The price of being the best.....is having to BE the best - Or: On how to make Homebirth even...

[Kanna]

Each year, there are several homebirth deaths due to a midwife that is not as well trained as she should be or, even worse, negligent.

Homebirth offers a great service to women, tending to their needs and their comfort better than it would be seen to in a hospital setting by a team of nurses and an OB/GYN.

Still, a woman choosing homebirth shouldn't have to worry about it if the midwife she chose is really as competent in an emergency as she seemed.....or if the midwifes' care will fall apart and end in catastrophe (and a dead baby) if complications arise.

This thread was started to discuss ways for the "Sisterhood of Midwifery" (and really, anybody knowledgeable and interested) to improve safety for moms giving birth under their care.

Heated debate welcome, but please, be tough on the problem, soft and polite on the people.

Don't make any claims without backing them up with data.

Anecdotal data welcome, but mark it as such. It's useful to illustrate a point, but not enough to prove one.

If you notice that the point you're trying to make doesn't have as much validity as you thought it did, don't be afraid to concede it. This isn't about winning or "who's to blame"....this is about IMPROVING the system and providing BETTER CARE.

Every once in a while, try to sum conclusions up, so people don't lose the overview.

Don't leave it at just discussing things. This is about the real world. This is about real people.

Make plans to truly affect change.

[Kanna]

BTW, the whole discussion started in THIS thread:

http://www.mothering.com/community/forum/thread/1261518/friend-s-baby-died-attempted-homebirth-then-transfer-need-some-encouragement

and was moved from there to here.

Anybody new to the discussion, please don't be surprised if things are referenced / answered that were started in the original thread.

[Paigekitten]

I would like to know why you feel it is important to waltz in and save women seeking midwifery care from themselves, and if you feel just as passionately about the problems with birth in a hospital setting.

[Kanna]

*sigh*

*points up to the initial post*

Please, if you want to personally attack me, when I just did what you asked me for (opening a new thread), couldn't you do it in a private message?

And yes I DO feel as passionnately about birth in the hospital setting.

From the data I have so far (not including the studies you posted, I just noticed you posted those (they got lost in the comment thread, sorry), neonatal mortality IS higher with homebirth than with hospital birth and saving lives sounds kinda like a priorty to me.

However, I've also gotten the impression that OBs in the States are rotten bad at giving patient-centric care, often riding roughshod over their patients rights and dignity. And given time, and this thread running well, I'll start a thread for that too.

I'm writing an answer to one of your old posts in another window. Once I've posted that, why don't you bounce some of the thoughts in there around and see if you can expand those or come up with something better?

P.S.: Why I feel passionately about it in general: I'm mother of a two year old whom I love to bits.

The thought of anything having happened to her during birth terrifies me like nothing else on earth.

Knowing that other mothers have gone exactly through that, when it could have been preventable, makes me want to take action because if it can be avoided NO mother should lose her baby like that.

[Paigekitten]

I'm not trying to attack you.  I genuinely want to know.  

[Kanna]

Sorry.

I guess after people implying several times that I'm doing this because I'm some arrogant b****, who just breezed in to lord her non-existent superiorty over everybody else, and having to explain myself again and again, I think I'm being a bit oversensitve right now (Plus, it's one in the morning over here and I'm tired)

[mtn.mama]

Originally Posted by Paigekitten 

I would like to know why you feel it is important to waltz in and save women seeking midwifery care from themselves, and if you feel just as passionately about the problems with birth in a hospital setting.

Gosh, that sounds pretty rude.  Let's let the discussion unfold...

[Kanna]

Originally Posted by Paigekitten 

Kanna I mentioned that it seemed odd because it DID seem odd to me.  Since you asserted you didn't know it was old thread and was genuinely interested in intelligent discussion I figured I'd stick around and discuss instead of go back to lurking.  That said, it does make me personally very concerned when people post threads talking about need reassurance about homebirth, in the homebirth forum, and people jump in talking about the risks of homebirths.  When I read the original post it seems to me to be a mother asking LIKE-MINDED mothers for a reminder about why she has made a choice she has already researched and chosen. When a thread title is asking specifically for encouragement, it seems rather rude to me to jump in and start a debate about the risks of homebirth, especially when one of the things the OP was specifically concerned about was how it was going to reflect on the HB community in general.  That said, since you say you don't have an agenda to push, and are here in an effort to discuss and come away with more information then, I'm sorry I doubted your intentions.

It seems very easy to say things along the lines of if homebirth and midwives were more regulated, there would be fewer incidences of negligence and incompetence therefore, everyone will be better off with more oversight.  What I am trying to point out is there are many many of us who DON'T WANT more government oversight in our birthing choices.  We simply don't want it.  Those individuals who do want that are going to choose a care provider that is more highly regulated, the OB's, the CNM's, the licensed midwives.  Those of us who don't WANT that, still want the ability to make our own choices regardless of what others think of the risks.  It frankly scares the crap out of me when people want to walk in and start taking away my freedoms in an effort to protect me.  Would I rather be safe, or free?  I choose free.  Others choose safe.  That doesn't mean they should take away MY freedoms by limiting the options of care providers I have.  

And it seems to me that you are under the impression that women who have been subjected to poor medical care by the medical establishment have great recourse for retribution. I don't see that.  I suggest you research the deaths from cytotec inductions and the general lack of regard for the families of the women who have died to get a feel for the climate here in the U.S. in regards to medical negligence in the OB community. Here's a link to the Tatia Oden French Memorial Foundation. http://www.tatia.org/id7.html.

*chuckles* I resurrected another old thread today and somebody was surprised....this time it was one about author Neil Gaiman (LOVE his books).

It might be odd when one looks at the dates...not so much when one looks at the technical set-up of the site (just a small scroll of the button down the list).

And uhm...you didn't only remark on the oddity of the resurrection of the thread....you also said something about "pushing, pushing, pushing". I wouldn't have minded if it had been just you...but on a supposedly friendly forum, it was several people, one after another, and that gets a bit tiring.

As for jumping in on the thread when (to you) it was obvious that the mother wanted support for her HB choice....it wasn't to me. As has been said before, MDC used to have a certain "culture" that was very much focused on being supportive (Turquesa said something about coming here for the fluff....because it was missing from most other places she visited). Well, I come from those "other places", I didn't know about the culture of MDC to date (apart from e.g. that people were supposed to be nicer to each other than elsewhere) and so I read the OP's original post in an entirely different way: as a request for input from both sides. Which, since I'm interested in the subject in general, I obliged.

I think we can both agree that it'd make sense to implement measures that lower neonatal mortality during HB and that weed out incompetent, negligent midwives.

State regulation seems to work well over here in Europe / Germany (I googled the german words for HB and death and found just one death....in Austria, last year).

I hadn't even heard about homebirth deaths until I surfed a bit on US websites.

State regulation has great acceptance over here....but then, we're USED to being more regulated. So obviously, the US needs an approach that's more tailored to your culture.

1. I think SOME kind of regulation and accreditation of homewifes is necessary.

2. Also more accountability for negative outcomes (=dead babies) when the midwife, for whatever reasons, did NOT adhere to the best possible standards of care for whatever emergency was the cause, might be necessary too.

Since most midwives don't seem to want state intervention and malpractice isn't seen as workable either from what I've seen? So how by a midwife run organization? ONe for the whole US?

Yes, I know there are already midwife organizations out there. But (admittedly as a total outsider) I get the impression that they're not doing a very good job of improving safety of midwifery care. (see the Andaluz case we discussed).

I'm a bit on the fence about the Tatia Oden case you mentioned, because even on their website they say that evidence strongly SUGGESTS a connection between cytotec and AFE....but it hasn't been proven.

I think however that the use of Cytotec in birth is something that requires more research and better clinical practice. (I got cytotec too, but then, I was overdue with a BIG baby and the doctor took a lot of time to inform me of the risks and asked me if I was sure I was o.k. with it. (Says nothing about the safety of Cytotec btw, but it seems german OBs have better bedside manners than their american counterparts).

Edited by Kanna - 8/11/11 at 12:34am

[Kanna]

Originally Posted by mtn.mama 

Gosh, that sounds pretty rude.  Let's let the discussion unfold...

^_^  Paigekitten said it wasn't intended to be, and I'll take her word for it.   ^_^

[Storm Bride]

Originally Posted by Kanna 

P.S.: Why I feel passionately about it in general: I'm mother of a two year old whom I love to bits.

The thought of anything having happened to her during birth terrifies me like nothing else on earth.

Knowing that other mothers have gone exactly through that, when it could have been preventable, makes me want to take action because if it can be avoided NO mother should lose her baby like that.

FWIW, I've been through exactly that, and I disagree with you on most of your points.

I also have to point out that your assertion here:

"Anecdotal data welcome, but mark it as such. It's useful to illustrate a point, but not enough to prove one."

contains a fairly major flaw. It carries the implication that the data does prove these points. It doesn't. There is nowhere near enough data, nor complete enough data (and I doubt there ever will be, for a lot of reasons) to prove one side or the other of the "homebirth is safer" vs. "hospital birth is safer" debate. The issues are far, far too complex. For example, my case , where my baby died during an attempted homebirth, but after transfer, and there were multiple factors going back to my first "birth" 14 years prior, and even to my own "birth" 39 years prior, that affected the outcome. There is no data set in the world that would show everything that went into that, and since every birth is different, the data isn't going to prove a point about which is safer for any individual woman/baby dyad.

[Paigekitten]

So what are your thoughts on NARM?

( I am not sure if MDC allows for cut and paste quotes from one thread to another, and I don't have time to look it up ATM).

[Kanna]

O_O

DD just woke up and puked in the bed. I think she's coming down with something....

I might be a while....

[lovebeingamomma]

If you want to really makes changes, wouldn't it be better for you to focus your efforts where you have a passion, that is, hospital births?  I'm being serious.  There was a mom in the past year who started a thread about how to make c-sections better, when she had never had a c-section, boy did she get back-lash from a lot of c-section mom's...I think your intention is good but is better served trying to improve safety/care of births in hospital, because that's where your passion is.  You're the right person to do that, and I think that would be a great discussion to have, but not here obviously.  You're going to offend a lot of people unintentionally, just warning you, from all the debate threads I've been a part of I know it'll happen.  There was a loooong homebirth safety debate thread posted a few months ago by a mom who had lost a baby from homebirth.  So it has been discussed in length fairly recently, and overall it was a productive discussion.  Maybe someone could find that thread for you so you can see for yourself that yes, we care about homebirth safety, and have discussed it to the point where everything that could be said, was said.  And by the way I was planning a homebirth for my third, and ended up switching because of the deceptive practice of a CPM.  So I'm all over this topic, but I couldn't possibly discuss it more because I already have in that other very lengthy thread.  If others want to open up the discussion again that's fine and I respect that.  Just my two cents.

[Alenushka]

I do not understand why CPMs are allowed to take a NARM exam simply with portfolio which is not even checked by anyone. To me, a MW should have a BA to start with, then a required list of medical courses (Anatomy, Physiology, microbiology etc) and  then no less that 3 years of clinical work under constant supervision in different setting.  I think working for at least 6 month in the hospital would teach one how to recognize when things are outside "normal an low risk".  Then the exam. CEUs and  malpractice insurance.

[xzaviers_mama]

Originally Posted by Kanna 

Sorry.

I guess after people implying several times that I'm doing this because I'm some arrogant b****, who just breezed in to lord her non-existent superiorty over everybody else, and having to explain myself again and again, I think I'm being a bit oversensitve right now (Plus, it's one in the morning over here and I'm tired)

Good grief.  I really, really don't think it was ever that serious  No one ever referred to you as "some arrogant b****", or anything of the sort.

[Kanna]

Originally Posted by Paigekitten 

So what are your thoughts on NARM?

( I am not sure if MDC allows for cut and paste quotes from one thread to another, and I don't have time to look it up ATM).

*back....for a short while. DD sleeping now*

Yes, you can cut and paste between threads.

I don't know enough about NARM (german and all that, ya know), but there seem to be people (points to Alenushka) who have doubts wether it's standards are rigourous enough.

[Kanna]

Originally Posted by lovebeingamomma 

If you want to really makes changes, wouldn't it be better for you to focus your efforts where you have a passion, that is, hospital births?  I'm being serious.  There was a mom in the past year who started a thread about how to make c-sections better, when she had never had a c-section, boy did she get back-lash from a lot of c-section mom's...I think your intention is good but is better served trying to improve safety/care of births in hospital, because that's where your passion is.  You're the right person to do that, and I think that would be a great discussion to have, but not here obviously.  You're going to offend a lot of people unintentionally, just warning you, from all the debate threads I've been a part of I know it'll happen.  There was a loooong homebirth safety debate thread posted a few months ago by a mom who had lost a baby from homebirth.  So it has been discussed in length fairly recently, and overall it was a productive discussion.  Maybe someone could find that thread for you so you can see for yourself that yes, we care about homebirth safety, and have discussed it to the point where everything that could be said, was said.  And by the way I was planning a homebirth for my third, and ended up switching because of the deceptive practice of a CPM.  So I'm all over this topic, but I couldn't possibly discuss it more because I already have in that other very lengthy thread.  If others want to open up the discussion again that's fine and I respect that.  Just my two cents.

LOL. Thanks for the warning. I kinda noticed.

And yeah, hospital stuff needs improvment too....but right now, I know and talk to a lot more people in here than to OB/GYNs in Germany (and even less in the US) so it makes sense to start here. If this works out, it certainly would be worth to start another thread concerning hospital stuff too.But one thing at a time.

Maybe I should explain once more that I didn't create this thread so I could tell midwives what to do. They're professionals and I figure they take enough pride in their profession to go ahead and figure out on their own how to improve things, since professionals in general have an interest in quality managment.

I'm just trying to give them a forum where they can match up with people from "the other side", so they can bounce ideas around and see if those ideas will hold in the face of fire.

Acutally, it shouldn't be that different from when they pick up a new client. Those have concerns too that have to be addressed, and from what I've heard from midwives so far, they like it when clients do some work and gather some information on their own to talk to them about it.

I have no idea if this thread is actually going to work out like that, but I feel that the point of this whole exercise (more safety, better service) makes it something worth trying, and there acutally DOES seem to be a bit of support amongst the "old" MDC'ers for the idea:

To illustrate:

Originally Posted by Turquesa 

It’s funny….everytime somebody here makes the factual statement that babies die in hospitals as well as at home, they get jumped on for lacking compassion.  I don’t think they do, and I don’t think you do.  Yes, agreed.  Babies die at home, babies die in hospitals. 

Originally Posted by SaveTheWild 

Kanna: 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.

Quote:

Originally Posted by MidwifeErika 

I also believe that in all aspects of maternity care we should always, always, always be looking to be improving out outcomes. Regardless of birth location or attendant.

Originally Posted by SaveTheWild 

I do think that midwifery should have more quality control, because an incompetent midwife stains the entire child birthing world. 

[Kanna]

Originally Posted by MidwifeErika 

I really don't think malpractice insurance has much to do with providing safe care. I don't think lawsuits have done much to improve our medical situation here in the US and doctors are sued left and right and up and down. If anything, I believe it destroys good care. Good doctors have left medicine due to inability to keep up with the rising costs of malpractice insurance. Hospitals have brought in policies that are not at all about evidence-based care and are all about avoiding lawsuits and liability.

There are doctors who practice without malpractice, but then they cannot accept certain insurances. No problem. They usually make up for it with being quite affordable. This is the same with midwifery care. I disclose in writing and in oral format to all potential clients that I have no malpractice and that I also own nothing. If they want to sue me, they could get a 1998 subaru with 200,000 miles on it. If they enter into a contract with me for care, they go in with it being quite transparent.

What I do see about malpractice insurance requirements.... it is a good way to shut down homebirth providers. It is a good way to drive people out of private practice. I would be curious to know what the costs of malpractice insurance in Germany are in comparison to the US for providers who are attending births. It can be absolutely insane here in the US due to people being quite "trigger happy" with lawsuits. For many doctors the cost of insurance goes up with the more experience they have because the insurance company starts to feel their time is coming for a lawsuit. That is insane. One would think the more experience one would have the better as they would be less likely to make mistakes.

OK......from what I gather, there are a lot of midwifes out there who don't think the benefits of malpractice justify it's drawbacks, probably even if you could get the insurers to lower premiums to a reasonable rate for midwives.

Any ideas if theres something that would be set up differently, but would get better results in

a) promoting midwife accountability

b) seeing to it that parents are recompensated in a sufficient way ( a bit more than an old subaru ^_~) if their babies are killed or crippled in a case where a midwife did act negligently?

[Kanna]

Originally Posted by lilikoi 

Kanna-- That's the reason why to me it seems like you are pushing an agenda here. You don't ever refer to the studies posted by others who have shown the outcomes of homebirth to be quite different from what you keep stating. I just read this thread and that was my first impression. Hope that helps you understand why this conversation can strike a bad note for some people.

Actually, if you go back some, you'll find that this isn't the case. When Turquesa came up with some data that showed that the time for a crash induction was o.k. at somewhere around 30 minutes instead of the 15 minute period I thought would be best, I conceded the point.

As for not reacting to the studies paigekitten posted: At first, I simply overlooked her post (there were a LOT of new comment) and right now, I haven't gotten around to it yet. But is IS on my "to do" list.

Originally Posted by Kanna 



As to post #8, well, I live in Germany, and here the recommended decision-to-incision time is 20 minutes and going by the post you linked ( http://www.obgmanagement.com/article_pages.asp?AID=4284 )  shorter decision-to-incision time are considered better by experts in cases of complication like major abruption or a cord prolapse, since they are associated with better newborn outcomes.

Well, specifically, here is how the author worded it:

These recommendations are based on the opinion of experts, not on prospective trials. Many authorities believe that in some clinical settings, such as with a major abruption or a cord prolapse, “decision-to-delivery” times in the 10- to 20-minute range are associated with better newborn outcomes than times in the 30- to 45-minute range.

The key words are "opinion" and "believe."  So even in the cases of abruption and a prolapsed cord (the latter of which could happen anywhere and at any time, regardless of the planned birth site), it is opinion, not science, that is guiding the 30-minute protocol, which has been contested multiple times:

http://cat.inist.fr/?aModele=afficheN&cpsidt=2714626

http://journals.lww.com/greenjournal/Abstract/2006/07000/Decision_to_Incision_Times_and_Maternal_and_Infant.4.aspx

http://onlinelibrary.wiley.com/doi/10.1002/jhrm.5600190105/abstract

As you can tell from the third link, this is a critical issue for obstetricians who fear being sued for not doing a cesarean "in time."

Originally Posted by Kanna 


The studies you dug up do seem to indicate that for fetal distress, if you get the cesarean done in about 30 mins, that's fine, and I think that's something worth considering. If you know you can do things speedily but WITHOUT getting hectic, that's worth a lot, since trying to get to the 10-15 min margin would probably also increase the risk of errors occuring, and as you said, crash c-sections ARE more dangerous than regular ones, so staying somewhere around the 30 min margin will probably contribute to making them safer.

[Kanna]

Hi there Xzaviers_mama,

since you're here and since we ARE finishing up some stuff from the old thread, can we get back to the subject of whether you were being rude to me or not? Because the jury is still out on that subject. Here's where we left off:

Originally Posted by Kanna 

@Xzaviers_mama

O.K., since you don't seem to understand why I believe you were being rude, let me try to put this another way. Let's have a look at what was being said first:

Paigekitten:

Seems odd for someone to dig up an old thread on the homebirth forum and start pushing pushing pushing to prove that homebirth isn't safe.

LittleStar:

Couldn't agree more. And if you look at her posting history, this isn't the only resurrected thread she's preaching her agenda on.

You:

I noticed this as well.

1. You agreed with Pk and LS.

2. LS an Pk were saying that

• I had an "agenda." People that have an "agenda" are not being honest with you and they're trying to push something on you which you don't actually want. In other words, people that have an "agenda" are trying to harm you in order to advance their own goals.

• I was "pushing pushing pushing" and "preaching". People that push and preach are disrespectful of others. They disregard others' rights to their own opinions and thoughts and instead try to force them to give them up and exchange them for the opinions of the one "preaching".

• I deliberately dug up this old thread. If you deliberately go somewhere to "push an agenda", then that's a bit stalkerish and creepy.

To sum it up, preachy, pushy people with an agenda that deliberately go hunting for places where they hope they will find people that they can be preach and pushy to are, to use an euphemism "not nice" (=a*******).

And since you were basically agreeing that I was someone "preachy, pushy with an agenda" who deliberately came here so I could preach and push my agenda on the people here…..yes, I DO feel that you were being rude.

The fact that you're now saying that "Maybe" I'm "looking to feel attacked?" and basically implying that I'm being oversensitive and whiny about your accusations is not exactly helping your case.

I don't hesitate to call a spade a spade, and you were being rude and you still ARE being rude.