH providers on this front. Yes, institution specific C/S rates, VBAC success rates, rates of IOL etc. are available, at least in my geographic area. Certainly birth/death specific data has long been available related to hospitals through State Vital Statistics where perinatal/neonatal/maternal death rates can be established reliably through issued death certificates. Mortality rates related to OoH birth management are completely unknown as any numbers related to transports to hospital, which include the vast majority of any cases resulting in sentinel events, get folded into hospital numbers.

Ms. Black, for once I agree with you: more women should be delivering OoH. But in my opinion, it must be the right women: LOW risk. Inclusion of high risk will result in higher incidence of adverse outcome, specifically perinatal death. That is clearly established in the literature. So with ongoing bold defense of providing high risk management out of hospital, one must accept higher than acceptable death rates. The two will go hand in hand. High risk inclusion will also continue to keep the DEM/LDM/CPM community marginalized. How can hospitals be expected to be excited about collaboration with such bold rejection of evidence? I believe ongoing high risk inclusion OoH is undermining the evolution to a more comprehensive national birth culture.

Every DEM/CPM/LDM website I encounter touts safety of home birth utilizing studies based on conservative, thorough ongoing risk screening. Yet, this same prudence is not practiced. Thus the outcomes will not be the same. I feel that US home birth consumers are currently misled.

If the DEM/LDM/CPM community feels so certain of positive outcomes, work proactively with State licensing agencies to establish a reliable mandatory data collection system on every OoH managed pregnancy and birth. Prove it with accurate numbers.

I suspect your geographic area may be a stunning exception when it comes to hospital maternity care transparency concerning methods of care, and outcomes, bailefeliz. From what I've seen and heard, it is just as true in most places that mortality and morbidity rates related to *hospital* birth management are completely unknown. Just as true that non-evidence-based practices (and ANTI-evidence practices, as IOL and csec rates clearly show) are not analyzed well, and are kept hidden from the public.

Do you have any idea how hard it can be for a family seeking med maternity care to find the actual IOL and csec rates of a hospital and it's particular practitioners? It is made difficult--the asker of such questions is too often met with suspicion and defensiveness and PR methods designed to throw them off the track of the info they seek. Why can't we just walk in and receive what we ask for? You know for damn sure that those stats are being carefully kept by the hospital admin--and should be a matter of public record.

As for your statement (bolded) that 'high risk inclusion' will keep hb mws marginalized...well, sorry, but our marginalization has little to do with acceptance of high risk moms. As far as I can see, those with a predisposition to hate hb simply use that as a seemingly reasonable excuse for what is, in reality, driven solely by needs relating to power and money. And how can anyone 'be excited about the bold rejection of evidence' practiced daily in *hospitals*? Wow.

You seem to believe that medical maternity care is automatically and necessarily The Authority, with the inherent right to judge others' standards. Well, not so surprising, I suppose--the AMA has spent untold billions by now (yes, billions if not more over the years) in PR efforts to gain both primacy in the public's eye and political power in our legislatures, to create laws favorable to med practice, and highly unfavorable to 'alternatives'. Lies told often enough and persuasively enough by well-dressed people who clearly have the power of money and 'higher education' are generally believed, no matter what the evidence against those lies. And, sociologically/anthropologically speaking, it is 'true' that once a society has accepted a 'norm', it is extremely resistant to change. We tend not to really understand WHY we believe and follow a norm, we only know that it 'feels right' to comply and feels VERY wrong to contradict it --such is the power of our need for social acceptance and the power of taboo in our psyches as social creatures. A fact, by the way, that is maximally capitalized upon by those in a position to influence public thought.

And let me assure you that US hospital birth consumers are likely even more greatly 'misled' than you claim homebirth consumers to be! Remember that OB care DOES have that socially-accepted status. Spend a few hours here reading threads here to discover how many women found out the hard way, just how non-evidence-based OB care is, how much damage it does to women and babies....and causes that damage primarily through women's unwitting compliance with the dictates of OB/hospital care--because they were MISLED, often intentionally (because hey, you *did* sign that General Consent, and we can't be actually explaining everything to everyone, easier to pull the dead-baby-card to get to do what we want without patient fuss). The very care that they grew up believing was THE authority, THE safest, best, 'most guaranteed-safe, etc kind of care to receive.

At least with homebirth care--in any region, but perhaps most especially in unregulated states--families enter care knowing that hb care is 'alternative to the Norm', knowing that it comes with certain risks and questions relating to a mw's training, accountability, and lack of seamless continuity with medical care. Not that all hb consumers ask hard enough questions of their prospective mws, not that all hb consumers are as pro-active as others in discovering all facets of 'safety'...and not that every mw is as forthcoming from the start as all others, about her training, limitations, etc--only that the opportunity to do so is inherent and readily available to them. As opposed to med care, that is--where the expectation of all concerned, both Drs and consumers--is that the provider and the setting come complete with the best training, backup, 'authority' and all anyone needs to get a safe birth. And where even assertive, research-inclined, pro-active 'patients' are daily tricked and harmed by the imposition of protocols, technologies, etc, that come with the medical maternity care package...heck, the whole point to me is that even those who *are* assertive, research-inclined, etc, are choosing the hospital because it IS the norm, and they believe they can work within that norm with some tweaking here and there ('birth plans'). It IS the Gold Standard by which all else is deemed 'alternative'--the hospital is where they feel safest, only to discover that they and their babies were none too safe there. Only to discover that they were in fact, misled--in general and in particular, and far too often to the tune of birth trauma along with various degrees and kinds of harm to mother and baby.

But let me be clear also--I agree that in some cases, hb families are misled, both by their chosen mw, and by the general community that supports the mws. Truth in advertising/self-representation, accountability among mws, and transparency to the public are things I have fought for in my own region--without much success, and bringing about my own marginalization with that community for being 'disloyal' to hb mws and worse. I do share your concern over this, for sure! But my concern for families' safety at birth is just as inclusive of Dr/hospital based care as for hb care.

Meaning no disrespect here. I realize that your own attitudes are coming from a place of real concern, and from a far more inclusive, informed perspective than that of many other hb doubters. I really do appreciate that in you! Also, it seems that you live in an unusual region in certain respects--so perhaps you are used to that and really don't know how it is most everywhere else. And you are certainly welcome to own your own chosen perspective; for you, hospital maternity care IS the standard from which you choose to perceive and judge other care. I just hope to point out where you are--and where too many others are--blinded by your perspective, making statements against hb care that are in fact, as true or truer for hospital-managed care. You make it sound so simple and direct--but it's not. US maternity care is in a mess, I think--and no more so for hb than for hospital. And I (as is surely evident) do NOT hold med maternity care as the standard by which all else should be judged; that comes from research and experience both.

[MsBlack]

liz-hippymom--

I can see where you would feel I was snarky in calling the study 'idiotic', and I apologize for a poor choice of words. No, I don't think you or anyone else is stupid for giving the study a serious read (and thanks Turquesa and mwherbs for pointing out my intended meaning). I might better have said that I thought it was a poorly designed study with too many flaws for *me* to take it seriously...that is what I meant

There are few losses as hard to bear as the loss of a baby...so very hard, most especially when it seems that perhaps *something* might have been done differently to bring about a 'happier outcome'--a living baby to hold and grow with. And so I understand that for you, choosing the hospital for other births makes the most sense--it is where you feel safe, and for a woman to feel safe is among the top 3 things that actually helps her births go well, IMO as a homebirth mom with one transport for csec, and as a hb mw.

Yet I ask you to understand that there are women who lose babies in the hospital as well, and who similarly come away from the experience knowing that it could well have been birth management that led to their child's death or disability. I mean, apart from the times when it birth management was actually known to have caused or contributed to neonatal loss, and apart from the fact that every parent who loses a baby asks "why" and questions their birthing choices and helpers, even when there is no evidence that their care had anything to do with the loss.

In the end, we all have to choose a place of birth where we feel safest--and that is not an entirely rational thing, no more than any important choice is life is entirely rational. We have to go with what we feel. Most of us prefer to find some evidence supporting that feeling and choice--and in some cases the evidence is clear, but often it is not.

I am trying to say--I fully respect your choice of birth care now, and respect your perspective based on experience and research both, for making that choice. I only ask you to recognize that even if the hospital is the best place for *you* to give birth, it is not necessarily the safest place for everyone. I ask you to accept that your choice is your choice, made for your own reasons that do not apply to everyone; and I ask you to allow that even when a piece of research upholds your personal choice in this matter, it is still not necessarily a valid, sound piece of research. This is something I, too, have to remind myself of, every day in encountering research and info that supports homebirth. I try to remember--and sometimes remind others--that just becomes something 'sounds smart', does not mean it really IS 'smart'.

In making our own choices as well as discussing/influencing such choices with others, we need to keep our critical analysis in gear. And we need to respect that there is no one right choice for everyone, no matter how strongly we hold our own opinions.

[liz-hippymom]

Originally Posted by MsBlack

liz-hippymom--

I can see where you would feel I was snarky in calling the study 'idiotic', and I apologize for a poor choice of words. No, I don't think you or anyone else is stupid for giving the study a serious read (and thanks Turquesa and mwherbs for pointing out my intended meaning). I might better have said that I thought it was a poorly designed study with too many flaws for *me* to take it seriously...that is what I meant

There are few losses as hard to bear as the loss of a baby...so very hard, most especially when it seems that perhaps *something* might have been done differently to bring about a 'happier outcome'--a living baby to hold and grow with. And so I understand that for you, choosing the hospital for other births makes the most sense--it is where you feel safe, and for a woman to feel safe is among the top 3 things that actually helps her births go well, IMO as a homebirth mom with one transport for csec, and as a hb mw.

Yet I ask you to understand that there are women who lose babies in the hospital as well, and who similarly come away from the experience knowing that it could well have been birth management that led to their child's death or disability. I mean, apart from the times when it birth management was actually known to have caused or contributed to neonatal loss, and apart from the fact that every parent who loses a baby asks "why" and questions their birthing choices and helpers, even when there is no evidence that their care had anything to do with the loss.

In the end, we all have to choose a place of birth where we feel safest--and that is not an entirely rational thing, no more than any important choice is life is entirely rational. We have to go with what we feel. Most of us prefer to find some evidence supporting that feeling and choice--and in some cases the evidence is clear, but often it is not.

I am trying to say--I fully respect your choice of birth care now, and respect your perspective based on experience and research both, for making that choice. I only ask you to recognize that even if the hospital is the best place for *you* to give birth, it is not necessarily the safest place for everyone. I ask you to accept that your choice is your choice, made for your own reasons that do not apply to everyone; and I ask you to allow that even when a piece of research upholds your personal choice in this matter, it is still not necessarily a valid, sound piece of research. This is something I, too, have to remind myself of, every day in encountering research and info that supports homebirth. I try to remember--and sometimes remind others--that just becomes something 'sounds smart', does not mean it really IS 'smart'.

In making our own choices as well as discussing/influencing such choices with others, we need to keep our critical analysis in gear. And we need to respect that there is no one right choice for everyone, no matter how strongly we hold our own opinions.

i never said that i think the right to homebirth should be taken away from woman- my problem lies with ill-trained midwives with regulating bodies who do do no regulating. from the OBs i ave talked to , this is their opinion also. there are a few midwives that i would recommend to a friend here, but frankly all are CNMs. and yes, CNMs do homebirths. i know three in Austin, which is more than the number of CNMs delivering in hospitals in Austin.
But still, these CNMs (homebirth) don't have OB backup and are not trained in intubation. In the countries that fair best in all these studies the midwives doing homebirths are CNMs with doctor backup and intubation training.

[bailefeliz]

I agree there needs to be transparency with hospital OB care. In my State, institution specific method of delivery (c/s rates) are published quarterly in Vital Statistics. My institution totals following rates monthly: c/s (differentiating primary from repeat), successful VBAC, water birth, epidural use, assisted delivery, etc. True, one may not get the numbers from the unit secretary, but can get rates by asking for the nurse manager. This transparency is common in my region, as evidenced by chart below:

http://oregonianextra.com/olive-spec...omparison.html

Originally Posted by MsBlack

Meaning no disrespect here. I realize that your own attitudes are coming from a place of real concern, and from a far more inclusive, informed perspective than that of many other hb doubters.

I am not a home birth doubter. I had two home births, and believe home birth to be safe with careful risk screening. I am the voice within the hospital supporting women's important choice to birth OoH. I am simply concerned about what I perceive to be an unacceptable rate of perinatal loss OoH--and I suspect it is related to the willingness to maintain high risk OoH. We need data to truly assess outcomes.

[mandib50]

Originally Posted by liz-hippymom

i never said that i think the right to homebirth should be taken away from woman- my problem lies with ill-trained midwives with regulating bodies who do do no regulating. from the OBs i ave talked to , this is their opinion also. there are a few midwives that i would recommend to a friend here, but frankly all are CNMs. and yes, CNMs do homebirths. i know three in Austin, which is more than the number of CNMs delivering in hospitals in Austin.
But still, these CNMs (homebirth) don't have OB backup and are not trained in intubation. In the countries that fair best in all these studies the midwives doing homebirths are CNMs with doctor backup and intubation training.

although Canada does not have CNM's, we have direct entry midwives, and a fair portion of the midwives (maybe 10 - 20% or so?) actually end up coming through our bridging programs from the US (not just CNM). also, intubation training is fairly new, at least in Alberta, and if you talk to the midwives, many of them are actually on the fence about being trained in intubation for various reasons (too much to get into here).

[mandib50]

this is actually a fairly good look at why the study is not an accurate picture:

http://www.cbc.ca/health/story/2010/...hs-safety.html

[MsBlack]

Originally Posted by liz-hippymom

i never said that i think the right to homebirth should be taken away from woman- my problem lies with ill-trained midwives with regulating bodies who do do no regulating. from the OBs i ave talked to , this is their opinion also. there are a few midwives that i would recommend to a friend here, but frankly all are CNMs. and yes, CNMs do homebirths. i know three in Austin, which is more than the number of CNMs delivering in hospitals in Austin.
But still, these CNMs (homebirth) don't have OB backup and are not trained in intubation. In the countries that fair best in all these studies the midwives doing homebirths are CNMs with doctor backup and intubation training.

Ah...respectfully, I did not say that you were saying the right to homebirth should be taken away. It might help if you read my posts more carefully--or not at all (it wouldn't offend me)--this is the second time you have put words in my mouth (so to speak).

What I said is that you were using poor ammunition (that study) to support your personal choice about place of birth.

And also respectfully, there is nothing about homebirth or midwifery that I would ask an OB about--there's nothing an OB had to say about these things that I would take seriously. Well, maybe a select few OBs (Michel Odent comes to mind), who actually know something about homebirth and midwifery--but most do not. And their ideas about training are necessarily based upon their OWN training, which really does not apply.

IMO, even more important than hb mws learning intubation, OBs should be learning more about normal birth and the many intuitive and natural skills that hb midwifery is famous for. And IMO, THAT training for OBs is way more critical than mws learning intubation for the simple reason that OBs assist way more births than mws do in the US.

[nikirj]

Unfortunately, whenever we talk about making homebirth transfer situations safer, the focus falls somehow on legislating midwives. Requiring that midwives have agreements makes life more difficult without improving the situation. What we need is some way to improve the way we are received at the hospital, and to remove the stigma against doctors who consult with us.

When midwives feel like their reception is going to be less than friendly, they consult less often and transfer later. I've seen this firsthand, working with a CNM with hospital priviledges, CPMs with very friendly relationships with doctors and hospitals in their area, and CPMs with shaky relationships with doctors and hospitals in their area. The issue wasn't the skill or safety of the practitioners, it was the political climate re: homebirth and midwives. In fact, the CPMs with the shakiest relationship practiced in the most conservative way of anyone I worked with. Poor reception at a hospital/ poor professional relationships aren't usually about how good or bad midwives are.

The unfortunate fact is that doctors are leaned on from several angles to avoid developing positive relationships with midwives. From ACOG, from their malpractice carriers, from hospital admin. From what I've seen in trying to hammer out smooth transfers is that the biggest problem is actually the malpractice carriers and hospital administrators, who insist that doctors not formally consult with midwives because they view it as opening the doctors up to liability. The fact is, we may then later have to transfer blind to one of those same doctors with a train-wreck-in-the-making...how is that any better?

When we talk about legislating a need for collaboration between OBs and MWs, that legislation should lean on the OBs, who are the ones with the power in this situation. If it leans on the MWs, it will just put us out of business.

And yes, FFS, how could anyone not believe that ACOG has it out for homebirth midwives after multiple issue briefs to that effect?

[MsBlack]

bailefeliz--

thanks for sharing that bit about your own births.

When I said 'hb doubter', I didn't mean to imply that you are 'anti hb'--I have NOT been reading you that way. It was just shorthand for what I read as your doubts about hb care as it exists in the US.

clearer?

[MsBlack]

Nikirj--

Well put, thanks for saying that!

[kittywitty]

Originally Posted by MsBlack

I am trying to say--I fully respect your choice of birth care now, and respect your perspective based on experience and research both, for making that choice. I only ask you to recognize that even if the hospital is the best place for *you* to give birth, it is not necessarily the safest place for everyone. I ask you to accept that your choice is your choice, made for your own reasons that do not apply to everyone; and I ask you to allow that even when a piece of research upholds your personal choice in this matter, it is still not necessarily a valid, sound piece of research. This is something I, too, have to remind myself of, every day in encountering research and info that supports homebirth. I try to remember--and sometimes remind others--that just becomes something 'sounds smart', does not mean it really IS 'smart'.

In making our own choices as well as discussing/influencing such choices with others, we need to keep our critical analysis in gear. And we need to respect that there is no one right choice for everyone, no matter how strongly we hold our own opinions.

Thank you for saying this! Just because someone chooses one or the other does not mean that the other should be taken away as a choice or is not a good choice for another person. The hospital here is not a good choice for me, other VBACers (over 39% c-section rate, no VBACs allowed), and many more people does not mean that it would be a good choice for someone. Just like my homebirth would not be a good choice for some other person. It's not a one size fits all situation.

[liz-hippymom]

again-i am not saying athing about taking away choices, mearly A. making choices either safer or B. making the true safety known , or both.

i had no idea how ill trained my midwife was, she came highly reccomended. i also had the foolish notion there was accountability in the world of midwifery- like midwives who are responsible for babies dying have actual consiquences. It would have been great to know ahead of time i should not waste my time even voicing complaints, since it quickly lost me several friends and gained me MANY enemies.
what i have recieved ( here and ITRW) is comments about how A. i am trying to take away other woman's rights, and B. my baby would have died in hospital too (or "babies die in hospitals too)..llike either statement has any bearing in what i am actually saying?
my point is my baby would not have died in a hospital. I was not high risk in any way- yet my daughter is dead. not all homebirths are safe-not all midwives are good. Woman should not be telling other woman to put there fingers in thier ears so they dont hear what is true, allthough not nice to hear.
i want accurate studies, available to all woman about the safety of homebirth ~in America~ and i want regulating bodies that actually do there jobs. that is what i want.

[Veritaserum]

Originally Posted by liz-hippymom

i had no idea how ill trained my midwife was, she came highly reccomended. i also had the foolish notion there was accountability in the world of midwifery- like midwives who are responsible for babies dying have actual consiquences. It would have been great to know ahead of time i should not waste my time even voicing complaints, since it quickly lost me several friends and gained me MANY enemies.

I am so sorry for this. It makes me really angry that there isn't better accountability within the home birth community. I have experienced some of what you talk about here (anger from others when I voice my concerns about my SIL's midwife). I have lost friends within the home birth community for siding with my SIL instead of the midwife because they LOVE their midwife and simply refuse to believe that she is capable of such a terrible mistake. They'd rather believe that it was my SIL's fault or that she would have had the same outcome in a hospital, neither of which is true. I can certainly understand why they'd want to believe either of those things, but it doesn't change the facts in the case. The midwife in question is still practicing. While I believe she has some wonderful things to offer to a normal, healthy mom/baby in a normal birth, I do worry about what may happen to other families in situations that turn high risk.

[liz-hippymom]

Originally Posted by Veritaserum

The midwife in question is still practicing. While I believe she has some wonderful things to offer to a normal, healthy mom/baby in a normal birth, I do worry about what may happen to other families in situations that turn high risk.

i am sorry for you and your SIL. this quote is exactly how i feel about the midwife from Aquila's birth.

[carriebft]

liz-hippymom- thank you for sharing your story and for your posts here. I share many of your views and your story inspired me to ask a lot harder questions of my midwife the other day. I plan to do more in person next week. I feel better about her now that I have her answers and am researching some more tough ones to ask.

edit- sorry- this thread and the other one have the same title. i didnt mean to post in birth professional forum)

[mwherbs]

so this is ot but I am curious what do you mean " have actual consiquences."? a for instance loss of license or jail time or???
and there is no way to know if your baby would have survived in the hospital - the stats are quite varied on abruption but with a hospital mortality rates being 20-40% the serious consiquences I see doctors get is higher malpractice rates- the local doc in town who had so many deaths that his malpractice ran him out of private practice right into a federally funded program that pays for his malpractice- and he is back in business- and the whole time even when he temporarly had no hospital preiveledges he did not tell his patients and threatened the hospital employees if they were to tell the patients who did show up in labor or for testing so no one told the patients he could not attend them --

[Veritaserum]

Originally Posted by mwherbs

so this is ot but I am curious what do you mean " have actual consiquences."? a for instance loss of license or jail time or???
and there is no way to know if your baby would have survived in the hospital - the stats are quite varied on abruption but with a hospital mortality rates being 20-40% the serious consiquences I see doctors get is higher malpractice rates- the local doc in town who had so many deaths that his malpractice ran him out of private practice right into a federally funded program that pays for his malpractice- and he is back in business- and the whole time even when he temporarly had no hospital preiveledges he did not tell his patients and threatened the hospital employees if they were to tell the patients who did show up in labor or for testing so no one told the patients he could not attend them --

At the very least, I would expect a peer review of the case to evaluate the situation and see what, if anything, might be done differently if the same situation presented itself again. Where clear negligence can be proven, loss of licensure may be appropriate. I'm particularly concerned with my SIL's case (not only because she's a family member) because she was 34 weeks, had multiple symptoms of pre-e, and was bleeding heavier than her normal period. Despite these risk factors, her midwife told her that they could stay home and that everything would probably be fine. My SIL trusted her midwife, so she stayed home. Her labor was something around 12 hours total, so there was PLENTY of time to transport even before my nephew's heart rate started dropping and the placenta abrupted completely. Sure, that couldn't have been predicted, but the heavy bleeding earlier was a clue that it might. Had she transported for prematurity (I still don't know why she didn't), they would have been where they needed to be when the abruption did occur.

Sometimes *&^% happens in birth and it is nobody's fault (eg. a sudden complete abruption with no risk factors or warning). Sometimes #$&* happens in birth and the responsible parties make harmful (and sometimes deadly) mistakes (in all birth settings). Care providers who take a cavalier attitude toward the risks of birth complications or medical interventions are dangerous. I think part of the problem in the home birth community is to place some kind of negative moral judgment on interventions in the birth process. Women/midwives who use interventions "didn't trust birth enough." Part of the problem in the hospital birth community is to believe that medical interventions always make birth safer and should therefore be used with every mom/baby. In either extreme, moms and babies get hurt.

[mwherbs]

I can agree with the peer review- if the midwife is a CPM they do offer peer review independent from a licensing board hearing -

[mwherbs]

bailefeliz I have a question about the over all published info in Oregon- on the born in hospital -and all the providers are listed - under LDM in 2007 there were 66 babies born in the hospital attended by LDMs or does that mean 66 recorded tranports? do you know what that number means? there is also some non-medical attendants on there which could be anyone in the hospital or on the way but may also include the unlicensed mws because they do not claim to be medical professionals

as far as recording clients- perhaps if they are established and then there would be all sorts of things involved as far as when someone may risk out of care- or even if someone decides that they do not want a home birth because of xyz not medical or moms who UC. I am pretty sure that many states already collect this data- but it is not included on birth certificate data collection so does not make it to the federally funded data calculations-


and it is fine and well that it is said that women can hire unlicensed mws - but that is not so in my state AZ it is a felony to practice without a license and a license does not mean you get paid by the state- LMs in Az are not eligable to receive state or fed funds