The price of being the best.....is having to BE the best - Or: On how to make Homebirth even... - Page 3

[Kanna]

Originally Posted by Adaline'sMama 

Really? Who is this "we" "us" you refer to? Are you more than one person?

Do you realize how rude this sounds? "Please take a look at this and then get back to us." This isnt a job interview, its a message board.

By "we" I mean the people in this thread. If we're to discuss this, we need to start out with a consensus on the data that sparked the debate. Please note that I said I needed to go back too and check some of the studies others posted, since I hadn't gotten round to checking on it all either.

If I sounded rude, I apologize. I didn't mean to. I'm just trying to build a basis for everybody to work from (including myself)

Edited by Kanna - 8/11/11 at 11:07pm

[Kanna]

Originally Posted by Turquesa 

Kanna, the topic of EFM is getting slightly tangential to this thread, ...

I know. I'm just trying not to leave anything that got started in the first thread hanging.I suggest we call it a day on this subject after this.

.....

The foremost reason for routine, continuous EFM of all laboring women is for provider convenience, provider protection (monitoring strip used in court) and hospital cost-cutting (ability to short-staff maternity floors for less personal care).

The real kicker: Physicians are not informing women of these factors; rather, they are kowtowing to hospital "protocols" and strapping women down without evidence to support it.  When women aren't given their options in a truthful and thorough manner (informed consent, after all, requires disclosing even those facts that you don't like!), the practice of medicine is nothing short of unethical.

Assuming the studies are accurate (I AM assuming they are, but in science, things only are accurate as long as there's no other, bigger, badder study that comes along to prove the contrary (I'm thinking e.g. about the numerous changes rescusitation codes went through throughout the years)  ^_~)

I think physicians definitely would need to inform patients about that kind of thing and offer an alternative option.

But I think that would only be possible (trigger happy suing in the US again....) if it were possible for moms to sign an "against medical advice" waiver for the EFM, which would also have to hold up in court.

ETA: I disagree with the ACOG opinion that either option is "acceptable."  Gee, they both work, but one of them has a high false-positive rate AND increases the chance of a cesarean delivery?  Not a tough choice.  And as the health care consumer, I---and I alone--will decide which option is acceptable for my body and my baby.

*g* I think we've already establishe that as a patient, I'm a bit on the paranoid side. I'd rather have the EFM, even if it does increase my risk of getting an "unnecesarean". I feel moms should be offered the full information on both kinds of monitoring (preferrably in a birth preparation class or on a comprehensive website about the characteristics of both "sides",or something similar) so they don't have to make that kind of decision under pressure.

[Kanna]

Summary so far:

There's quite a bit of controversy about the data available and whether it indicates that homebirths are more dangerous then hospital births or not.

I'll try to make a post later on (I need to get back to work right now) that summarizes the data we have so far, so we get a common starting point (and no, I still haven't looked at all of it. Working on it)

Mind you, right now, I have the impression that the data is not so reliable, because there seem to be "holes", like "other midwife" not being specified enough and data, like the one from MANA not being widely available (for whatever the reason may be).

For now, I think that one thing that might be worth lobbying for is to get a nationwide, well-run database started that collects data on homebirth and midwives, since it would allow midwives to solidly prove in how far they provide better care than OBs and hospitals.

One thing that people here in the forum seem to agree on (as far as I can tell), is that there ARE midwives around that are incompetent and negligent, and that it would be a good thing if they got "caught" before anything happens (would mean less dead babies and less damage to the reputation of midwifery).

Doctors have a system to catch and sanction "bad" doctors, but that system seems to be insufficient.

What should such a system for midwives look like and how could it be designed so that it works better than the one the doctors have?

(*g* Excellent opportunity to avoid the mistakes of others  ^_~)

Edited by Kanna - 8/11/11 at 11:53pm

[Kanna]

Originally Posted by Storm Bride 

I haven't found that there's much adapting done. Of couse, that's just my experience (and that of my friends and family). But, whether this is a foundation for good care depends on whether the "checking" is benign or not. GD is a particular "thing" of mine. I've never had it. My children's sugars have all been fine (determined by sticking them - why bother putting me through that disgusting GTT, if they're not going to trust the results, anyway?), despite having a fat mom, and being over 10 lbs. - well dd2 was 9lb. 15oz. DH and his brothers, born to my very short and slight MIL, were all between 9.5 lbs. and 10 lbs. They didn't test for GD back then (they didn't do that one when I had my first, either - he was much smaller...but he also had a different dad), but there was no evidence of any issue, except that they were big. It runs in dh's family.

You're right, there probably isn't much adapting being done. But there SHOULD be, when appropriate. The thing is in order to adapt, you need to define standards on when where and under which circumstances to adapt, and I think that's not being done much.

On the oral Glucose Tolerance Test: It's more accurate than just random blood sugars you get by sticking. And if you have someone that is "special", I think you might want to do some "special" checking (like re-running the oGTT after a while)....but if the results of that come back o.k., then you need to adapt your treatment to those findings (=NOT treat person like a diabetic)

I also think that, when a "patient" explains what's going on, and a particular standard clearly doesn't apply to said "patient", then applying said standard is a pretty good indicator that the standard is more important than the patient. (As an example of the kind of thing I'm talking about - dh's family all being big babies, combined with my "passing" the GTT tends to strongly suggest that GD wasn't at play, even though I'm fat - and I told the OB dh's family history of both "post-dates" and "macrosomia". My kids still got heel sticks, and one ped insisted on supplementing with formula to stabilize ds2's sugars, even though they were within normal ranges. As far as he was concerned "big baby = GD". Period. The OB paid no attention to family history or test results, and the ped didn't even know about them. All they cared about was that the baby was 10lb. 8oz, and clearly mom had GD and baby had sugar issues, because he was 10lb. 8oz.).

I DO get the part about the heel sticks. As they say in here: "It is possible to have both lice AND fleas", meaning your kids might have been big because of genetics (like my DD too), but they had to rule out GD too, just to be on the safe side. I can't make a definite call on supplementing with formula (there might have been other factors at play), but yeah, I agree with you that it DOES sound like it was unnecessary and uncalled for.

I had a better OB /pediatrician. They kept close tabs on DD and even did an ultrasound of DD's heart to make sure (with GD babies, there can be changes), but after doing those, they gave us a clean bill of health.

I have no idea if the doctors I've encountered were thinking globally and locally or not. They were acting as if every "patient" fits precisely into the random pigeonhole they were assigned to. I didn't fit the pigeonholes, in multiple ways, and the repeated attempts to stuff me into one didn't protect me. They caused me tremendous emotional - and physical - trauma. Having more "standards" (ie. trying to standardize individuals, which doens't work) actually terrifies me. I want my daughters to have not only "standards", but options.

I think that yes, you DO need standards...but only to serve as a baseline. They need to be modifiable on a case-to-case basis. In some areas, this is getting started, e.g. they're adjusting some standards of treatment for women / men or for people with a different racial background (and I mean the latter in a good way, since race sometimes influences the health problems people are. e.g. there's a race of indians that has overproportionally often problems with gall-stones, just to name one example).

[Gena 22]

Originally Posted by Jane93 

Gena -- can you dispute that it is in the best economic interest of midwives to broaden the scope of their practice as much as possible?   The pool of women willing to even contemplate homebirth is so small.  I can see where there might be an monetary motive to keep homebirth interested women in the pool of potential clients even though their pregnancy contains factors that make a homebirth ill advised. 

Also, if a midwife is unlicensed isn't is true that she has had no external examination of her past personal history and ethics?  Or even any evidence that she has made any study or consideration of medical ethics at all?  The most recent homebirth death out of Oregon, where 2 unlicensed midwives allegedly left a woman to labor for 8 days, and then isolated her from her friends and family (to the extent of not letting her husband, then out of the country, speak to her by phone) is instructive on this point.

Yes, of course I can.  No provider, midwife or OB wants to take on a client where there is a high likelihood of a poor outcome.  A MW might be more choosy, since she is without malpractice insurance.  My possibly-negligent MW had to dive deep into her savings and mortgage her house to pay her legal fees and keep herself out of jail.  It was a position she took on knowingly.  So no, MWs do not take on risky patients without a serious risk to themselves.

Midwifery isn't surgery.  It isn't nuclear physics.  It isn't math.  There is a shocking lack of good science in the area of labor and birth:

Let's start with simple gestation.  How long is a human pregnancy?  40 weeks is a number that a 19th century philosopher pulled out of . . .  let's say thin air to be nice.  But doctors adhere to it, why?  Because studies lump together mothers who shouldn't be lumped together.  Don't even get me started on how long a twin pregnancy should last.

Delayed cord clamping - why is this not standard?  OBs have RIDICULOUS superstitions about this one, which have been proven false for THOUSANDS of years of medicine.

Totally with Storm bride on GD, this was what had me running from the OBs.  The results of 1-hr GTT are less than 50% repeatable.  Know what that makes it?  Worthless.  Yet docs treat it like scripture.  Gave me a 0% chance of having a normal 3-hr OGTT, despite my lack of any symptoms and my statement that there was no family history whatsoever.  Guess what, I passed.

The list could go on and on. 

So who do I want teaching providers and making licensing requirements?  OBs?  Insurance companies?  No.  I'm happy with the marketplace.  I want a midwife who is professional, as evidence based as possible, with a long apprenticeship and a good reputation.  In order for that to work, we have to be open and honest about reputations.  We have to have client reviews.  Published and verified resumes.  Like Angie's list.  My second midwife was a saint on earth, and I have loudly recommended her.  I feel guilty about keeping quiet about my first MW.  But in the US we have such a messed up system, i don't want to be a voice adding to the assaults on birth choice.

So, good question.  My answer is NARM or some similar organization needs to have a place where clients can give detailed reviews and prospective clients can make a informed choice.

[Kanna]

Originally Posted by Gena 22 

Yes, of course I can.  No provider, midwife or OB wants to take on a client where there is a high likelihood of a poor outcome.  A MW might be more choosy, since she is without malpractice insurance.  My possibly-negligent MW had to dive deep into her savings and mortgage her house to pay her legal fees and keep herself out of jail.  It was a position she took on knowingly.  So no, MWs do not take on risky patients without a serious risk to themselves

Midwifery isn't surgery.  It isn't nuclear physics.  It isn't math.  There is a shocking lack of good science in the area of labor and birth:

For these

Let's start with simple gestation.  How long is a human pregnancy?  40 weeks is a number that a 19th century philosopher pulled out of . . .  let's say thin air to be nice.  But doctors adhere to it, why?  Because studies lump together mothers who shouldn't be lumped together.  Don't even get me started on how long a twin pregnancy should last.

Delayed cord clamping - why is this not standard?  OBs have RIDICULOUS superstitions about this one, which have been proven false for THOUSANDS of years of medicine.

Totally with Storm bride on GD, this was what had me running from the OBs.  The results of 1-hr GTT are less than 50% repeatable.  Know what that makes it?  Worthless.  Yet docs treat it like scripture.  Gave me a 0% chance of having a normal 3-hr OGTT, despite my lack of any symptoms and my statement that there was no family history whatsoever.  Guess what, I passed.

...can you maybe add links with the original information, please?  I know zilch about delayed cord clamping and the thing about the reliability of oGTT tests sound interesting (and I'd also like to read up on the reliability of 2hr oGTT).

The list could go on and on. 

So who do I want teaching providers and making licensing requirements?  OBs?  Insurance companies?  No.  I'm happy with the marketplace.  I want a midwife who is professional, as evidence based as possible, with a long apprenticeship and a good reputation.  In order for that to work, we have to be open and honest about reputations.  We have to have client reviews.  Published and verified resumes.  Like Angie's list.  My second midwife was a saint on earth, and I have loudly recommended her.  I feel guilty about keeping quiet about my first MW.  But in the US we have such a messed up system, i don't want to be a voice adding to the assaults on birth choice.

This

So, good question.  My answer is NARM or some similar organization needs to have a place where clients can give detailed reviews and prospective clients can make a informed choice.

sounds like a good suggestion. We should keep it in mind and expand on it. Anybody feel like throwing in their 2 cents?  ^_^ 

[Right of Passage]

Originally Posted by Gena 22 

Delayed cord clamping - why is this not standard?  OBs have RIDICULOUS superstitions about this one, which have been proven false for THOUSANDS of years of medicine.
 

ITA with what you've said but the term "delayed" cord clamping is something that bothers me in general. Physiological cord clamping is what needs to be done(and will happen when the cord is left alone), anything else is premature, why is premature cord clamping the standard? Not picking on you, just the whole thought behind "delayed" cord clamping.

So who do I want teaching providers and making licensing requirements?  OBs?  Insurance companies?  No.  I'm happy with the marketplace.  I want a midwife who is professional, as evidence based as possible, with a long apprenticeship and a good reputation.  In order for that to work, we have to be open and honest about reputations.  We have to have client reviews.  Published and verified resumes. 

YESYESYES!

So, good question.  My answer is NARM or some similar organization needs to have a place where clients can give detailed reviews and prospective clients can make a informed choice.

I'm not a huge NARM supporter, too basic, too entry level, and too many stories of answers being given before the test. I think there needs to be at a minimum peer and client reviews(together at the same time), so midwives review how they've chose to serve, the services they offer, etc and see where and how they can improve. Any practices that have been in use for 2 or more years need to be reviewed for evidence to affirm the continued use or reasons to end the use. I have more ideas but that's just the tip of the ice burg. I think dissatisfied clients can be the best people for a client review for a midwife, it's what will make her take a hard look at herself and fix the problems, some of that problem could be burn out and the midwife needing to take a break from midwifery.

[Storm Bride]

Kanna - You and I are coming at this from completely different directions and viewponits, so we're not likely to have a meeting of the minds. If my doctors did a freaking ultrasound on my baby's heart, just because he/she was large, I'd have gone ballistic. You are obviously of the school of thought that sees all the "just in case" checking as a good thing. I'm not. So, we're not going to agree.

DS2 was my first baby who didn't get formula for other reasons (ds1, because I was knocked out for the first 14 hours of his life, and thusly unable to initiate breastfeeding, and dd1 got a small supplement, because we were having isuse, and she was so insanely frantic from hunger that she was destroying my nipples and not getting anything to eat). I strongly wanted hm to be exclusively breastfed, but he still got formula (two feedings, of miniscule amounts - and I'm not even sure if he really swallowed them) because of a non-existent sugar issue. To you, that's probably not a big deal. But, for me, for a whole lot of reasons, it was a huge deal. However, I wasn't really given any options, and it's not like I could wrestle the formula or the baby away from the nurse, while recovering from a c-section.

The direction of more and more regulation to protect pregnant/labouring woman is part of how the North American obstetrical situation got as ugly as it is, imo.

[Right of Passage]

The direction of more and more regulation to protect pregnant/labouring woman is part of how the North American obstetrical situation got as ugly as it is, imo. 

I agree with you 100%!

[Gena 22]

Me too!
 

Quote:

Originally Posted by Right of Passage 

I'm not a huge NARM supporter, too basic, too entry level, and too many stories of answers being given before the test. I think there needs to be at a minimum peer and client reviews(together at the same time), so midwives review how they've chose to serve, the services they offer, etc and see where and how they can improve. Any practices that have been in use for 2 or more years need to be reviewed for evidence to affirm the continued use or reasons to end the use. I have more ideas but that's just the tip of the ice burg. I think dissatisfied clients can be the best people for a client review for a midwife, it's what will make her take a hard look at herself and fix the problems, some of that problem could be burn out and the midwife needing to take a break from midwifery.
 

Those are very interesting suggestions, and I think you're definitely on the right track.  Yes!

----------------------------

Tangentially, here are some thoughts in response to Kanna's question:

...can you maybe add links with the original information, please?  I know zilch about delayed cord clamping and the thing about the reliability of oGTT tests sound interesting (and I'd also like to read up on the reliability of 2hr oGTT).

Right of Passage, you're right (no pun intended), I should be using the term physiological cord clamping, or refer to the current practice as immediate cord clamping.  I brought this aspect of OB-directed standard of care up because it is so widespread, and so obviously harmful.  Immediate cord clamping deprives an infant of up to 20% of its blood volume, and has other important effects.  It seems to have become routine purely for the convenience of providers, intervention for intervention’s sake.  Waiting to clamp may be most important in surgical and preterm births, but these are the births for which many doctors are quickest on the draw.

Here are two decent links:

http://www.sciencedaily.com/releases/2007/08/070816193328.htm

http://www.cordclamping.info/publications/LIT%20REVIEW%20ARTICLE-MERCER.pdf

And two good quotes to looks at:

“Another thing very injurious to the child, is the tying and cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases.  As otherwise the child is much weaker than it ought to be, a portion of the blood being left in the placenta, which ought to have been in the child.”

Erasmus Darwin,  Zoonomia, 1801

“Immediately after delivery of the neonate, a segment of the umbilical cord should be doubly clamped ...”

ACOG Practice Bulletins #127, #216, #348, 1989 – 2006

What I don’t get is how doctors, and I do have some lingering respect for their training and qualifications, how thinking scientists could get so caught up in a culture of tradition based practices that they insist on actions which are counter-intuitive, and well proven to do harm?  I’d bet this is one of the many areas OBs and pediatricians differ vehemently on (gestational age being another).  One considers their job done once the OR door swings closed, the other has 15 years of thriving child to worry about.

---------------------------

OK, on gestational diabetes and the GTTs.  I don’t have time to delve deep into the strategy and research on this, especially since I think the fault lies more with the providers and protocols.  Standard care in the US is to have pregnant women tested with the 1-hr 50-g GCT.  Results on this test turn around a huge number of false positives depending on the cut-off blood sugar level used.  Lower cut-off = more false positives but also = more cases of GD identified.  Many different things affect the 1hr values.  There is some thought that the higher the 1-hr number, the more chance of GD.  There is also a school of thought (backed up with studies) that a normal diet prior to the test will return more accurate results.  The reliability of this test is seriously questioned.  (http://www.jstage.jst.go.jp/article/internalmedicine/47/13/47_1171/_article )  It may be that the 2 hr test is more reliable.  There have been calls for the US to switch to universal 3-hr tests instead of the two step 1-hr, and then 3-hr if high values on first test.  Might be a good idea.

In my case, I believe there was a problem with different providers in a practice disagreeing.  One OB said I could schedule the 3 hr test whenever was convenient  for me.  Another OB told me I had to go for the test immediately following his appointment or I was risking fetal death (a direction that showed a fundamental misunderstanding of the test, you need to fast before the 3-hr OGTT and he saw me mid-day.)  So, I’m going to chalk this one up as poor, inconsistent practice rather than bad science.  And it’s worth considering whether putting all pregnant women through a test that returns an approximate 85% false positive is a good idea.  Maybe, maybe not when a false positive is itself a predictor of adverse outcomes.  (http://journals.lww.com/greenjournal/Abstract/2004/01000/False_Positive_1_Hour_Glucose_Challenge_Test_and.25.aspx )  Wouldn’t it be smarter to look for indications first?  OK, that would be me – twin moms have more GD.  But I would have liked to get real info from my doctors, and I’d at least like them to understand how the tests worked and why.  More studies to develop a more reliable protocol and more accurate practitioner understanding is clearly needed.

[Turquesa]

Originally Posted by Kanna 

What should such a system for midwives look like and how could it be designed so that it works better than the one the doctors have?

(*g* Excellent opportunity to avoid the mistakes of others  ^_~)

The answer to that is in the last paragraph of this post, but I have to lead up to that. 

To elaborate further on the  Public Citizen paper that I cited in a previous post, it refers to The National Practitioner Data Bank, which contains the names of over 100,000 doctors who’ve had lawsuits filed against them, made settlements, or had states take disciplinary action against them.  As I mentioned in the previous thread, and as the American Medical Association states in this policy paper, obstetricians are more likely to be sued than any other kind of physicians. 

So you’d think this databank like that would be a goldmine for maternity care consumers wanting to ensure that they have a safe provider.  Not so.  To date, only physicians can access the databank, and the AMA fights like a tiger to keep it that way.

Their excuse: “…malpractice information is a poor indicator of a physician's quality.”

Gee, I’d get reamed in this forum for saying the same thing about negligent midwives….

I *could* make the case that these doctors don’t want to release their data because, among other malpractice and negligence issues, too many obstetricians are responsible for preventable neonatal deaths and don’t want the public to know.  Sound familiar?  It should.  

If people like "Jane93" in the previous post would take HALF of the time they spend whoring the anti-homebirth cause to message boards and demonizing MANA, (whose clients represent a tiny fraction of the bithing population), and focus on greater transparency from doctors and hospitals, the resulting transparency and accountability would result in astronomical improvements in U.S. maternity care.

ETA: Compounding the problem are the inevitable "gag orders" on patients who settle out of court and are prohibited from letting the public know about in-hospital negligence.  Yes, Virginia, this includes dead babies that we'll never get to know about.

Here is one idea, to get back to Kanna's question.

In New York and Massachusetts, hospitals and other maternity care services are required to provide data on maternity care interventions, and this data must be made available to the public.  Physicians and the hospital lobby resisted compliance to this law for years.

Nonetheless, I would support such legislation in all states, for all hospitals and birthing services, and have it INCLUDE information on maternal and neonatal deaths.  It would be tricky to provide context; for example, high-risk obstetric cases and congenital abnormalities in a baby, but I think that a Maternity Information Act in all 50 U.S. states would be a step in the right direction.  What are your thoughts? 

Edited by Turquesa - 9/12/11 at 3:23pm

[Turquesa]

Regarding delayed cord clamping, there's an excellent talk on this for anyone with an hour to spare.  Yea.  That's all of us, right?

http://academicobgyn.com/2011/01/30/delayed-cord-clamping-grand-rounds/#comments

[Paigekitten]

Originally Posted by Turquesa 

If people like "Jane93" in the previous post would take HALF of the time they spend whoring the anti-homebirth cause to message boards and demonizing MANA, (whose clients represent a tiny fraction of the bithing population), and focus on greater transparency from doctors and hospitals, the resulting transparency and accountability would result in astronomical improvements in U.S. maternity care.

I'd go for a Maternity Information Act.  That would be awesome.

[Kanna]

Data on the safetey of midwife attended homebirth so far:

Note:

I'll post the data / links and maybe a short comment what I think it means. Given that while I've analyzed data in the course of my studies, but am not actually a scientist who analyzes data on a daily basis, my reasoning may or may not be off, so please look over the data and make your own interpretation.

A disclaimer, kind of:

I'd also like to add that yes, of course I'm biased. I know that. I don't really want to be though, so I have strive to keep an open mind to evidence that will challenge that. Not that you NEED to challenge me, if you don't feel like it. I'm perfectly o.k. with keeping that bias until I find evidence to the contrary somewhere else. What I'm trying to say is: if you find error with my findings, and you'd like to point them out, I'd be happy to listen and adapt to better information. Also, feel free to add more data.
 

1. CDC database

CDC: http://wonder.cdc.gov/lbd-current.html which is collected for the entire US.

Set the request form to

4. in the hospital

6. age of infant at death 1 hours / years = all years

Death rate / 1000 at

the hospital: 1

If you set the request at 6 to age of infant at death to "1-23 hours" the death rate per 1000 at the hospital is 1.71

Now, if you try the samt thing, but substitute " at the hospital" for "NOT in hospital"

you get a death rate per 1000

of 2.11 for children under 1 hour old and 3.44 for "1 to 23 hours old"

So basically, if you give birth at somewhere else than the hospital (e.g. at home), then the risk of your kid dying is HIGHER compared to giving birth at the hospital.

To fully interprete this though, one would have to know how many of those births were attended by midwives and what kind of qualification those midwives had.

2. Netherlands

Data indicates worse outcomes in births at home attended by midwives than in births at the hospital attended by OB's: http://www.bmj.com/content/341/bmj.c5639.full.pdf

To quote the study: "Infants of low risk pregnant women who started labour in primary care (=midwives) had a higher risk of delivery related perinatal death than did infants of high risk pregnant women who started labour in secondary care (=OB's)"

Not the US, granted, but to me, that sounds very troubling.

Qualification of midwives in the Netherlands (according to wikipedia): "Education in midwifery is direct entry, i.e. no previous education as a nurse is needed. A 4-year education program can be followed at four colleges, in Groningen, Amsterdam, Rotterdam and Maastricht."

3. Maternal death in Wisconsin

Concerning maternal mortality in Wisconsin, here's a paper on the subject: http://www.hawaii.edu/hivandaids/Pregnancy-Assoc_Deaths_and_Preg-Related_Deaths_in_Wisconsin.pdf 

Leading cause of death were embolism and hemorrhage....both of which is something a midwife attending a homebirth might have trouble treating adequately and where speedy treatment is of essence (transfer time!). Granted, though, with the embolism bit, even an OB at a hospital might run into trouble.

Also, midwives DO carry equipment to handle PPH, so they CAN take care of it in most cases. I'm assuming though (and I might be wrong) that even a well equipped and trained midwife would need to transfer a patient with severe PPH in need of sugery....and maybe even in need of a hysterectomy *shudders*.

4. Noskomial / Iatrogenic Problems

A wide wealth of problems people might encounter at the hospital. http://www.safepatientproject.org/topics.html 

Main risks are: hospital aquired infection, medication errors and medical errors. I find the website a bit unwieldy to navigate and I'm a bit strapped for time right now, but if any of you would like to dig up the dirt on the failings of OB's and the rate of noskomial infections (e.g. MRSA and suchlike), that would be very much welcome.

5. Outcomes for CNM's in Wisconsin

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. I don't know that the CNM being the required credential is the answer to this. If we were going to go based on the Wisconsin website, for example, the rates for death in births in a residence came up as follows:

MD: 2.07/1000

CNM: 4.85/1000

Other midwife: 1.87/1000

Now, obviously, there is so much missing information that it is quite difficult to base any sort of policy-making decisions on this ;) Who knows why these numbers came out this way. I just don't know that making the CNM into the only credential is the right answer.

I'd like to add to that that the outcomes of "other midwife" (not sure about the exact qualifications required of those) might not be as good as they look compared to the MD, since MD's also attend to high-risk pregnancies / births (which by their very nature have a higher incidence of negative outcomes) while midwives tend to stick to the low risk pregnancies / births.

6. Homebirth in Canada

According to this study, homebirth in Canada seems to work quite well:

http://www.cmaj.ca/content/early/2009/08/31/cmaj.081869.short

Quote of the interpretation of the study:

Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetricinterventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.

They also have a long list of things that excludes a mom from a homebirth: no GD, no twins, no breech, no over due-dates, no VBA2C.

On the qualification of the midwives involved:

Midwives are registered by the College of Midwives of British Columbia if they have a baccalaureate degree in midwifery from a Canadian university. If they trained outside of Canada, they are registered by the college after passing written, oral and practicebased exams. Registered midwives are mandated to offer women the choice to deliver in hospital or at home if they meet the eligibility criteria for home birth defined by the college.

So here, midwifery and homebirth seem to work, and work well, but the qualification of the midwives looks to be above the qualification of a CPM / DEM (I might be mistaken about that) and they seem to rigourously enforce criteria concerning the fitness of the mother.

On american HB websites I've read stuff like "Breech is a variant of normal" and VBA2C and HB with twins and "Babies are not library books, they don't come with a due date"....so I kinda suspect these criteria might not be as vigorously enforced in the US as they are in Canada.

7. Planned HB with CPM's in the US

http://www.bmj.com/content/330/7505/1416.full?ehom

This study indicates that "Planned home births with certified professional midwives in the United States had similar rates of intrapartum and neonatal mortality to those of low risk hospital births. Medical intervention rates for planned home births were lower than for planned low risk hospital births"

One pick that I have with this one that it is quite old (moms in the study gave birth in 2000) and the other results were more recent. This doesn't disqualify this paper, mind you, I'm just wondering how standards of clinical and midwives care have changed in the last 11 years and how this affects outcomes.

8. Wisconsin

They're pretty good at keeping their statistics up to date and they have a site where you can make queries with the data:

http://www.dhs.wisconsin.gov/wish/measures/inf_mort/long_form.html

change basic settings: neonatal mortality rate, step 3: all years, step 5: gestational age: full term, delivery method: vaginal (n c-section)

If you add: step 6: birth facility / birth attendant, you can go and compare neonatal mortality rates per 1000 births. The results:

residence/CNM: no data available

residence / other midwife : 1.96

residence / other: 4.92

hospital / medical doctor : 0.87

To make things a bit more challenging for docs, change settings of delivery method to "All", so it includes c-sections and such:

all delivery methods/ hospital / medical doctor: 1.12

So basically,

a) if you give birth at somewhere else than the hospital (e.g. at home), then the risk of your kid dying is HIGHER compared to giving birth at the hospital.

If you're attended during a homebirth by "other" (would include unattended births as well as births attended by the husband / the neighbour, etc.I guess) the neonatal mortality is highest overall.

b) The neonatal mortality is about DOUBLE for homebirths with "other midwives" than at a hospital with an OB

c) Assuming that "other midwives" usually get all the normal, non-risky births and pregnancies and doctors have to deal with all the risky, complication-riddled stuff on top of that, and doctors at the hospital STILL have lower neonatal mortality rates, then I think that's a darn fine compliment to the capabilities and competence of OB's and hosptital staff (even if midwives DO seem to have the better bedside manner....doctors could really learn from midwives in that department, I think).

There's one quibble with these statistics though:

I'm not so sure about the definition of "other midwife". I suspect "other midwife" might be just CPM's while "other" might include unlicensed midwives (as far as I know, Wisconsin only started licensing in 2006, after a HB death that resulted in a lawsuit).

There's input on that subject by other posters though:

Originally Posted by Turquesa 

Every baby must be issued a birth certificate, and providers generally fill out the necessary information.  This information is compiled as public health data by both state health departments and federal agencies such as the Centers for Disease Control.  This is the data that Wisconsin's health department compiles and relies on.

Each state gets to choose what kind of form to use.  A boilerplate form was released in 1989, which you can view here: http://upload.wikimedia.org/wikipedia/commons/c/c3/United_States_long_form_birth_certificate.gif

In 2003, the federal government issued a new form and encouraged states to adopt it.  Here is an explanation of that changeover process.

http://www.marchofdimes.com/Peristats/calculations.aspx?reg=&top=&id=6

And here is the 2003 form: http://www.cdc.gov/nchs/data/dvs/birth11-03final-ACC.pdf

You will note that both the 1989 and 2003 forms have the category OTHER MIDWIFE.  There is no category for a CPM.  But here's the important part: The OTHER category on both forms has the words "please specify."    There is room, in other words, to specify CPM.  And apparently, nobody did, or we'd have some concrete data on CPM outcomes.  

ETA: I'm not sure if Wisconsin uses the 1989 or 2003 form to compile its data, but either way, we have the "Other Midwife" conundrum.

Originally Posted by MidwifeErika 

A few things:

*Other for attendant is not unlicensed midwife, they would be listed under "other midwife". The license was not available until the middle of 2007. The act passed in 2006 and honestly was in the works LONG before the poor outcome that you mention.... that was not the reason for the license coming about. The license came about because midwives pushed for it to be available. So, anyhow, "other midwife" is the category that lists anyone who checks the box on the birth certificate that they are a non-CNM midwife this absolutely, for sure, includes non-licesned/non-CPM midwives. One does not have to be licensed to check that box or be a CPM (I have filed Wisconsin birth certificates) So, "other" could be a friend or partner or complete stranger. It could be the taxi cab driver bringing a woman to the hospital.

[Kanna]

(Bolding and colouring mine)

Originally Posted by Turquesa 
 

.....and focus on greater transparency from doctors and hospitals, the resulting transparency and accountability would result in astronomical improvements in U.S. maternity care

Here is one idea, to get back to Kanna's question.

In New York and Massachusetts, hospitals and other maternity care services are required to provide data on maternity care interventions, and this data must be made available to the public. ....

Nonetheless, I would support such legislation in all states, for all hospitals and birthing services, and have it INCLUDE information on maternal and neonatal deaths.  It would be tricky to provide context; for example, high-risk obstetric cases and congenital abnormalities in a baby, but I think that a Maternity Information Act in all 50 U.S. states would be a step in the right direction.  What are your thoughts? 

Originally Posted by Paigekitten 

I'd go for a Maternity Information Act.  That would be awesome.

Totally in favour. I think this suggestion is a keeper.

[MidwifeErika]

Originally Posted by Kanna 

5. Outcomes for CNM's in Wisconsin

I'd like to add to that that the outcomes of "other midwife" (not sure about the exact qualifications required of those) might not be as good as they look compared to the MD, since MD's also attend to high-risk pregnancies / births (which by their very nature have a higher incidence of negative outcomes) while midwives tend to stick to the low risk pregnancies / births.

Kanna, you are missing something very important about those numbers. That was only for "in residence" (homebirths) So, doctors and CNMs would not be attending to anyone any higher risk than "other midwives" in the home. One could assume the risk factors across these numbers is all equal. All risk factors being equal and location being equal, untrained, unlicensed, and CPM midwives had better outcomes than doctors or CNMs in the home. Interesting, isn't it?

[Kanna]

Originally Posted by MidwifeErika 


Kanna, you are missing something very important about those numbers. That was only for "in residence" (homebirths) So, doctors and CNMs would not be attending to anyone any higher risk than "other midwives" in the home. One could assume the risk factors across these numbers is all equal. All risk factors being equal and location being equal, untrained, unlicensed, and CPM midwives had better outcomes than doctors or CNMs in the home. Interesting, isn't it?

Hi Erika,

I just went back to the Wisconsin to check once more on the basic data, because I after reading your post, I had a "hey....wait a minute...." moment, because I couldn't figure why many doctors would be attending homebirths in the first place, and so I tried to replicate your results....and except for the neonatal mortality / 1000 =1,87 for "other midwives", I couldn't.

I think you fiddled with the basic settings in some way that right now I can't figure out. Could you please tell me which other settings you used for your original findings? Thanks

Once we've got that figured out, we can go back to trying to explain the results.

[starrlamia]

6. Homebirth in Canada

According to this study, homebirth in Canada seems to work quite well:

http://www.cmaj.ca/content/early/2009/08/31/cmaj.081869.short

Quote of the interpretation of the study:

Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetricinterventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.

They also have a long list of things that excludes a mom from a homebirth: no GD, no twins, no breech, no over due-dates, no VBA2C.

On the qualification of the midwives involved:

Midwives are registered by the College of Midwives of British Columbia if they have a baccalaureate degree in midwifery from a Canadian university. If they trained outside of Canada, they are registered by the college after passing written, oral and practicebased exams. Registered midwives are mandated to offer women the choice to deliver in hospital or at home if they meet the eligibility criteria for home birth defined by the college.

So here, midwifery and homebirth seem to work, and work well, but the qualification of the midwives looks to be above the qualification of a CPM / DEM (I might be mistaken about that) and they seem to rigourously enforce criteria concerning the fitness of the mother.

On american HB websites I've read stuff like "Breech is a variant of normal" and VBA2C and HB with twins and "Babies are not library books, they don't come with a due date"....so I kinda suspect these criteria might not be as vigorously enforced in the US as they are in Canada.

can you elaborate a bit on what criteria is not as vigorously enforced (last line) sorry I dont have the time to read the whole thread ATM but I can comment on Canadian midwifery care. Though you quoted about BC, it is the same for the country. 4 years of rigorous training and specific guidelines to follow. No over-due dates, it depends on how over the date it is. It is a bit more complicated then that, but for the most part that is correct.

You also have to understand that ACOG is more of a business then a registry and guiding organization. A lot of the suggestions they come out with and even studies can be quite biased. It is about them and making money, whereas in Canada it is not about money.

I gotta run to work but i will come back and elaborate!

[Kanna]

Originally Posted by starrlamia 

can you elaborate a bit on what criteria is not as vigorously enforced (last line) sorry I dont have the time to read the whole thread ATM but I can comment on Canadian midwifery care. Though you quoted about BC, it is the same for the country. 4 years of rigorous training and specific guidelines to follow. No over-due dates, it depends on how over the date it is. It is a bit more complicated then that, but for the most part that is correct.

You also have to understand that ACOG is more of a business then a registry and guiding organization. A lot of the suggestions they come out with and even studies can be quite biased. It is about them and making money, whereas in Canada it is not about money.

I gotta run to work but i will come back and elaborate!

criteria (probably) not being as vigorously enforced in the US as in a Canada (at least for the purpose for the study):

a long list of things that excludes a mom from a homebirth: no GD, no twins, no breech, no over due-dates, no VBA2C.

What "BC" are you referring to?

Btw, I'm german, so about the only thing I know about ACOG is what the acronym stands for.

Also, if I'm not mistaken, one of the studies here was done in cooperation with NARM, and THEIR members probably are a bit biased on the subject too (since they also depend on their income from attending births)

Still, I think that, even if a study is funded by a certain group, in most cases the findings will be mostly valid regardless. To quote (from an entirely different thread):

Originally Posted by Turquesa 

When you completely discredit a point that somebody is making based on who they are or what their circumstances are, it is a fallacy:

http://www.nizkor.org/features/fallacies/circumstantial-ad-hominem.html

An industry-funded study could, technically speaking, have a solid design and valid conclusions, and even the most wretchedly bigoted anti-Semite could make a true point about vaccine safety.  Of course you consider bias and funding.  But you have to go deeper and evaluate the actual points that somebody is making.  

(taken from page 2 of this thread: http://www.mothering.com/community/forum/thread/1325057/do-you-think-there-is-common-ground-in-vax-discussion-effective-communication-101/20 )

On the other hand "evaluating the actual points someone is making" can be tricky, since our own psychology can get in the way:

http://motherjones.com/politics/2011/03/denial-science-chris-mooney?page=1

Quote: Sure enough, a large number of psychological studies have shown that people respond to scientific or technical evidence in ways that justify their preexisting beliefs. In a classic 1979 experiment , pro- and anti-death penalty advocates were exposed to descriptions of two fake scientific studies: one supporting and one undermining the notion that capital punishment deters violent crime and, in particular, murder. They were also shown detailed methodological critiques of the fake studies—and in a scientific sense, neither study was stronger than the other. Yet in each case, advocates more heavily criticized the study whose conclusions disagreed with their own, while describing the study that was more ideologically congenial as more "convincing."

[MidwifeErika]

Originally Posted by Kanna 

Hi Erika,

I just went back to the Wisconsin to check once more on the basic data, because I after reading your post, I had a "hey....wait a minute...." moment, because I couldn't figure why many doctors would be attending homebirths in the first place, and so I tried to replicate your results....and except for the neonatal mortality / 1000 =1,87 for "other midwives", I couldn't.

I think you fiddled with the basic settings in some way that right now I can't figure out. Could you please tell me which other settings you used for your original findings? Thanks

Once we've got that figured out, we can go back to trying to explain the results.

So, what I did was chose all years, residence for place of birth, full term for age of baby, and then at the bottom you can choose a row or column variable and I chose "attendant at delivery" for a column variable. Then it shows the rate for MD, CNM, Other Midwife, and Other each in a different column.

If you want to see something frightening, go back and remove the "full term" criteria and choose all ages and then the results come out as:

MD: 7.81/1000

CNM: 4.72/1000

Other midwife: 2.89/1000

Other: 10.68/1000

YIKES!!