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Thoughts on "planned home births are associated with double to triple the risk of infant death... - Page 16

post #301 of 394
Quote:
Originally Posted by AlexisT View Post

The risk of rupture in VBAC is low enough, and the probable number of VBACs in that Ontario study low enough, that it doesn't actually say anything about the safety of HBAC. All we know is that it's not so unsafe it can affect the numbers... which we probably already knew, given the existing literature on VBAC. Ontario wasn't taking the highest risk VBACs for birth at home, either. Single lower transverse incision with no other complications. 

 

 

However, when we look at the death/injury rate for VBAC, does anyone know of a study which separates the place of birth? Although the rate of catastrophic uterine rupture is very low, and we understand which risk factors predispose to UR, we are terrible at predicting whether those risk factors will cause a catastrophic UR in any given woman. The NIH report lists outcomes for mother and baby for UR, but these were all hospital births. I suspect that the baby's chance of surviving a catastrophic UR OOH will be 0%.

 

Every birth is a crap shoot. However, we improve the odds of not shooting craps when we make sure that only women in the lowest risk categories, i.e. "no identifiable risk factors" are the women being cared for OOH.

post #302 of 394
Quote:
Originally Posted by erigeron View Post

 

 

I second this question from Serenity Now: "Mwherbs, as a midwife, if it turns out that homebirth increases the risk of neonatal death by 6-8 times like in Oregon, what, if anything, would you do to improve outcomes for your field?"

 

This is a really important question. So far, from this thread, it seems your approach to this data out of Oregon is to try to find reasons it couldn't be true. 

 

I have heard from several midwives I know that the Oregon midwives are reviewing the data and looking for reasons why the conclusions are not true. I agree that it would be better to have them ask, " If this is true, what are we going to do to change it for the better?"

post #303 of 394

Quote:
Originally Posted by mothercat View Post

However, we improve the odds of not shooting craps when we make sure that only women in the lowest risk categories, i.e. "no identifiable risk factors" are the women being cared for OOH.

This conversation has come full circle for me.  When we have been discussing higher risk births and MWs with limited training and experience, I had in the back of my head that some of this just doesn't apply to me and how I make choices about birth. I know I would not have opted for a new MW, even with extensive training. I would not have had twins at home and, although I was AMA when my second was born, I don't think I would be comfortable giving birth at home with many risk factors.  

 

That said, I do understand the caution some may feel about putting limitations on who may choose HB. It just seems like such a challenging situation in several ways. Take VBAC, for instance, it is nearly impossible to find a VBAC doctor in my area so a woman's only choice for VBAC may well be at home. She may even prefer a hospital birth but simply can't find the care she feels is best in that setting.  

 


Quote:
Originally Posted by mothercat View Post

I have heard from several midwives I know that the Oregon midwives are reviewing the data and looking for reasons why the conclusions are not true. I agree that it would be better to have them ask, " If this is true, what are we going to do to change it for the better?"

I can related to feeling frustrated by this. I feel like I see this kind of thing a lot - people looking for information that confirms what they want to be true - rather than just for the fullest picture we have available. I see this both sides of any issue, it seems.  

 

But, I will side a bit with mwherbs on what our obligation is with information that doesn't seem quite right to us. I think MWs should always be continuing to question and learn (as should clients!) but I kind of feel this "what if it is true" challenge is a bit off base for some reason.  

 

I definitely think openness, honesty and the willingness to acknowledge the shortcomings of homebirth are of the utmost importance and I can see legislating any breach of conduct as far as that's concerned. I also support some limitations on what sort of medical care can be practiced at home. Legislating licensure and I like the comment about lay MWs not being allowed to use the term midwife in other parts of the world - I think that's very interesting. Other things too...

 

But,  (and I have not yet read your link) I do wonder about putting limitations on care in the home setting beyond honest, straigforward information about risk and etc. It just seems so problematic to me. What about those with religious objections to hospital birth? Or those without access? What of 

the lost knowledge for how to handle some of these birth scenarios outside of the most advanced hospital interventions? What about those girls who give birth in the bathroom at school? What do we see down the road as we start to have our medical choices for ourselves and our child lay ultimately with the medical establishment and our legislative system?  

 

I'm really talking off the cuff right now so I'm sure I'm wide open to be picked apart. But, that's ok. ;-)  I'm all for making HB as safe as possible and I am not at all opposed to acknoweldging that HB can be safer...I'm just not sure if the end of the road for me is the same as it is for you. And, I guess I also see imporvements in hospital birth options as directly related. 

post #304 of 394

IdentityCrisisMama,

 

I do not want to have hospital birth as the only option. Part of it is that I am a home birth midwife so this is my livelihood, part of it is that I had a home birth myself, and the other part is that I have seen how a good birth can really change women for the better. Some of what is offered at home just can't be duplicated in the hospital. They can come close and I have been in enough hospitals to know that nurses who work in L&D are probably some of the nicest people around.

 

My problem with home birth is that there are midwives who don't fully inform mothers with unbiased information. I have talked with more than one mom who had planned a home birth with a midwife she thought was competent and who was giving her unbiased information. Turns out neither assumption was correct. Frequently the mother is then blamed for not making better choices, but if no one talks about  the facts as have been laid out here, or don't talk about the midwife's reputation, then how are the parents supposed to find this out before something disastrous happens.

 

But, then we need to go back another step and ask why this information is not available to women. Sara Snyder at Safer Midwifery for Michigan is developing a website for families to use as a resource. It includes basics like what should be included in prenatal care, what tests should be offered, "red flags" for  asking more questions and finding out if your midwife's policies for care when the baby and mother develop complications. I would like to see really good informed consents and if discussing risk factors, then pictographs so women have more than one way to process the risks of things like being GBS positive and not having IV antibiotics. There are some really good consents out there, but often enough, the midwife brushes aside the risks and the families trusts her judgement.

 

Safety of birth at home, or at a birth center, depends on the education, knowledge, competence, and skills of the midwife. Every family should have access to the same information that is objective and unbiased as possible. In some cases that information should include the risk of the baby dieing. I don't like the "dead baby card", but parents do need to know that there are times when the baby's death is a real consequence of the choices they make. Whether they can survive that outcome as a family is something only they can answer.
 


Edited by mothercat - 4/17/13 at 5:45am
post #305 of 394

I agree 100% with everything you just said, Mothercat!  

 


Quote:
Originally Posted by mothercat View Post

But, then we need to go back another step and ask why this information is not available to women. Sara Snyder at Safer Midwifery for Michigan is developing a website for families to use as a resource. It includes basics like what should be included in prenatal care, what tests should be offered, "red flags" for  asking more questions and finding out if your midwife's policies for care when the baby and mother develop complications. I would like to see really good informed consents and if discussing risk factors, then pictographs so women have more than one way to process the risks of things like being GBS positive and not having IV antibiotics. There are some really good consents out there, but often enough, the midwife brushes aside the risks and the families trusts her judgement.

 

I like this, especially. This sounds like a wonderful resource!  And, coming from within the midwifery community is wonderful.  

post #306 of 394
I think good peer review associations, along with jointly processing broad data and putting together protocol lists... Are ways to improve outcomes- many of the "rules" were developed from what midwives knew at the time they tried to reform some were extensive like when OMC was in high sway and others were more or less outlines like the protocl list written into Az rule- but static things like az rule that havent been changed and somethings are dated and the midwives who helped to develop them are all older and know why the rules exist but younger ones feel a bit more rebellious so i think that protocols should be something that everyone has invested input on and understands why they would or would not make a certain choice and why their peers would also and step out side those perameters rarely and if so they know why.
I think that some of the births like the twins in Oregon, have been unfortunate losses , it is one year and isnt really a study but a single year sample- since personally i would not do twin births at home because I have no experience and am not young enough to be rallied by boisterous encouragements including multiple youtube videos that show really simple births of all sorts of complicated things with good outcomes. By outlawing breeches and twins in some licensed states or just the 100 + years of attempted prohibition on midwifery is how much of the traditional techniques were lost, As a result we have old midwives like me without those skillsets. The midwives i know who have learned these skill sets, have mostly done so in foreign countries, some,learned in places like Texas or with the Amish....
I certainly havent seen that licensing has truly gotten rid of the ego-driven or the would be liar- peer support - and peer review does have some good effects if the groups are fair enough and medium sized- if it is too rough or too liberal...

My understaning is that the question about intended place of birth has been in existence in Oregon for 5 years atleast but only this one year have the numbers not been parity. So perhaps it is not indicitive of the over all trend, understanding the loss circumstances and if there were things that could have been done differently - like transferring sooner-if that applies or were the mother/babies transferred to a high enough level hospital soon enough? In my state there are hospitals that do not do births at all- if someone transferred to one of those hospitals when a mom is in labor then it is almost useless- if you have a centralized system even the smaller hospitals transfer to the bigger centers where they have round the clock mfms and neonatal intensive care staff that is skilled- so was that system utilized by the midwives? Can it be utilized by the midwives if not licensed? Say something like late decels is detected and if transferred to the RIGHT place would have netted a timely intervention that could save a life but the shuffeling process of one instution and the evaluation there and then the recognition to call in help just makes delays- So not just have a simple transfer plan, but an effective one, does there need to be better outreach and education with transports systems? Both ways- if i have take bp and pulse and....and what really matters is to pick up and go, then lets do that-get your stats in the van- what i see happening sometimes is well we all lumber in and then get oriented, take report or not take report and try to get answers from parents and do vitals make calls back and forth and then go in- even when we have talked with the inhouse OB and they are waiting... Or there is an in house OB but they are waiting for a "back up" to arrive--- so has time been wasted? How were the heart tones taken? Are there other ways to do it that would net better info? For a long time now we have been saying that continous monitoring has only served to increase intervention- but judicous use of continous monitoring may improve outcomes for high risk births-and can be had even in home for special situations or perhaps a different pattern of listening- i have been reading about a different style of intermitent monitoring it would have to be implemented and studied or atleast evaluated. I dont have alot of answers just ways to approach things.

Consumers really need to know that skilled successful experience trumps alot of theory... It is one thing to be supportive and genuinely caring for a mom and another to intergrate skills into that mix, for a growing number of women mainstream care has lost its foundation of benign well meaning care- and it in some ways has brought about a mistrust of any and all conventional providers- if that continues to happen and providers are shown to be more self-serving than useful and supportive there will be more and more experiments in the realm of things we thought were already understood- reinventing the wheel...
post #307 of 394
I agree with you Mothercat in informed concent... And even. Looked at and adopted that vbac, workbook, you recommended.
post #308 of 394

 Thinking more on this...


Quote:

Originally Posted by mothercat View Post

Every birth is a crap shoot. However, we improve the odds of not shooting craps when we make sure that only women in the lowest risk categories, i.e. "no identifiable risk factors" are the women being cared for OOH.

 
Quote:
Originally Posted by mothercat View Post

My problem with home birth is that there are midwives who don't fully inform mothers with unbiased information.

 

When you talk about limiting all but the lowest possible risk factors in the home setting, are you talking about limiting through informed consent? I agree with this!  And perhaps more...  We have touched on some other ways of limiting high-risk HB (though limiting midwifery practice and through legislating the right to choose where to give birth). What are the thoughts on this? 

post #309 of 394
The Ontario study on vbac had over 3000 - the stats on rupture for in hospital is 1 in 200 so there should have been aprox 15.
post #310 of 394

Which study? There were only 6700 births in the entire home birth study. 

post #311 of 394

IdentityCrisisMama

 

There will always be those very rare complications that crop up during labor and  may result in a baby's death. I have one story that illustrates this point very well. Maybe I'll add it later. The only baby I have ever lost.

 

However, we have a really good idea of what things may cause complications, either during the pregnancy or labor. Various state laws regulating midwives, like Colorado's, delineate these. CNMs, because they probably saw at least some of these complications during their clinicals in hospitals, would probably recognize such things right away and consult with the OB or MFM. OOH midwives, who are working only with low risk women may never have seen such things and may not understand the significance of what they are seeing. This is the reasoning for listing in state statute the conditions that require a consult.  I have read through a few of the midwifery laws and it seems obvious to me that those things require another set of eyes with a higher degree of learning than mine. Almost always when I have sent a client for a consult with the MFM, he tells the client that I was correct to be concerned, whether a few extra precautions are needed, call if needed, but go home and have a nice birth.

 

Some of informed consent will be accomplished through women having better access to information. As Sara on Safer Midwifery has blogged, there are red flags in the midwife's language that women should look for. If a woman has a concern, and the midwife brushes it aside, but the woman feels her question wasn't really answered, that is a red flag. I'll try to find that blog post and link it here.

 

I think it is an abrogation of the midwife's responsibility to say that the woman understands the risks involved in her high risk condition and is allowed to choose where and with whom to have her baby. Women believe that if a midwife says she has the knowledge and skills to deal with this complication then she has them. Unfortunately, sometimes the midwife is engaging in wishful management, hoping that she doesn't need to prove she can handle such things, or that she has seen this before and it  turned out well, so this time will also. This is why some legislatures have found it necessary to define what is generally accepted as low risk, "no identifiable risk factors", because there have been too many cases of midwives (and a few doctors) who have taken a big risk OOH and baby or mother, or both have died or been permanently injured.

 

It would be nice to think that all of us as health care providers are altruistic, but in some cases there may also be monetary reasons why midwives keep clients who are high risk. The percentage of women choosing OOH birth has been a steady 1-2 % over decades. If there are more midwives, the pool of potential clients stays the same but each midwife may get fewer clients. The way to increase the number of clients that each midwife sees is to accept those women who may be in denial about their health and pregnancy, or disaffected by the medical system. There is also the issue that is common in the "helping professions" which is to be a rescuer. To see the woman as needing to be saved from the larger medical system. It also doesn't damage the midwife's ego when one of these births turns out well and the woman is singing the midwife's praises. However, that doesn't mean craps couldn't have happened just as easily. That particular roll of the dice (the birth), was just lucky.

post #312 of 394
Quote:
Originally Posted by mothercat View Post

I think it is an abrogation of the midwife's responsibility to say that the woman understands the risks involved in her high risk condition and is allowed to choose where and with whom to have her baby. Women believe that if a midwife says she has the knowledge and skills to deal with this complication then she has them. 

Maybe the disconnect for me with some of this is my assumptions about how things go down when a woman chooses to have a homebirth with some risk factors. I only personally know one woman who had a HB with a high-risk pregnancy. I know that she had to search high (literally, she had to go up in the mountains!) and low for a HB MW to take her case. It was not a situation where MWs were scrambling to take her - to the contrary, I think even the MW who agreed to see her did so reluctantly, believing (correctly so) that this woman would have chosen to birth unassisted w/o the option for midwifery care in the home setting. I assumed that most high-risk homebirths were more the mother vying for that option and not about the MW pushing to continue care. 

 

Honestly, I don't think a MW's job is to do any kind of convincing. 

 

And slightly off track but something I've seen mentioned on this thread - I also don't think it's anyone's place to recommend a birth setting. Providing info is one thing but having an unsolicited opinion on where someone chooses to give birth seems out of place to me. 

post #313 of 394

To add to this discussion is a nice Q&A that was published in the Ottawa, Canada newspaper today explaining home birth in Canada.

 

http://www.ottawacitizen.com/health/family-child/Home+birth+debate+from+settled+leaving+expectant/8249097/story.html

 

This is just one quote that I found:

 

"In Canada the profession of midwifery is tightly controlled in terms of maintenance of competence — as opposed to other countries where there is less control and where one may end up with a midwife who may be deviating from the accepted standard of care.

Many midwives in Canada have established a mutually respectful relationship with obstetricians. They know when to ask for help and if there are unexpected acute problems, they are quick to hand over care to those more skilled in reducing the risks of fatal outcomes."

post #314 of 394

I realize that midwives may be caught in a situation where it's "provide care or see something worse happen," but by attending high risk cases they continue to give the impression to would-be clients that these scenarios are acceptable before the fact and contribute to wrong impressions about appropriate care. Regulations remove that burden from the midwife--"well, I found webpages from these other midwives that say it's okay." And on top of that, there are differences of opinion about what is safe, so while in one place, the culture may be against risky cases, in another it is pro. Where I live now, it would not be easy to find a midwife to take me for an HBAC. I know places where this wouldn't be true at all and where my hypertension might even be shrugged off. I know someone who wanted a home birth of twins. She interviewed several midwives and was shocked to find that some were completely unhesitant about the idea, despite only attending one or two births of twins. 

 

It's part of a midwife's professional duty to recommend options. Health care isn't just about laying out options and treating all options as equal and neutral. Health care providers are trained to have opinions. My thinking comes from the other end of the spectrum, having been through high risk pregnancies, but I certainly think it was my OB and MFM's job to recommend a course of action. I could take their advice or not--it isn't their job to force me--but they would have been shirking responsibility not to do it. And if I had chosen a course of action they thought was unsupportably risky, they would have been well within their rights to refuse to continue to care for me. In the end, they would have been the ones held responsible if it had gone wrong. 

post #315 of 394

"In the end, they would have been the ones held responsible if it had gone wrong."

 

I have seen some midwives advocating the position that by having a homebirth the parents are assuming responsibility for the outcome and she is merely there to assist them reaching the outcome they desire.

 

I'm interested in whether that is ever an ethical position for a healthcare provider to take?   Could a doctor ever disclaim responsibility for a surgery he performed on the same basis?

post #316 of 394
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post #317 of 394
Quote:
Originally Posted by AlexisT View Post

I realize that midwives may be caught in a situation where it's "provide care or see something worse happen," but by attending high risk cases they continue to give the impression to would-be clients that these scenarios are acceptable before the fact and contribute to wrong impressions about appropriate care. Regulations remove that burden from the midwife--"well, I found webpages from these other midwives that say it's okay." 

I agree with this and it's not that I oppose restrictions on HB care in terms of risk factors. BUT, I do think it's better if that is handled from the perspective of informed consent because that's so much less complicated.  As you point out, what is a risk factor is somewhat tricky and subjective. I'd love to see a group of HB MWs establish risk, forw instance, over OBs. Where I really wigged out on this thread was when I thought we were talking about legislating prenatal/birth choice from the side of the mother.  I just do not see this turning out well.at.all.  I'd MUCH rather see heavy restrictions on midwives before we start dictating the type of care a mother must avail herself of. Because that issue stretches way beyond HB into territory that would make me very nervous.

 

I do see some complications with limiting HB risk factors (like the end of VBAC all together) but I'm open to legislating that. Not that I have a say. ;-)  

post #318 of 394

Most healthcare providers take responsibility for the outcomes of care they provide. I am a healthcare provider myself and ethically by the terms of my profession I could never get away with saying that my patients use my treatment and advice at their own risk, nor would I want to take this stand even if my licensing body would back me up. I am the one with the knowledge in my field; my patients shouldn't be expected to have as much knowledge as I do, and even though they do make their own personal decisions based on whatever knowledge they have/acquire, that doesn't mean I'm not responsible for the care I provide. Some HB midwives take the opposite stand, saying that they aren't health care providers, they're providing assistance but the responsibility for the outcome of birth ultimately lies with the parents. I interviewed with a group of HB midwives but did not use them, and the fact that they took this stand was one of the reasons. 

post #319 of 394
We have had paternalism for a very long time. As long as the majority feels like that is acceptable there will be no real tort reform and no true informed consent honored. I do know midwives who act the same way doctors do in that they have a way they always practice and only give nod to true informed concent. look at that Flordia case where the doctor felt his view was so correct that he call the police on the mom who went home to make arraingements for her family in stead of just having an immideate 5 th c-section. That there a so many c-sections not truly related to the best outcome of mother or baby or future childbearing but to a physician's comfort- physicians as a whole with obviously very poor peer advice- at this point in time.
It should be shared responsibility . And there are no easy paths to get there and get it right. I think that Bryne Potter who put together that computerized charting has a grasp on that idea, and link to references and data for the informed consent- clients already use the internet and cross reference what you recommend or are saying, but this way if there are any good links on a subject you can direct that to a degree .
What i find is that women come to me with their minds made up about most things, and if I am offering a more conventional medical thing like vitamin K- i am going to either end with my advice not followed or with parents who will compromise and use oral vit K - and i feel that there are no good well done articles to even touch on all the details- misinformation abounds on this subject by conventional as well as alternative sources. So if parents do choose to not give vit K i am looking a bit more carefully, palpating an abdomen, the liver and spleen, looking at how long jaundice remains, looking at bms.... A whole list of things and i say if you see any funny blood spots or bruising or get diarrhea, take antibiotics you may want to revisit giving vit k, i could still end up with a baby that is harmed. Is that my fault?
post #320 of 394

"We have had paternalism for a very long time."

 

Can I say that I find the way midwifery attempts to appropriate the feminist position to be rather off-putting?  Are you really a feminist, really "with women" if you are letting their babies die at a much higher rate than in hospital? 

 

Talking about informed consent -- how many Oregon homebirth midwives will be including Ms. Rooks' numbers in their informed consent discussions with patients do you think?

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