Originally Posted by SaveTheWild
A bit condescending, yes. Seemed appropriate under the circumstances (i.e. your posts came across as you trying to "teach" us all about the real risks of home birth from your "medical" perch when many of the folks here have many many years of training, experience, etc.)
I've had a look at the practical education young doctors get in the States and I tell ya, it's nothing to sneeze at. They work about 80 hours a week and this is what the programs look like: http://www.uphs.upenn.edu/pahedu/gme/ob.html#program
I am very familiar with US medical training and don't think it is shoddy, but they are teaching OBs to be surgeons, not labor and delivery experts. I would absolutely go to a US trained OB to have uterine surgery, or even an emergency c-section if one was necessary, but not for a normal vaginal delivery. They aren't trained in that and frankly that isn't their interest in most cases.
Also, I'm not worried about the "well-educated skilled midwives". I had wonderful midwives at the hospital that gave excellent care. It's the not-so educated, rather less skilled midwives that don't know how to handle emergencies that I'm worried about, and I believe that is a legitimate worry.
I actually agree with this statement. But lumping them all together in a "homebirth is unsafe" attitude is harmful. And I absolutely don't agree, if your are trying to suggest this, that "in-hospital" midwives are more skilled than "out of hospital" midwives. Homebirth midwives handle labor from beginning to end with one woman and learn inately how labor progresses, how to see a problem coming down the road, how to avoid letting small issues turn into big ones. Hospital based midwives are often forced by the reality of L&D wards to act basically the same way an OB does. The nurses do most of the laboring time and the midwife is there for the delivery only.
Another thing: I NEVER claimed that c-section was "no big deal" for EVERY mother. I said that there are women out there, who are fine with their c-section and others that are not. No more, no less. Yes, you can feel traumatized by a c-section. But it's not like it's a law of nature: Get a c-section = be traumatized. It's perfectly possible for moms to have the outcome: got a c-section = everything is fine.
I am not talking about emotional trauma, though I don't downplay how devastating it can be. I am talking about actual damage to the mother and baby (and future babies). Even if not immediate (e.g. the c-section is a success and the mother feels fine) there can often be long term negative health effects from c-sections that are rarely discussed within a hospital setting (because they are generally balanced against the possible mortality of mother or baby, even when, in most cases, it was never a life or death situation.)
If the c-section is elective, then the doctor HAS TO by LAW to mention the (at that point scientifically proven) risks.If placenta accreta in further pregnancies is one of them, it needs to be mentioned, just like an increased risk of uterine rupture. Otherwise any woman developing placenta accreta could sue him for malpractice and his insurance would drop him her like a hot potato. If the c-section is non-elective (=necessary to save the life of mother and/ or child), then the possibility of maybe developing p.a. is moot, since the lives of mother and child take precedence over that.
See, but distinguishing between "elective" and "non-elective" is very squishy. More often than not what happens here is 1) labor starts and is going fine but too slowly for hospital protocol, 2) mother is put on pitocin, 3) mother needs spinal anesthesia to cope with pain, 4) mother put on monitor, 5) monitor detects distress (often/usually falsely) 6) "non-elective" c-section performed. However in many of those situations there was no distress and the c-section was entirely unnecessary, but the mother still has to face all the "undisclosed risks".
Also, informed consent is a joke. Often the docs themselves aren't aware of all the risks or new research, etc. They basically give the risks of anesthesia and infection and other of the most obvious stuff, but the idea of an OB taking the time to talk to a laboring mother about the possible bonding, breastfeeding, hormonal, lung development, gut flora development in c-section vs. vaginal babies. .... not going to happen.
and in the case of c-sections that sometimes prefering to be safe....rather than sorry.
Sure, easy enough to say, but again, why cut off 100 people's legs to save 1 leg? In the US the c-section rate is approaching 30%. It is unjustifiable based on the real risk profile.
I think that one way to improve accountability would be to require midwives to carry malpractice insurance. If something happens (dead or handicapped baby due to midwife negligence), then the money will go a long way to help parents taking care of a handicapped child or take some time off to deal with their grief if the child died). Also, it's a motivation NOT to be negligent if you want to keep practicing as a midwife.
Fear of liability is one of the reasons so many unnecessary and proven useless and harmful (e.g. monitoring) practices occur. Adding that to midwives is not going to be a real problem solver.
I think that legitimizing the profession and making the steps to getting a license clear would help. If pregnant women had access to a bigger pool of qualified midwives they wouldn't have to resort to the bad ones. But I do believe there should be more supervision of inexperienced midwives. There is no excuse for bad medical care, no matter where it comes from.
Actually, NO, I'm not trying to "preach". I enjoy debating (which, granted, is not something everybody likes to do as a pastime). I seriously like getting to the bottom of things. And yes, since the majority of my experience on the subjects at hand is in the medical field, and since that's the information I've had access to so far, of course that's going to be my starting point. But by debating with others, I learn and expand my horizons:
I've learned about the kind of equipment american CNM's carry around with them.
I've learned about the recent change of atmosphere here on MDC and how it has been affecting members and about the atmosphere that was there before the change.
I've learned about the connection between c-sections and placenta accreta.
I've learned about about time frame in which crash c-sections should be done.
What have you learned?
As for OB's versus midwives: the way it sounds (and I can't really make a call on that, because, you know: german. In Germany.) american OB/Gyns could use a refresher course in normal birth. The best people to teach that "course", I think would be midwives. I also think, that at least some american CPMs need further training on "what can go wrong during birth" and how to handle that. The best people to teach that course ? OB/ Gyns.
Now, I think both sides in this whole homebirth vs. hospital birth in the US have closed up their forts and shut their doors.
I feel that if any positive progress is to be made, with better outcomes for caregivers and above all patients, OBs and midwives will have to start talking again to each other and will have to find some middle ground.
Concerning the next point: what I'm trying to suggest is that "in hospital" midwives in GERMANY (which are roughly equivalent to CNM's) are more skilled than AMERICAN "out of hospital" CPM midwives. But then (assuming they have the same years of practice) even in the US, a CNM is likely to be more skilled than a CPM / DEM, no?
In Germany, we don't have CPM's or DEMs and our midwives ARE required to carry malpractice insurance.
In the L & D department where I gave birth, my entire labour was overseen by a midwife, with the OB only popping by every once in a while to check on me and in the end to help with getting DD out, because she was BIG and we needed an episiotomy and a suction cup (circumference of the head was 38 cm and she weighed 4,8 kg....and no, it was not gestational diabetes, she just has really tall ancestors on both sides of the family....she was 60 cm long too). Actually, BY LAW births are overseen by midwives. The doctor is only allowed to assist birth without one present in case of an emergency (§ 34 Abs. 1 HebG).
As for the information about risks / benefits and necessity of c-sections: I think you need evidence based information materials (flyers, website etc.) for moms AND docs.
Not mentioning stuff like placenta accreta and risk of uterine rupture in future births in an elective c-section is NOT o.k. and also other, a bit more minor, negative effects should be mentioned (lung development, gut flora...) and how they are treated when they occur (e.g. uterine rupture - possible hyterectomy).
Concerning the squishy border between elective and emergency c-section: yep, I too feel that doctors are pushed to opt for a c-section earlier and are not doing enough to avoid c-section. And if midwives can offer lower c-section rates AND neonatal mortality rates that are equivalent or better than those of OBs, it would be a total hot-seller. Actually, I think there are already some areas where CNMs have achieved that, but "other midwives" (hello Wisconsin....) are still a bit away from that mark.
On the c-section rate being unjustifiable by the real risk profile: we're not talking gangrenous legs here. We're talking dead babies and inconsolate, grieving mothers that just finished decorating the nursery. It's not something that even has a remote chance in hell getting judged based on the real risk profile.
If there's something that can be done to save every last baby and there's no risk stacked against it that is equivalent to the horror of an intrapartum death, then people will want to see it done.
Also, if what you do (e.g. monitoring) is evidence based and you have the research to back what you practice, then even if something out of your control goes wrong it'd be pretty hard to make you liable. In order for a liability suit to stick, I believe you must have been negligent in some way...which you're not if your're practicing according to scientifically accepted standards.
I think that legitimizing the profession and making the steps to getting a license clear would help. ... I do believe there should be more supervision of inexperienced midwives. There is no excuse for bad medical care, no matter where it comes from."
Im a 100 % with you on this one.
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