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Thoughts on "planned home births are associated with double to triple the risk of infant death... - Page 19

post #361 of 394
So what about the women who leave medical care to seek out a home birth alternative? Hasnt that already been done? Where the physician or CNM has already given mom/family the risks and she has sought out another way.
I think that the English method sounds good, i also dont see that happening anytime soon here. Actually when i was younger doctors would interact with our clients much more freely and it wasnt such a hard thing to accomplish . But then again those docs probably had done some home births or were trained by docs who had done homebirths, could do some diagnosis with hand skills, including diagnosing a breech without an ultrasound... And even until recently we had less hostility in the hospitals, but the ACOG position on home birth since the WAX paper has made for a great deal of building hostility - when clients are treated rudely or with an attitude, they are less inclined to even hear a message that may be specific to them, more often we have been finding that every situation is an opportunity to disaprove of home birth- with that kind of prepackaged message ( that if not delivered, BTW, ACOG is suggesting the doc should be peer reviewed, fined and punished in any other way possible) you end up with patients just ignoring their imput, even when it may be truley the best advice.

A friend of mine while working in Washington state, attempted a vaginal breech birth at home with for a couple who had been in ob care and transfered to her- the doctor she was seeing had no vaginal breech delivery skills and so never offers it as a possibility, the baby was a complete breech but labor did not bring the baby down timely or simply so they transfered in and had a csection- the baby wasnt compromised or sick for even one day and the mom was fine- doctor made a complaint that went all the way thru to court- the result, that it is reasonable to have an alternative , and that it is legal in the state of Washington for midwives to assist in Select breech deliveries. The primary state organization of midwives did not change their protocols to include this legal ability /option because as a group they have decided to not offer this- so here you even have a rather large group of midwives that have decided to not practice to what is legally allowed but to their own comfort level . Many states allow for breeches vbac and twins, those are all increased risk births at home or in the hospital you will find many midwives who will not do these births and some who will, not every midwife willing to attend these births has the skill set to do so - advice on breech birth written by Mary Cronk an English midwife is very straight forward - she is selective about the breech births she will attend at home, so the primary skill sets have to do with recognizing what is usual and normal when something is abnormal and what to do, that is where experience comes into play, either to transfer timely, or to manage a complexity when it occurs because you already have experience and a good idea of what to do and how to do it- "hands off the breech" is for when everything is going textbook- hands on skills are for when things are not textbook. I have a retired midwife neighbor who has alot of experience with both twins and breech births- one day she would tell me an important detail, and another time she may say something very different- because she is thinking about what worked for particular births-



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post #362 of 394

Judith Rooks wrote a guest piece for today's Safer Midwifery for Michigan blog. She explains how midwifery education in the US compares with other midwifery education programs around the world. From what she is writing, the CNM and CM programs are comparable to how European midwives are educated. The only other midwifery program that is comparable is at Basytr (formerly Seattle School of Midwifery) which uses the educational model that the Netherlands uses.

 

Ms. Rooks does explain that it is extremely difficult for women to know how the midwife's education will affect her competency and decision making and that this is why licensing and regulation such as every other first world country has is necessary to protect mothers and babies here in the US.

 

Here's the link to the article.http://safermidwiferyformichigan.blogspot.com/2013/04/the-education-of-midwives-around-world_29.html

 

I think Safer Midwifery plans to discuss the education offered through MEAC approved schools in the near future.

post #363 of 394

I find her view in the article that the PEP method of midwifery training was intended only as "transitional" to be fascinating. 

 

I wonder what the breakdown is between MEAC trained and PEP midwives in the CPM population currently?  It would also be interesting to see whether the breakdown has changed over time.

 

I get the feeling that the goal of MANA, etc. is to make becoming a midwife as accessible as possible.  I'm not sure how wise that really is.  Ideally, positions that carry significant responsibility should have some barriers to entry.

post #364 of 394
Quote:
Originally Posted by Buzzbuzz View Post

I find her view in the article that the PEP method of midwifery training was intended only as "transitional" to be fascinating. 

 

I wonder what the breakdown is between MEAC trained and PEP midwives in the CPM population currently?  It would also be interesting to see whether the breakdown has changed over time.

 

I get the feeling that the goal of MANA, etc. is to make becoming a midwife as accessible as possible.  I'm not sure how wise that really is.  Ideally, positions that carry significant responsibility should have some barriers to entry.

 

I am pretty sure that in Michigan (my state) there are not any CPMs who have attended a MEAC school. And, we have quite a few CPMs and DEMs in this state. MANA and NARM have stated in the past the % of CPMs who have some college education or have completed a degree. However, the majority of them do not have classes specific to the health sciences. The last version of the new Indiana CPM  bill grants them certification, but not licensure. However, they also need to complete a health science  associate's degree or become an RN to obtain that certification. The designation in Indiana will be CDEM, and to practice a sa CDEM, the midwife will need to be certified and registered.

post #365 of 394

i am pretty sure the majority of students in my state for the last 5 years maybe more have primarily been students of schools. 

I am not sure that schools actually will turn out the same type of study midwifery for life students. What you have to think about is that women who will not do self study or are not good at it but can go and have information fed to them- like they were trained to do via school systems in general - are probably not going to be life long learners . then you have to keep raising the education bar because they wont do it themselves...   and you can see by the way that ACNM changed to controlled CEUs or the option of retesting every go round cuz they needed to enforce quality continuing ed. of course it makes for a great deal of mono-culture and adopting trends that may have been supported by studies that were not completely thought out- like active management for all... 

post #366 of 394
Wow, so CPMs just don't need continuing education since they are natural "lifelong learners"?
post #367 of 394

And they don't need evidence-based medicine either because it doesn't matter if there is evidence for a particular technique, what matters is that it is "thought out" (whatever that means)?

post #368 of 394
There are fads and trends in evidence.. The more recent evidence has been against active management. Just like the past "evidence" supporting that epidurals dont change the c-section rate.
. And no I am not saying that we dont need ceus but there is a different beginning mind set, for people who will not and do not do selfstudy.
post #369 of 394
Quote:
Originally Posted by mwherbs View Post

There are fads and trends in evidence.. The more recent evidence has been against active management. Just like the past "evidence" supporting that epidurals dont change the c-section rate.
. And no I am not saying that we dont need ceus but there is a different beginning mind set, for people who will not and do not do selfstudy.

Formal education does not preclude self-study. In fact, it requires it.
post #370 of 394

So a provider should look at a variety of evidence and compare different studies, their strengths and weaknesses, try to account for discrepancies... and/or consult consensus documents, which are written by experts in the field who have done this sort of analysis. Not dismiss stuff they don't like as a fad or a trend and keep doing what seems "thought-out". Not lean on one or two studies that show what they like while ignoring others that don't.

 

Also, evidence-based medicine sometimes shows that things that seem logical are not actually a good idea. An example from my field is that beta-blockers, which slow the heart rate, don't sound like they make sense for heart failure patients--the drug would make it harder for their hearts to do the work they need to, so it would seem "thought-out" that these drugs would be a bad choice for them. But in fact studies show that beta-blockers improve long-term survival in these patients. 

post #371 of 394

This article is not about the evidence part of the discussion. It is about the difficulty for women and families in general to know the qualifications of the midwife they choose and how she will react when complications occur. Yes, the people who wrote this blog piece are attorneys, but they are not soliciting, they are simply talking about a friend who chose to birth at home.

 

http://www.consoleandhollawell.com/law-blog/the-terrifying-side-of-trendy-are-home-births-safe

post #372 of 394

Assuming his story is the way it really played out, she should have been arrested and charged with two counts if manslaughter.

post #373 of 394
Quote:
Originally Posted by mothercat View Post

This article is not about the evidence part of the discussion. It is about the difficulty for women and families in general to know the qualifications of the midwife they choose and how she will react when complications occur. Yes, the people who wrote this blog piece are attorneys, but they are not soliciting, they are simply talking about a friend who chose to birth at home.

 

http://www.consoleandhollawell.com/law-blog/the-terrifying-side-of-trendy-are-home-births-safe

 

Posts like this remind me of the things we read all over the internet about how co-sleeping led to this death or a SIDS death is blamed on co-sleeping (which, in & of itself, is wrong because a SIDS death is an unexplained death & something like being suffocated between couch cushions is not "unexplained.").  There's no talk of how to co-sleep safely or avoiding the risk factors for SIDS.  

 

I'd have much more respect for this blog post had they included ways to avoid the potential for a midwife who does what this one *apparently* did.  I'd have more respect for it if they allowed comments.  I'd have more respect if they didn't make it sound like if you have a baby in the hospital that you will avoid all risk that is inherent in birth.  The author seems to think moms who choose OOH birth are only wishing to avoid the "ambiance." Um, no.  Much bigger things that the ambiance is what I was looking to avoid & I don't think that's the biggest of most moms-to-be's concerns.  

 

Seems like another way to try to scare moms into the hospital.  Much like the scare tactics of anti-cosleeping campaigns.

 

Sus

post #374 of 394

I am adding this as the newest Dutch study showing the safety of home birth, especially for women having a second vaginal birth or beyond.

 

This link is a summary from Science Codex. The original article is published in the BMJ.

 

 

This is the part we need to replicate here:

      "The researchers also stressed that their findings may apply only to regions where midwives are well trained to assist women at home births and where facilities for transfer of care and transportation in case of emergencies are adequate. In 2009, 82% of Dutch women planning to give birth at home were in a hospital within 45 minutes from the time a midwife called an ambulance if the need arose."

 

We need to have an educational system that educates all midwives to the same standard just as the Dutch system does. Without those standards, we can't expect the same results. I also need to read the entire article to see the neonatal mortality rates, but I believe the only outcome they looked at was maternal mortality.

 

Autonomy within any profession without responsibility and accountability is simply anarchy.
 

post #375 of 394
Quote:

In 2009, 82% of Dutch women planning to give birth at home were in a hospital within 45 minutes from the time a midwife called an ambulance if the need arose."

 

 

That sentence reads funny... They mean that 82% were within a 45 minute frame from home to hospital, not that 82% transported right?

 

But 45 minutes seems rather a bit long to me. I have always heard 30 min. max. We don't live in town and I have actually been transported via ambulance while pregnant (early on, not labor) after passing out and while the ride itself went very quickly, and the first responders got here within a couple of minutes, it seem to take a bit for them to get me in and going. It wasn't a complete, lights on emergency, so maybe that is why they didn't feel rushed. But I understand that paramedics have very little training in childbirth, though our local flight team now has a neonatal nurse available, so I am just not sure how things would go in a true birth emergency. Which may be another reason I was a little leery on homebirth last time and decided against it.

post #376 of 394

45 minutes seems like a long time. In some situations it might not be that big a deal (mom is getting tired and wants to get an epidural, say), but I would be interested in how much time it took for a real emergency! 45 minutes from placental abruption to c-section equals dead baby. 

post #377 of 394

I've read a lot of transfer stories, and one thing that comes up in a large proportion of them is a drastic underestimating of the amount of time it actually takes to transfer to the hospital.

 

One classic one involved the mother having to wait in the driveway while family and friends moved their cars out of the driveway so she and her husband could get out and the midwife managed to trip and break her ankle while they were waiting.  Another involved a UC where the mother was bleeding out while Dad was strapping their other kids into the car seats (since they were truly alone).  Another involved a birth center with a tight staircase that made stretchering out the mom extremely difficult and time-consuming.  You are never as close to the hospital as you think you are. 

post #378 of 394

I agree with a previous poster that transfer time is underestimated in a home birth transfer.  But, as an L&D nurse for 10 years and home birth midwife for 14 years, I would like to correct a falsehood about emergency care for those planning a HOSPITAL birth.  The false belief that C-sections can be performed within minutes of detecting a true emergency (NOT distress) is much longer than people think if you are in a small community hospital (which most women are in the United States).  If it is the middle of the night, and the ONE anesthesiologist is in the OR with an appendectomy, they will be calling in the second anesthesiologist from home, which might take 30 minutes for him/her to arrive.  How much different is this to those who plan a home birth 15-30 minutes from a hospital?  Most C-sections need a First Assistant (another doctor or nurse) to help the surgeon perform the C-section.  That person also has to be called from home. 

post #379 of 394
Quote:
Originally Posted by joycnm View Post

I agree with a previous poster that transfer time is underestimated in a home birth transfer.  But, as an L&D nurse for 10 years and home birth midwife for 14 years, I would like to correct a falsehood about emergency care for those planning a HOSPITAL birth.  The false belief that C-sections can be performed within minutes of detecting a true emergency (NOT distress) is much longer than people think if you are in a small community hospital (which most women are in the United States).  If it is the middle of the night, and the ONE anesthesiologist is in the OR with an appendectomy, they will be calling in the second anesthesiologist from home, which might take 30 minutes for him/her to arrive.  How much different is this to those who plan a home birth 15-30 minutes from a hospital?  Most C-sections need a First Assistant (another doctor or nurse) to help the surgeon perform the C-section.  That person also has to be called from home. 


yeahthat.gif  And it's not just community hospitals where it can take longer than expected to "transfer" within the hospital.  I've met several women who had to wait in line at the maternity hospital because both OR's were in use.  I met one woman who ended up with an unplanned VBAC simply because she kept getting bumped out of the ORs by more critical cases. 

post #380 of 394
Quote:
Originally Posted by joycnm View Post

I agree with a previous poster that transfer time is underestimated in a home birth transfer.  But, as an L&D nurse for 10 years and home birth midwife for 14 years, I would like to correct a falsehood about emergency care for those planning a HOSPITAL birth.  The false belief that C-sections can be performed within minutes of detecting a true emergency (NOT distress) is much longer than people think if you are in a small community hospital (which most women are in the United States).  If it is the middle of the night, and the ONE anesthesiologist is in the OR with an appendectomy, they will be calling in the second anesthesiologist from home, which might take 30 minutes for him/her to arrive.  How much different is this to those who plan a home birth 15-30 minutes from a hospital?  Most C-sections need a First Assistant (another doctor or nurse) to help the surgeon perform the C-section.  That person also has to be called from home. 

A good point. This certainly isn't going to be improved, though, by being the person who's planning a home birth and said small community hospital is their backup. With many/most homebirth midwives not being integrated into the medical system, this just means the time from hospital door to C-section is 30 minutes on top of however long it takes to get to the hospital. Even where I live, in a large metro area with multiple well-equipped maternity hospitals, there will still be time from ER arrival to stat C-section, though probably it'll usually be a shorter wait. In the Netherlands it's (presumably) different with the midwife being able to call ahead if a c-section is needed and have everyone ready and waiting. I agree that home birth 15 minutes from the hospital with a well-trained midwife who is able to call ahead to the hospital before transfer if a c-section is needed is probably equivalent in terms of safety to this small community hospital scenario. 

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