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# Apgar Score of Zero at Five Minutes - Page 5

Quote:
Originally Posted by loveneverfailsÂ

Aggie, your math is wrong. Â It's 1 in 600 home birth moms with a midwife, and that counts none of the moms who transferred. Â That number could be higher. Â 1 in 6,000 is hospital, MD. Â But I agree that 1 in 6000 feels very low. Â I would not agree that 1 in 600 is low at all, and this does not capture very well the rate of babies who were damaged but not so severely compromised in utero that they managed to get a 5 minute Apgar of 0. Â Damage is still very possible with a 5 minute Apgar of 5.

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arg, sorry.Â  mental math in the middle of the night is bad.

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still, i think 1 in ~600 is low.Â  Then there's the problem of "damaged" babies who were revived in the hospital for a life of varying degrees of difficulty.Â  Don't really want to go into my thoughts on reviving people "heroically."

Quote:
Originally Posted by loveneverfailsÂ

Sure, no problem. Â Table 2 shows the rate per 1000. Â The rate for hospital MD is .16 per in every 1000 women, rate for home midwife is 1.63 per 1000, rate for hospital midwife is .09 per 1000. Â  1000/1.63= 613. Â I am not sure why I had it as 600 instead of 613, and I apologize for the discrepancy. Â .09/1000 for hospital midwife is 1 in 11,111. Â Those numbers make me wince quite a bit. Â The P value for these relative risks is very very very low at p < .0001, so likelihood that this is a fluke is extremely low.

I don't really understand statistics but to get to the "1 in x" number you don't divide the number if 0 apgers by the number of HB?
Quote:
Originally Posted by IdentityCrisisMamaÂ

MC, I was not implying that your experience would have been different. I posted to clarify that your birth was not a planned HB, a reasonable assumption in this forum. Though I disagree that your experience may not have been different with a planned HB, it may well have. You may have been recommended bed rest, more frequent monitoring, and your MW may have been there before the paramedics, may have advised a better transfer doctor, acted as a doula and etc. Of course maybe not.

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ICM, I was on bed rest. I was being followed, extensively, by CNMs at a hospital with a great rep for natural birth practices, and high-risk OB at a hospital with a Level III NICU.Â  The team on the floor at L&D was fantastic, and I don't recommend holding out for different OBs in my situation.Â  The ONE thing a HB midwife might have been able to differently in the circumstances is act as a doula.Â  She could not have made the ambulance get there faster.

Quote:
Originally Posted by aggie popÂ

arg, sorry.Â  mental math in the middle of the night is bad.

still, i think 1 in ~600 is low.Â  Then there's the problem of "damaged" babies who were revived in the hospital for a life of varying degrees of difficulty.Â  Don't really want to go into my thoughts on reviving people "heroically."

I agree. I think all should be done, if it can be done, but having worked as an EMT and in several other medical fields, I can see the statistics above skewed by heroic efforts that end up with mortality statistics not much better than the out of hospital ones.

This is the most important part of this study for me:

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"PhysiciansÂ also have the professional responsibility to address the root cause of patientsâ€™Â motivations for out-of-hospital delivery through continuous efforts to address patientÂ concerns about interventions, and to improve compassionate and safe care ofÂ pregnant, fetal, and neonatal patients in the hospital setting."Â

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Personally, home vs. hospital wouldn't be nearly as big of a debate if hospitals were better places in which to give birth. Out of my real life friends, those of us who care about natural birth, skin to skin, etc. don't really care where it happens as long as we are with trusted caregivers. It's just that "the hospital" is not often enough one of those safe places.Â

Quote:
Originally Posted by IdentityCrisisMamaÂ

I don't really understand statistics but to get to the "1 in x" number you don't divide the number if 0 apgers by the number of HB?

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My numbers were based on the rate calculated per 1000 by the study authors. Â There were 98 total confirmed Apgars of 0 in the home birth, midwife group out of over 60,000 births, all parities. Â The hard numbers are 98 women out of 60,296 midwife attended births completed at home, singleton full term and normal birth weight, had significant enough fetal compromise to result in a 5 minute Apgar of 0. Â 60,296 divided by 98 gives a rate of 1 in 615.265306. Â

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For first time moms at home, it is worse. Â Those hard numbers were 35 full term, singleton normal birth weight out of 14,801 births completed at home for a rate of 1 every 422.885714 having a 5 minute Apgar of 0. Â

Got it!
Quote:
Originally Posted by aggie popÂ

Â

arg, sorry.Â  mental math in the middle of the night is bad.

Â

still, i think 1 in ~600 is low.Â  Then there's the problem of "damaged" babies who were revived in the hospital for a life of varying degrees of difficulty.Â  Don't really want to go into my thoughts on reviving people "heroically."

Â

At the same time, we don't know how many babies were revived in the hospital with more success because they had access to crash carts and intubation who would have been a 5 minute Apgar of 0 without access to aggressive resuscitation but because of access had a 5 minute Apgar of 5, or how many started to have heart tones crash to hell and were lights blaring c/s with apgars of 1 and 8 at 1 and 5 minutes respectively. Â I think it's far more likely that a home birth baby winds up being revived heroically because no one wants to give up before absolutely everything has been tried and the kid didn't even have access to the crash cart and ventilator, and then have severe brain injury that might have been prevented if the intubation and epinephrine was available at minute 3 instead of minute 23.

I'm following this discussion with interest. Currently 28 weeks pregnant with my 4th and planning my 2nd homebirth (first two were born in hospital). I've been sitting on the fence about another HB this entire pregnancy. I agree completely with cynthiamoon about what drives many (including me) to seek OOH birth in the first place. I am very wary of having another hospital birth for fear that my wishes regarding treatment of the newborn will be ignored and met with resistance. My DD2 was vaccinated and given abx against my wishes in hospital, with the reasoning that because they couldn't find my medical records (I had preregistered with the hospital, THEY made a mistake) she needed to be treated as though I'd had no prenatal care and my demands were ignored. I remember all too well the hostile, disrespectful treatment we received.

Because of incompetent care by a MW (not my MW, but her back up) during my last delivery, I'm also wary of going the homebirth route this time. We switched to a different MW team, because although we thought our MW was great, she now practices with the MW we felt failed us. I am concerned because the nearest hospital that accepts HB transfers is about 20 min from us. Like Meepycat I've also had a chance to experience slow ambulance response times. When I miscarried last fall I hemorrhaged and my MW called 911 for me. The first responders were quick, but the ambulance took almost 30 minutes to get to my house. This leaves me with very little hope for a quick transfer should we need one.

I feel like my options aren't great. This study adds food for thought.
Quote:
Originally Posted by JennyanydotsÂ

I'm following this discussion with interest. Currently 28 weeks pregnant with my 4th and planning my 2nd homebirth (first two were born in hospital). I've been sitting on the fence about another HB this entire pregnancy. I agree completely with cynthiamoon about what drives many (including me) to seek OOH birth in the first place. I am very wary of having another hospital birth for fear that my wishes regarding treatment of the newborn will be ignored and met with resistance. My DD2 was vaccinated and given abx against my wishes in hospital, with the reasoning that because they couldn't find my medical records (I had preregistered with the hospital, THEY made a mistake) she needed to be treated as though I'd had no prenatal care and my demands were ignored. I remember all too well the hostile, disrespectful treatment we received.

Because of incompetent care by a MW (not my MW, but her back up) during my last delivery, I'm also wary of going the homebirth route this time. We switched to a different MW team, because although we thought our MW was great, she now practices with the MW we felt failed us. I am concerned because the nearest hospital that accepts HB transfers is about 20 min from us. Like Meepycat I've also had a chance to experience slow ambulance response times. When I miscarried last fall I hemorrhaged and my MW called 911 for me. The first responders were quick, but the ambulance took almost 30 minutes to get to my house. This leaves me with very little hope for a quick transfer should we need one.

I feel like my options aren't great. This study adds food for thought.

I am so sorry that you feel like you have such bad options. Â I can relate in many ways. Â My solution that is working this pregnancy is that I'm delivering in the hospital, but I went with a family practice doctor who will really go to bat for me if I need it, and because he's family practice he takes care of both me and baby. Â My contact with other physicians is minimal. Â

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Maybe something like that would be an option for you? Â If there are other hospitals in your area, maybe talk to local doulas about what options might be around that would be better for you? Â The more you investigate perhaps the more clarity you'll have, because at least you'll know for certain whether you really don't have any hospital option that is workable for you.

Thanks so much to members for being so supportive and gentle with me as I tried to be involved in this thread from my phone. I think stuff like this is one of the more stimulating parts of being a parent and I so much appreciate our members for being so open to discussing these topics. I do think that we all come to this type of information with our own bias but my experience is that HB mamas in particular are pretty open to new information.Â

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Originally Posted by JennyanydotsÂ

I'm following this discussion with interest. Currently 28 weeks pregnant with my 4th and planning my 2nd homebirth (first two were born in hospital). I've been sitting on the fence about another HB this entire pregnancy. I agree completely with cynthiamoon about what drives many (including me) to seek OOH birth in the first place. I am very wary of having another hospital birth for fear that my wishes regarding treatment of the newborn will be ignored and met with resistance. My DD2 was vaccinated and given abx against my wishes in hospital, with the reasoning that because they couldn't find my medical records (I had preregistered with the hospital, THEY made a mistake) she needed to be treated as though I'd had no prenatal care and my demands were ignored. I remember all too well the hostile, disrespectful treatment we received.

Because of incompetent care by a MW (not my MW, but her back up) during my last delivery, I'm also wary of going the homebirth route this time. We switched to a different MW team, because although we thought our MW was great, she now practices with the MW we felt failed us. I am concerned because the nearest hospital that accepts HB transfers is about 20 min from us. Like Meepycat I've also had a chance to experience slow ambulance response times. When I miscarried last fall I hemorrhaged and my MW called 911 for me. The first responders were quick, but the ambulance took almost 30 minutes to get to my house. This leaves me with very little hope for a quick transfer should we need one.

I feel like my options aren't great. This study adds food for thought.Â

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With my first, it seemed every child development expert and everyone in the medical field was pro-HB. There wasn't the internet - just classes, text books and magazines and the library.

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I had a transfer (we drove so I have little experience with waiting for an ambulance) and my hospital experience was so-so. Not bad but not this wonderful thing either. My MW for that birth wasn't a great fit for me. She just wasn't able to give me the incentive I needed to dig down to what strength I had left to get my baby out. But, she advocated for me wonderfully in the hospital and even performed uterine massage and I believe prevented me from a major complication - this to the gratitude of the OB who didn't spot the problem (even with me telling her something was wrong, sigh). Looking back on that birth I do think I would have a c-section and, although not the worst thing by any stretch, I'm very happy to have avoided one by beginning my birth at home. I also had some pressure about vaccinations, some concern over my baby being "too big" (she was only 9lbs) and some curd after the baby was born.Â

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BUT, with my second (third with miscarriage) pregnancy, I felt my mortality as a mother. I worried about complications and how dealing with that would be too much for my first child. There was also the internet and all the skeptics and stories...Â

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And, I didn't like the local CNM and chose a CPM (in a state that did not recognize CPMS). She was a good fit for me because I was confident and familiar with birth. The way she was with me would not have been a good fit for another mother but I'm not sure if she would have been the same with a new mom. This MW was able to really guide me through birth (I have a long 2nd stage, or I did for both births). But, a few times through the pregnancy I made it clear that I was not going to let any issues of legality get in the way of the safety of me or my child. My research at the time indicated to me that the biggest short-fall of HB is in infant care following birth so I was especially cautious during that period (was sure to see a pediatrician and do all my post-natal visits).Â

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I dislike how clueless I seemed on this thread regarding apgars. I do know what they are, of course, but having a child born with low scores, a zero at 5 minutes seems crazy bad news. And, I don't know what to make of the study, honestly. I think this forum should be a safe place for us to toss around a few "but waits" without being labeled defensive or whatever... and it should be a safe space for us to really try to understand this stuff and help each other.Â

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I will say that I didn't go into either of my births thinking that HB was "safer" than hospital birth. I went into both factoring in a lot of things. I sort of cringe when I see people boldly say that "HB is way safer than the hospital" but I also cringe at the strong opposition to HB that comes from ignorance. Â

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I don't think a lack of comment on this study is indicative of anything... Â I don't know the medical and midwifery establishements well enough to know what the norms are with this. As far as I can tell this study is floating around on mostly skeptic sites.Â

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But, I do hope to read more about it. I really appreciate articles about studies and will often read every "side" about a study. I love science but am humbled by what I don't know or don't quite understand. Another reason I so appreciate discussions like this one.Â

Quote:
Originally Posted by cynthiamoonÂ

This is the most important part of this study for me:

Â

"PhysiciansÂ also have the professional responsibility to address the root cause of patientsâ€™Â motivations for out-of-hospital delivery through continuous efforts to address patientÂ concerns about interventions, and to improve compassionate and safe care ofÂ pregnant, fetal, and neonatal patients in the hospital setting."Â

Â

Personally, home vs. hospital wouldn't be nearly as big of a debate if hospitals were better places in which to give birth. Out of my real life friends, those of us who care about natural birth, skin to skin, etc. don't really care where it happens as long as we are with trusted caregivers. It's just that "the hospital" is not often enough one of those safe places.Â

I agree with this even if I didn't personally choose HB for these reasons. I chose HB because I feel that HB should be embraced as part of the spectrum of birth options available to women. But, HB isn't embraced in this way. We see this in our transfers. I know there is a big movement in support of CNMs (and against CPMs) in this country and in favor of more restrictions and more training. I wish there was a better focus on transfer care, which could/should include better informed consent and improved transfer times and etc.Â

Having actually sat with firefighters and ambulance crew as a midwife talking about out of home birth, I know that in the cities surrounding me, the average response time is three minutes. Having called 911 on occasion, the response time was about three minutes in our metro area. Whether or not that changes outside of the metro, I can't say. We have specific terminology we say in a situation that needs immediate hospital attention. I do believe that all women have a right to birth as they see fit. But I believe that childbirth is a women's rights issue. Her body, her baby, her choice. I also think that she has the right to good care.
Quote:
Originally Posted by IdentityCrisisMamaÂ

I dislike how clueless I seemed on this thread regarding apgars. I do know what they are, of course, but having a child born with low scores, a zero at 5 minutes seems crazy bad news. And, I don't know what to make of the study, honestly. I think this forum should be a safe place for us to toss around a few "but waits" without being labeled defensive or whatever... and it should be a safe space for us to really try to understand this stuff and help each other.Â

Â

I will say that I didn't go into either of my births thinking that HB was "safer" than hospital birth. I went into both factoring in a lot of things. I sort of cringe when I see people boldly say that "HB is way safer than the hospital" but I also cringe at the strong opposition to HB that comes from ignorance. Â

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I share your frustration when people assume that a choice for home birth means that even basic medical supplies like pitocin or antibiotics are completely unavailable. Â I did go into home birth saying those things because I believed that home birth was an evidence based choice. Â I was completely convinced by the 2005 CPM study, and it was the major determining factor in why I chose home birth. Â Without it, home birth would have remained a really beautiful idea but it wouldn't be something I chose, and I did not have enough of a hard background in sciences to see what the flaws were. Â I didn't read the charts carefully enough to question why on earth perinatal mortality for a CPM in 2000 would be compared to hospital birth safety going back as far as 1969 in one study. Â I didn't understand the statistics so much as that they had been good enough to get published, and I felt that no good home birth midwife (and I thought they were all good!) would ever be less than forthcoming with the evidence. Â I thought that no home birth midwife and no home birth midwifery or birth advocacy organization would argue for "evidence based care" and then pick and choose the evidence as convenient. Â

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I was young and did not see my blind spots, and at this point I honestly feel somewhat betrayed, because the evidence I was presented with is why I felt safe even looking at the secondary concerns. Â Without it, and with the more recent evidence, I would not have chosen home birth as it is practiced on average in the United States. Â Because of it, even with a CNM with significant hospital experience, I had an emergency newborn transfer with a baby who was in extremely poor condition on arrival at the NICU. Â This is obviously anecdote, but the thought of seeing my daughter like that again and having NICU personnel standing over her offering minimal care for the 30-35 minutes it took from 911 call to admit is extremely painful to contemplate, but that is exactly the equivalent care she got in that interval of time because high level care was a transfer away. Â And she never had an Apgar of 0, but she still only narrowly avoided neurological injury, so to me this study (Zero Apgar) doesn't even really cover the full scope of what the increased risk of hypoxic brain injury could be. Â

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I want to tread lightly and be respectful, but I am struggling to understand why in spite of studies showing a marked increase in risk for first time moms at home, why a community dedicated to promoting "evidence based care" in pregnancy and birth are not at least telling a first time mom who wants to choose home birth that there is a higher risk to her. Â When the Birthplace Study hit my local midwifery communities, the buzzline that it was going around under was "home birth is safe for babies and even safer for moms!" Â That's an oversimplification to a significant degree, and most of us use our care provider's expertise as a proxy for reading the full bulk of evidence on everything ourselves. Â I don't understand how one study comes out in England showing good home birth outcomes, another comes out in Missouri showing a terrifyingly higher death rate but the one in England gets shared everywhere and the one from Missouri showing a 10-20x higher risk of death is irrelevant. Â And I'm not saying that the situation on the ground in Missouri is the same as the situation on the ground in Washington State. Â It bothers me when home birth communities that really have their acts together get lumped in with areas that don't, but it bothers me when communities that aren't Washington State act like because home birth is a safe and reasonable choice in England that it's totally reasonable and safe in Colorado or Oregon. Â

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This study also discusses neonatal seizures, and there is a growing body of studies that discuss the neonatal seizure risk associated with planned home birth in the US. Â I am less familiar with whether this risk is also present in countries with integrated, regulated midwifery care but the elevated neonatal seizure risk is in this study, it's in the Missouri study... this isn't a new finding and it keeps popping up. Â At what point does that become part of informed consent? Â I think it's something that we as a community really need to look at and be honest about. Â I think there is an ideological split in the home and natural birth communities based on the various reasons why people choose home birth. Â And I stand by home birth for low risk women as practiced in the UK or Canada. Â They have excellent midwives and excellent stats to prove it. Â Here it just seems so incredibly hit or miss, and that degree of variation makes it very difficult to say anything about whether home birth in the US is a reasonable choice or not. Â There's too much variation of education, practice and outcomes to be able to say much of anything aside from that in this study when averaged all together, throwing the bad eggs in with the good, there is a 10-18x higher risk of encountering an Apgar associated with poorer outcomes, and that this relative risk is an underestimate. Â And I'm sure that there are some areas with stats much better than this. Â There are also some areas with statistics that must be much poorer in order to average out at that high a relative risk.

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I feel like the greater home birth and birth advocacy community needs to either drop the title of being advocates for evidence based care or they need to be more willing to discuss when the evidence suggests that something is more dangerous than previously thought. Â Home birth with eyes wide open, with full informed consent is absolutely a woman's right to choose in birth. Â But she deserves the full information as she is making that choice, and at this point I have serious concerns as to whether she is getting it. Â I think we can do better, and I think we need to.

Your experience, LNF, is a wonderful example one aspect of NFL that I have most appreciated over the years - that we need to advocate for ourselves and our children. Anyone going into homebirth thinking they will never need an emergency transfer or that there are not some circumstances where birthing in a hospital would have been a better choice is wrong and doing themselves and HB a disservice. I would be surprised if there are any MWs out there who are not willing to discuss this with clients but I certainly can imagine MWs who are not forthcoming enough with information for various women's taste. Â

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I can't comment on greater MW advocacy organizations and whether they do enough to meet a basic need in terms of addressing studies or not and I can tell you that initiating that discussion from the perspective of someone who no longer supports HB is not a conversation we will host here. I can think of two options for continuing that discussion:Â

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• We can see if we can host a more diverse HB discussion in the general birth forum so that members can post within the guidelines of the forumÂ
• If you have a lot of passion towards the subject, I would love to work with you and of course someone more supportive of HB (and perhaps someone like Mamacat from the pro-CNM) perspective to create a sticky with a list of all available studies on HB to date so members have them at their fingertips when they come here for information. Â

Â

Would you be interested in working on a project like that? Â

But I did not say that I do not support home birth, even though I am neither an appropriate home birth candidate nor would I personally choose it for my births at this point. Â I do support it, but it's not blanket support in the US the way I give blanket support to the home birth cultures in Canada and the UK. Â Home birth isn't a monolithic thing where you either support all the home birth or none of it, and how safe it's practice is varies from location to location. Â

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I think that we all have our comfort levels in terms of what home birth we will support. Â I assume there are many more people who would support a 25 year old 39 week multipara with no medical conditions or previous birth complications 2 blocks from a major teaching hospital than would support an advanced maternal age hypertensive breech triplet UBA6C3 hours from the closest hospital and both of those moms are going to legitimately be able to say "I had a home birth." Â There are shades of grey, complicated ethical issues in play, and I don't want to be categorized as wholly against home birth as a legal option and reasonable choice for a low risk mother to make, because that is not the position that I take. Â There is too much nuance and subtlety especially when looking at home birth around the entire world. Â

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I feel mislead from the discussions that I had with my midwives when I chose home birth initially in 2006 because what I was told by the midwives that I used was that the evidence showed that with inductions/epidurals/c-sections the hospital caused more problems than leaving things alone, so do you want to be in an environment where sure... most of the time they can fix the problems that they caused in the first place or do you want to be in a home setting where we aren't going to interfere and cause problems that didn't need to happen and run the much smaller risk that you run into a problem that can't be fixed fast enough at home? Â The calculus as it was presented to me by people who seemed so genuinely nice was that the hospital meddling will cause problems, and the only kind of problems you will encounter at home are either easily fixable by a midwife with just a shot of pitocin or the Gaskin maneuver or they are the type that babies die of in the hospital too therefore it's not worth worrying about. Â We all speak from our experience, so I can only report mine and that several of my friends had similar experiences. Â A friend of mine, college educated, very intelligent and so conscientious with the care of her babies had a shoulder dystocia in the hospital before going to home birth and basically the midwives she met with told her how the hospital may have caused the shoulder dystocia and how they made it worse during resuscitation. Â Different areas of the country with different cultures may truly present things differently, but those are the experiences that I have had and seen with my friends.

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I would be interested in the project you're describing because it really does fall under informed consent. Â Thank you for the opportunity to help! Â :)

Edited by loveneverfails - 7/10/13 at 6:32am

LNF, when working out "support" forums here at Mothering, there are always grey area perspectives. Obviously support of the choice to HB is on a spectrum and it is the freedom to discuss this with like minded members that we are trying to protect. Â It doesn't sound to me like you support HB in the way that the guidelines are intended. I'm not sure if I can adequately convey the reason for the need for a space for like-minded members to discuss homebirth but I can tell you that if "informed consent" is a main issue for you, helping to preserve a place where mothers interested in discussing these tough topics is a good place to start. Â

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Members wishing to participate in developing a good original source resource page with relevant HB studies is welcome to PM me a list of studies. We could format it to have articles and responses to studies filed below. We can also make room for HB resource websites where mothers can go for more information. Â

I think that women not only have the right to good care, that they have a right to home birth, and that they have the right to all the information about their care choices.Â  I think childbirth is a human rights issue.

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I support homebirthing as an option, at least in theory, but I have seen risks minimized and dismissed in discussion the same way that LNF has, first when I was considering homebirth and researched available midwives myself, and later when seeing the outcomes of homebirths among my friends.Â  It's frustrating for me to see women I love and care for make this choice, in full and confident belief in its safety, and then wind up with mom or baby spending *more* time in the hospital then they would if they'd given birth there, in grave danger, and totally losing the benefits they'd hoped for (things like no mother-infant separation, immediate breastfeeding and bonding), because of the very issues that midwives assured them were caused by hospitals.Â  I want this birthing choice to be available, and I want midwives to embrace safety and transparency in their practices, and full disclosure when discussing risk.

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It's very difficult to discuss articles like this in the homebirth support forum because, as soon as you engage with the data, you can be called on not being supportive of homebirth.Â  I think this data indicates a problem in the provision of homebirth services.Â  I don't have the expertise or experience to say exactly where that problem lies, but then, I'm not a midwife.Â  I wish there was a response from the broader midwifery community, ideally something along the lines of "in light of this data, we plan to do X to address these issues and improve safety for the mothers and babies in our care."

I haven't seen the risks minimized, and I think the Farm's statistics are pretty good indications on the safety of homebirth for most women. I'm sorry LNF if you've had a bad experience, but I don't see how scaring a first time mom with a statistic that is so ridiculously small will help things. I can't think of any hb moms who haven't thoroughly researched their options, but whether you birth in a hospital or at home, you need to do the research and know your options. Many people are not given a choice. And that definitely leads to danger.

I disagree that the Farm study is convincing proof of home birth safety. Â I'm looking at the full text, and it's citing a roughly 1% (10 per 1 thousand) death rate including preemies, respiratory distress, abruption, but also a case of suspected child abuse etc, 17 deaths in 1707 women. Â I have no idea why they wrote the study the way they did. Â It seems really oddly done, far less professional than the BMJ 2005, the Canadian studies, the Birthplace study. Â The best study on home birth safety really is the Birthplace Study from England in terms of how home birth can be, and I think that it's pretty unassailable that home birth for UK moms who have given birth before are extremely safe in a home setting.

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Full text on the Farm Study is here for anyone interested:

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1694364/?page=3

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And I would suggest that it is up to the first time mom in question whether that stat is scary or not to her. Â Different people have different risk tolerances, and that's ok. Â Knowledge is power, especially knowledge in a meaningful context within the full corpus of the literature, but education does not happen in a vacuum and those who are offering a specific choice regarding birth have an ethical obligation to ensure that all risks are disclosed to the client seeking care.

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