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post #181 of 394
Canadian midwives when they were included in that study were still CPMs and that is why they entered their own data into the data base Mothercat.

So the thing is that breeches and twins are higher risk both no matter which way the babies are born, c- section or vaginal births. For twins the majority are born via c-section before term and they have a very high death rate- also once you get a set of very small numbers it is hard to say if it is artifically high or low or even a clear trend.
The 34 week stuff may have been a local thing- but i am sure I had read some older recommendations- now that there are plenty of studies saying better off later up to a point 38 weeks is when unexpected stillbirths are an increased incidence so not really waiting that late.
There are religious midwives who do nothing other than pray, and religious sects in Oregon, Washington, and Idaho that I know of that refuse medical care completely or try to avoid it- if these families had babies in Oregon during this one year ... In any case we should really look at each case and figure out if there were avoidable cause deaths and what we could do if anything to change the outcomes.
As for religious midwives- Brenda Is religious in her calling and should not be persicuted but she is not a pray only midwife she has skills. The state of California has decided to go after her who knows why because they can and probably did a birth on some doc's turf that felt territorial the charges dont have to do with a bad outcome case... i think that faith gibson was charged similary in the past but set free because of religious exemption.


I have seen some more recent trends in out of hospital birth, like women with primary health issues that are medically controlled and so moms think that there is really nothing wrong with their health and so persue s home birth if turned away by a midwife or midwives she will continue to seek out the home birth experience and may birth UC- now I do think that a mom has a right to give birth where ever with who ever she chooses if they choose to participate with her but these are genuinely high risk situations and alter the mortality and morbidity rates.
post #182 of 394

If twins were included in that hospital data set, if anything they would make the hospital death rate worse, not better. So if it's as low as it is even including twins, that's a point in favor of the hospital over CPM care. We still don't have a clear answer on whether the twins were included in the hospital data. And this is not a thread about proper obstetric care of twin pregnancies so I, for one, would prefer if we didn't get dragged off in that direction. 

 

I agree that when we are dealing with a small number of cases it's worth examining each one, but I don't think we should be dismissing the deaths just because it's a small number. 

post #183 of 394

Since each province individually regulates midwifery it's inaccurate to say "Canadian midwives were still CPMs." Midwifery has been regulated in different provinces at different times. Ontario regulated in the early '90s. NS and SK only regulated within the past few years, and the Yukon and PEI still have no regulation at all. 

 

The CPM is not recognized in Canada and has never been part of the official regulations as far as I am aware. Prior to the introduction of university based midwifery education in Canada, Canadian midwives were educated through a variety of routes, AIUI. 

 

From everything I have heard about midwifery in Oregon, and the stories of women whose babies have died, I do not believe religious sects are a significant factor in their outcomes. The bulk of Oregon midwives appear to be practicing in cities and towns in the Willamette Valley with some on the coast, not in isolated rural areas, either. 

post #184 of 394

I have participated in MANA stats since 2002 and I am a CNM. Peggy Gardner who was, and may still be, the director of research for MANA is also a CNM.  I know several other CNMs who also do home birth or birth center and have used MANA stats. This means that although the majority of midwives contributing stats to the MANA stats project (Johnson and Davis) were CPMs, by no means were all of them.

Same goes for the current birth center study (Stapleton, et al, 2013). About 80 % of the contributing birth centers are CNM practices, the remaining 20 % of birth centers were either CPM alone or mixed CPM and CNM practices.

 

I would need to go back to check Johnson and Davis, but I don't think they separated out the stats between DEM, LM, CPM, CNM. Stapleton didn't either, her team just mentioned that that was who contributed.

 

mwherbs: I think it would be really helpful to the discussion if you could cite sources for the statements you are adding to this discussion. That way if someone wants to do further research on that statement they will know exactly where to find the information.
 

 

And to all that would like more information from Judith Rooks, she has said that I can send her additional questions and she will do her best to answer them.

post #185 of 394

There are a lot of topics of discussion that have arisen in this thread -  (thank you to the moderator for your work keeping it on track!) - I hope some of these tangential topics become their own threads so we can discuss specific details more thoroughly.

 

In keeping with the question originally posted by the OP - is there an increased risk of neonatal death with OOH - it's apparent that there are many factors that contribute to OOH birth safety.

 

Is it the provider? Is it the location? Is it the risk-status of the woman giving birth? I would argue that even the most skilled obstetrician could not save a baby or mother in certain situations in an out-of-hospital setting (uterine rupture, cord prolapse, vasa previa). It seems to me that it is not just one factor that makes OOH birth safe or risky.

 

I'm a strong advocate of not intervening during labor when it is not necessary. But I have to admit there are benefits to having a staffed and skilled hospital team when the poop hits the fan at a birth. In those rare instances, that team of professionals can ensure swift delivery of an infant and extensive resuscitation and life support if need be. Sometimes, these interventions save lives. Some of these situations occurring OOH (uterine rupture, vasa previa, prolapsed cord) would probably result in mothers and babies not faring as well. In these emergency situations, I cannot see how an OOH birth is protective in any way.

 

Does this mean we move all birth to high-tech environments where 24/7 immediate surgical capabilities are available? Some believe that is the answer. I do not. But I believe in interest of informed consent, women need to have all the information regarding how much risk they are taking when they choose to give birth OOH.

 

I also believe the profession of midwifery has the responsibility of knowing which circumstances, practices and factors contribute to the safest and healthiest outcomes in OOH birth.

 

I know many non-midwives are interested in the MANA data. Midwives need this data as well. Knowing what increases the risk of harm and what decreases the risk of harm should be the evidence that guides professional midwifery practice.

post #186 of 394
Quote:
Originally Posted by krst234 View Post
I'm a strong advocate of not intervening during labor when it is not necessary. But I have to admit there are benefits to having a staffed and skilled hospital team when the poop hits the fan at a birth. In those rare instances, that team of professionals can ensure swift delivery of an infant and extensive resuscitation and life support if need be. Sometimes, these interventions save lives. Some of these situations occurring OOH (uterine rupture, vasa previa, prolapsed cord) would probably result in mothers and babies not faring as well. In these emergency situations, I cannot see how an OOH birth is protective in any way.

 

I agree that having access to hospital equipment and staff is a good thing, but it's important to remember that there are some hospitals where the technology is being applied inappropriately, raising the risk of certain types of emergencies, so some of those babies and mothers who are "saved" because they were in a hospital were only in danger in the first place because of the practices used in their hospital.  Also, hospital birth often comes with a higher risk of infection, drug mixups, etc...  So, depending on the available hospital, available midwives, the logistics of transferring to hospital, and the mother's particular circumstances (for example drug allergies), OOH birth can offer protection against a variety of potential problems.

post #187 of 394

"Knowing what increases the risk of harm and what decreases the risk of harm should be the evidence that guides professional midwifery practice."

 

Isn't the UK's Birthplace Study fairly good evidence on what decreases risk of harm?  I have viewed that study with a fairly skeptical eye (because I think it springs out of a policy in the UK that is about saving money -- one of the most idiotic places to try and save money being, of course, maternity services) but it seems to have withstood a fair bit of scrutiny. 

 

Isn't the real problem not lack of knowledge but rather that many midwives in the United States don't want to practice within the parameters described in the Birthplace Study?

post #188 of 394

There's a great movie to watch called "The Business of Being Born" that even shows that midwives are better than hospitals and doctors. There are more C-sectoins than at home births and the U.S. infant death rate is higher than a large portion of the industrial and developed world. The reason is because of all the drugs they use to "speed up" birthing when in all actuality they simply slow things and make it so there are complications where mothers have no choice other than to give birth by C-section. No offense meant to any doctors, but I'm planning on having my kids at home with a midwife. ^^ And I look forward to it. This movie even showed that, yes birth is painful, but not nearly as painful as what it is in hospitals because you can get up and move around and be comfortable and without all the drugs. So I can definitely agree with any midwife here or mother that has had a wonderful experience with a midwife on here about the name of that supposed study.

 

Not to mention, that study was probably funded by hospitals which means the researchers are going to conclude in favor of the hospitals.

 

Keep in mind though, there are some midwives that are inexperienced or have not received the right training. But if you do your research and look for those who do have the experience and have received the proper training, you'll be more than likely to have a good experience.

post #189 of 394
Quote:
Isn't the real problem not lack of knowledge but rather that many midwives in the United States don't want to practice within the parameters described in the Birthplace Study?

 

I cannot say. I know midwives who do not want to operate within certain parameters - but I do not know why. I think data from US midwifery practices - from CPMs practicing in legal as well as illegal states - would be very telling. I know the goal of MANAstats is to "demonstrate the safety of midwifery" or something- but I think their goals are mixed up. That is not why a profession collects data - data should be collected to in order to assess the outcomes and safety of practices.

 

I believe a few decades ago anesthesiology went through a big change in practices - because patient outcomes weren't so good. They made changes, on a professional level - and patients fared better.

 

I just read an article about how NRP is revising its recommendation for resuscitation with 100% oxygen at birth. They collected data, found evidence that routine practices were causing harm, and now they are making steps and recommendations to change these practices.

 

Midwifery should be no different. Data should be collected not to prove something that people already believe to be true, but to provide information so improvements can be made.

post #190 of 394
Quote:
Originally Posted by fuyuumesan View Post

There's a great movie to watch called "The Business of Being Born" that even shows that midwives are better than hospitals and doctors. There are more C-sectoins than at home births and the U.S. infant death rate is higher than a large portion of the industrial and developed world. The reason is because of all the drugs they use to "speed up" birthing when in all actuality they simply slow things and make it so there are complications where mothers have no choice other than to give birth by C-section. No offense meant to any doctors, but I'm planning on having my kids at home with a midwife. ^^ And I look forward to it. This movie even showed that, yes birth is painful, but not nearly as painful as what it is in hospitals because you can get up and move around and be comfortable and without all the drugs. So I can definitely agree with any midwife here or mother that has had a wonderful experience with a midwife on here about the name of that supposed study.

 

Not to mention, that study was probably funded by hospitals which means the researchers are going to conclude in favor of the hospitals.

 

Keep in mind though, there are some midwives that are inexperienced or have not received the right training. But if you do your research and look for those who do have the experience and have received the proper training, you'll be more than likely to have a good experience.

 

I started this thread on that movie: http://www.mothering.com/community/t/1375938/the-business-of-being-born

 

I couldn't stand it. 

 

I fully support anyone who chooses a home birth just please don't base it on that movie. 

post #191 of 394

I liked the movie but I do not believe watching it was a good way to make a choice about where to give birth. I was watching it as a woman with 2 homebirths and 2 unplanned hospital births under my belt. I thought it was good as a conversation starter, but it seems like I keep seeing women who choose homebirth based on that and nothing else. 

 

Eta: and I must say having read both Cara's book and watched this movie, I would never hire her to attend my birth.

post #192 of 394
Quote:
Originally Posted by fruitfulmomma View Post

I liked the movie but I do not believe watching it was a good way to make a choice about where to give birth.

I also watched as someone who had already planned a HB (transfer) and deciding and researching the choice for the second time. I didn't care for it myself. 

 

Quote:
Originally Posted by fruitfulmomma View Post
I thought it was good as a conversation starter, but it seems like I keep seeing women who choose homebirth based on that and nothing else. 

 

I know it can seem that way sometimes but I wonder about that...  I mean, you eventually end up with a MW even if all the research you've done is BOBB, which I agree is not enough to make an informed choice. I realize that there are some inferior MW's out there (perhaps more than I once thought?) but all three MW's that I've seen have extensive libraries and encourage their clients to research. 

post #193 of 394
Quote:
Originally Posted by fuyuumesan View Post

Not to mention, that study was probably funded by hospitals which means the researchers are going to conclude in favor of the hospitals.

 

 

 

I don't know if you read the whole thread, but the study that has been discussed in the last few pages of the thread was not funded by hospitals. Not sure which study you're talking about here.

 

I do hope there are more C-sections in hospitals than at home. I really hope nobody is trying to do C-sections at home. winky.gif

 

Welcome to MDC!

post #194 of 394
Quote:
Originally Posted by rachelsmama View Post

Quote:
Originally Posted by krst234 View Post
I'm a strong advocate of not intervening during labor when it is not necessary. But I have to admit there are benefits to having a staffed and skilled hospital team when the poop hits the fan at a birth. In those rare instances, that team of professionals can ensure swift delivery of an infant and extensive resuscitation and life support if need be. Sometimes, these interventions save lives. Some of these situations occurring OOH (uterine rupture, vasa previa, prolapsed cord) would probably result in mothers and babies not faring as well. In these emergency situations, I cannot see how an OOH birth is protective in any way.

 

I agree that having access to hospital equipment and staff is a good thing, but it's important to remember that there are some hospitals where the technology is being applied inappropriately, raising the risk of certain types of emergencies, so some of those babies and mothers who are "saved" because they were in a hospital were only in danger in the first place because of the practices used in their hospital.  Also, hospital birth often comes with a higher risk of infection, drug mixups, etc...  So, depending on the available hospital, available midwives, the logistics of transferring to hospital, and the mother's particular circumstances (for example drug allergies), OOH birth can offer protection against a variety of potential problems.

 

What helps mothers (and fathers) make intelligent decisions about birth is solid data, backed by statistical analysis.  It's not clear to me how statements like "some of those babies and mothers who are "saved" because they were in a hospital were only in danger in the first place because of the practices used in their hospital" moves the conversation forward in any way:  it's scare-mongering, and worse, scare-mongering that isn't backed by even a shred of data.  Here are some other statements that are probably true:

 

-"Some midwives are addicted to methamphetamines."

-"Some doctors have robbed banks."

-"Some midwives don't recognize the signs of fetal distress."

-"Some doctors dislike children."

 

But none of those statements actually helps a mother or father make a rational decision because they're just an anecdotal discussion of an outlier.

 

On a more personal note, I guarantee you that your use of derision quotes around the word "saved" is hurtful both to parents whose children would not be alive but for medical technology, and to parents whose children didn't make it.  Please consider your audience.  And this should also serve as a reminder as to why some of us think it's extremely important to have actual data, as opposed to emotional anecdotes, backing our medical decisions: because that's part of informed consent.  If you show me data proving that outcomes are better for parents who let their births by assisted by wolves, and I'll be calling my local zoo tomorrow asking if we can borrow a canis lupus.  But as long as this discussion remains at the level of "Oh, midwives are terrible because they're all crunchy granola hippies" or "OBs are bad because they just want to play golf while ignoring your baby" it will never help anyone.

 

In short:  the data matters more than your opinion.  The data matters more than my opinion.  The data is what matters.  This thread is (if I understand IdentityCrisis Mama's point) about discussing the data.  Let's try to shed more light on that data, not cover it up with the fog of vague insinuations.


Edited by SympatheticDad - 3/21/13 at 5:58am
post #195 of 394

"In short:  the data matters more than your opinion.  The data matters more than my opinion.  The data is what matters.  This thread is (if I understand IdentityCrisis Mama's point) about discussing the data.  Let's try to shed more light on that data, not cover it up with the fog of vague insinuations."

 

You know, I think birth is uniquely difficult on this point.  There is so much cultural baggage with birth that discussions become much more fraught with expectations of how things "should" be than, for example, discussions having to do with appropriate treatments for kidney disease.

 

As a feminist myself, I have found the cultural expectations re: birth (as disussed ad nauseum on the interwebz) to be one of the least female friendly experiences I've ever had.

post #196 of 394
Quote:
Originally Posted by Buzzbuzz View Post

"Knowing what increases the risk of harm and what decreases the risk of harm should be the evidence that guides professional midwifery practice."

 

Isn't the UK's Birthplace Study fairly good evidence on what decreases risk of harm?  I have viewed that study with a fairly skeptical eye (because I think it springs out of a policy in the UK that is about saving money -- one of the most idiotic places to try and save money being, of course, maternity services) but it seems to have withstood a fair bit of scrutiny. 

 

Isn't the real problem not lack of knowledge but rather that many midwives in the United States don't want to practice within the parameters described in the Birthplace Study?

 

Yes and no--there's an unholy marriage of cost cutting and ideology in parts of the NHS and RCM--see also guidelines and targets about "normal" birth and previous proposals by the RCM to charge for epidural. However, actually funding a real home birth system is not as cheap as people think it is. It requires more midwives (which, several years ago when a 10% home birth target was mooted, the then Health Secretary said the government was not going to fund), and you can't simply shift them off hospital units, and it runs smack into other policies about consolidating units because units with >3000 births a year have better outcomes, and you need to be within a certain distance of said unit for home birth to be safe and.... So they talk a lot of talk, and the Birthplace study does come within that, but one of the great disappointments for women is how it works in practice. There aren't enough midwives now, and women aren't even getting 1:1 care in labor in hospital, so funding enough midwives to do it at home won't happen. 

 

I need to find the official criteria that were used for Birthplace (I read it when it came out but can't remember now) but again there is a gap between theory and reality when it comes to midwifery care on the NHS. The official criteria used (I know my trust's criteria, which have not changed since I gave birth 6 years ago, and I believe they are typical) are extremely strict. If I had stayed in the UK for my 2nd, I would have been risked out six ways from Sunday. In practice, though, not all midwives apply the criteria equally strictly. A scenario I have seen multiple times on message boards is, "I want a VBAC but the consultant says I have to give birth in the CU!" (Official guideline for VBACs is that they are consultant led and should birth in CU with EFM offered, though midwives will typically provide most care if the only issue is previous CS.) Inevitably, someone will reply saying this is nonsense, the person should insist on giving birth in an MLU or at home, and sometimes it works. In reality, in some trusts, the true stumbling block for me would not be my previous CS, or obesity (BMI >35 is CLC) but being on antihypertensives. I could get them to ignore the other things if I stomped enough (which I wouldn't). And it is possible to simply pull the ultimate gamble, refuse to go to hospital, and try to force them to send a midwife (there are organizations that will advise you to do so, too). 

 

The entire structure of the NHS under which the midwives operate is alien to US midwives, even CNMs, who are used to being more independent providers. NHS midwives do everything from home births to community midwifery to what we would consider obstetrical and postpartum nursing. It is, ideally, supposed to be a collaborative system in which women can be transferred up or down the levels of care if needed. We don't have anything resembling that structure here, nor the guidelines that hospitals and NHS trusts write to govern practice. 

post #197 of 394
Quote:
Originally Posted by SympatheticDad View Post

I'm responding to your post SympatheticDad to say that I think you really misinterpreted the post you were referring to. While this thread is mostly about the data, I think a large part of Rachelsmama's post (when taken as part of her entire contribution to this thread) had a lot to do with how we apply data to our own personal situations, which is relevant. 

 

For instance, transfer time (a big difference to live walking distance to a good hospital than living a three hour drive away), your hospital's record, the climate for transfer care in your area (a huge issue as far as I am concerned!), your personal risk factors (do you have none according to everyone's standards or do you have few according to a MW willing to take high-risk clients?), what testing you have used or not used...and on and on. A responsible choice-maker will take the data and fit that data to their situation and come up with the best choice they can with the information they have available. 

 

So the data (which, if it is so important to you, you are welcome to discuss!) is important but it factors into personal decisions uniquely for all of us. Of course if the safety records were dismal, we would be having a very different conversation but it seems like maybe we've hit a road block where we've looked at what's available, recognized their value and short comings and have kind of circled around.  

post #198 of 394
Quote:
Originally Posted by Buzzbuzz View Post

As a feminist myself, I have found the cultural expectations re: birth (as disussed ad nauseum on the interwebz) to be one of the least female friendly experiences I've ever had.

I think this is getting OT again but a good topic for discussion. Please post a spin-off in the general birth forum if you want to discuss this topic. 

post #199 of 394
I have had emergency transfers that i would have transfered in private car had I known it would take so long. The worst was 5 min from the hospital- they got lost and parked in the middle of the intersection about 1 block away when they finally got close enough- GPS failure maybe i dont know, anyway I saw the flashing lights and went out and yell down the street to them- then they unpacked and were very disorganized- wanted to stand around-

The thing is that with c-sections 1/3 of the births in the country and ACOG projecting it to be 50% c-section rate in the future . The centralized systems we have now will not be doing moms and babies any favors no matter their intended birth place. . So we already think of rupture and some of them will be before labor, the actual greater risk is abruption and that the risk increases with each repeat c- section- so we had better be thinking about how to have better and more informed transport/transfer systems not just for the benefit of homebirth but for all who live 30 minutes travel from a hospital , let alone a hospital that can manage their situation.
Do i think home birth stats could br better probably, but i also think that the birth place study mentioned above although dated, has some good core ideas and premises even the structure- The medical system has made some decisions - like c-section is better for certain high risk birth like twins or breeches. The numbers i got on twin births was from the CDC Wonder pages- i looked at one year - it gave me the approximate number of twin births - attributed all the late preterm twin births to c-sections. And it gave me the over all twin death rate/ 1000- which is a high death rate at 47/1000 this is the hospital death rate- That amounts to about 1 in 25- So my questions how many twin homebirths in Oregon ? Were there any losses? And were they included in Judith's research? If so how many hospital twin births were included in that same research? And what was the loss rate- lets compare apples to apples- And I would have teh same questions for breech birth- i havent looked it up on the wonder pages but will- but as i understand it they also constitute a higher risk that vertex. I am not aiming at saying we shuld forbid these types of birth ooh- only that the risks be taken into consideration and how the approach to the risks are managed differently-
post #200 of 394

I really have no understanding on the numbers you are getting. 

 

I'm looking at CDC wonder that shows results in 2008 for twins born in the United States.

 

At 36 weeks, the rate is 4.35 per 1,000 for c-section and 4.87 for vaginal birth.  At 37 weeks, 5.53 per 1000 for vaginal and 4.13 per 1,000 for c-section.  At 38 weeks, its 5.54 per 1000 for vaginal and 4.51 per 1000 for c-section, etc., etc.

 

This is for all births, regardless of attendant.

 

How are you getting 47 per 1000? 

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