Thoughts on new study showing homebirth increases risk of nenonatal death? - Page 3 - Mothering Forums

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#61 of 98 Old 07-04-2010, 06:57 PM
 
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At the very least, I would expect a peer review of the case to evaluate the situation and see what, if anything, might be done differently if the same situation presented itself again. Where clear negligence can be proven, loss of licensure may be appropriate.

Sometimes *&^% happens in birth and it is nobody's fault (eg. a sudden complete abruption with no risk factors or warning). Sometimes #$&* happens in birth and the responsible parties make harmful (and sometimes deadly) mistakes (in all birth settings). Care providers who take a cavalier attitude toward the risks of birth complications or medical interventions are dangerous. I think part of the problem in the home birth community is to place some kind of negative moral judgment on interventions in the birth process. Women/midwives who use interventions "didn't trust birth enough." Part of the problem in the hospital birth community is to believe that medical interventions always make birth safer and should therefore be used with every mom/baby. In either extreme, moms and babies get hurt.
I must say, I completely agree with above.
This thread is a very good discussion on how to improve upon U.S. midwifery. I don't think any of the posters on this thread is wrong. Just coming from different perspectives. These are very hard (and COMPLEX) things to face and fix. I know we want everything to be perfect for mams and babies, but maybe we should focus on one thing at a time, and be proactive.

I'm not a midwife, yet. But I want to help midwifery flourish in U.S. and help women get safe and respectful birth at a location of their choice. I hope all midwives are able to cross freely among home, hospital and in between, if they choose to do so. That is my goal: to find a path for midwives to practice at hospital, birthcenter, and home without restrictions and attacks, if that is what they choose to do. That will serve many women and babies well. I hope to practice between hospital and home. I know some midwives are already able to do this, but not all; there are only few. I want to expand this option to all midwives.

Homebirth is not perfect, nor is hospital birth. We all know that. What we should focus on is how to improve upon them, homebirth AND hospital birth. And to do this we have to face what is really going on, however painful to do so. (and academic research is one tool, but not be-all, end-all, and I think we all know that, too.)
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#62 of 98 Old 07-04-2010, 07:17 PM
 
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i am pretty sure MDC has rules pertaining to snarky comments such as this. Just because you don't like/agree with the study, does not mean the people discussing it are idiotic.
She didn't say that the people discussing it are idiotic. She said she found "it" idiotic. Meaning "the study".

Just because you don't like her outrage is not a reason to try to sic a mod on her. I recognize you're coming from a different perspective entirely... we all are, really, but I respect her enough to know that she was certainly not calling anyone idiotic.

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#63 of 98 Old 07-04-2010, 07:24 PM
 
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She didn't say that the people discussing it are idiotic. She said she found "it" idiotic. Meaning "the study".

Just because you don't like her outrage is not a reason to try to sic a mod on her. I recognize you're coming from a different perspective entirely... we all are, really, but I respect her enough to know that she was certainly not calling anyone idiotic.
thanks for standing up for her- but if you read her response , she understood why i saw it that way, and rephrased it. if i had "siced a mod on her" i would have flagged it. i did not. it was a reminder, hoping for clarification-which i got.
and respecting someone does not mean you assume they mean what you would like for them to mean..

mdcblog5.gif   Liz mama to DS 10, DSS 9, DD 6, DS 3, DD 2 , Aquila- dec 19th 2009 died at my homebirth, and....welcome Willow born 9-16-10 (9 weeks early)  nut.gif
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#64 of 98 Old 07-04-2010, 07:41 PM
 
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When midwives feel like their reception is going to be less than friendly, they consult less often and transfer later. I've seen this firsthand, working with a CNM with hospital priviledges, CPMs with very friendly relationships with doctors and hospitals in their area, and CPMs with shaky relationships with doctors and hospitals in their area. The issue wasn't the skill or safety of the practitioners, it was the political climate re: homebirth and midwives. In fact, the CPMs with the shakiest relationship practiced in the most conservative way of anyone I worked with. Poor reception at a hospital/ poor professional relationships aren't usually about how good or bad midwives are.
I'm in Canada/Ontario, but I have to say that as a client/consumer/patient, if I knew this in advance it would definitely make me wary about trusting my care to a midwife. The time of transfer -- whether before labour or during -- is probably the most fraught period for a mother and baby that have to do it, and I would not want a bad relationship (regardless of whose fault it is) to be an issue in my care.

One of the advantages I see (from the outside) of midwives practicing in hospitals is that it becomes a professional relationship for everyone. But I'm hazarding a guess some of the regulation came first where I am.

~ Mum to Emily, March 12-16 2004, Noah, born Aug 2005, Liam, born January 2011, and wife to Carl since 1994. ~
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#65 of 98 Old 07-04-2010, 09:55 PM
 
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One of the advantages I see (from the outside) of midwives practicing in hospitals is that it becomes a professional relationship for everyone.
Sometimes. Or sometimes it still is just a back and forth war with the women being the ultimate losers unfortunately.

I have to say that there is a lot of interesting food for thought here. I am seriously so happy for everyone who has a good hospital set up to birth in if they need to or want to. I think that it should be available to *every* woman because you never ever can guarantee you won't need to birth in the hospital (or at least have the hospital be the safest place for Mom, baby or both). Likewise I think midwifery care should be available to every woman because even if you know going in that you are going to have a medically necessary cesarean section I think there is a lot that a midwife can offer prenatally and postpartum and even at the time of birth. Not every woman wants that (just like not every woman wants to birth in the hospital) but I think it should be available to every woman.

That being said it's not. And it makes me shake my head when I hear how totally wonderful the Canadian system is when it comes to midwives. It's not that rosy everywhere. There are still "turf battles" as Storm Bride put it (I agree!) being fought with women as the turf and it's not fun. There are serious flaws in how care is being carried out and it is not at all seamless from home to hospital depending on where you are. In fact the midwives are the ones doing the throwing of women to the wolves even here sometimes.

There are frustrated midwives who have the skills to have a safe birth in a variety of situations, home or hospital being one of the choices decided during the pregnancy that get told no, you have no choice and the woman is left with no options except highly managed, medical ones, or else UC. I think UC is a viable option for some women and some births but it does not make for safe birth to make a decision like that out of fear or lack of options that aren't also dangerous (a non medically necessary cesarean for instance).

The whole system of care providers and place of birth choices could use some serious evaluation I agree.

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#66 of 98 Old 07-04-2010, 10:12 PM
 
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That being said it's not. And it makes me shake my head when I hear how totally wonderful the Canadian system is when it comes to midwives. It's not that rosy everywhere. There are still "turf battles" as Storm Bride put it (I agree!) being fought with women as the turf and it's not fun. There are serious flaws in how care is being carried out and it is not at all seamless from home to hospital depending on where you are. In fact the midwives are the ones doing the throwing of women to the wolves even here sometimes.

There are frustrated midwives who have the skills to have a safe birth in a variety of situations, home or hospital being one of the choices decided during the pregnancy that get told no, you have no choice and the woman is left with no options except highly managed, medical ones, or else UC. I think UC is a viable option for some women and some births but it does not make for safe birth to make a decision like that out of fear or lack of options that aren't also dangerous (a non medically necessary cesarean for instance).

The whole system of care providers and place of birth choices could use some serious evaluation I agree.
I'm sure it is the case, which is probably why I won't go for a midwife.

~ Mum to Emily, March 12-16 2004, Noah, born Aug 2005, Liam, born January 2011, and wife to Carl since 1994. ~
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#67 of 98 Old 07-04-2010, 11:56 PM
 
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although it may not be totally smooth in Canada if the mws have a job then they are not holding back transfer - as far as I know there are no licensed midwife practices that are strictly homebirth- the mws have to be able to attend a woman in hospital as well as home and that is where the bridge program comes in, they have to know how do do the typical medical things like meds in hospital - I have an ex-pat friend who did the bridge program and the midwifery group she is in hired her because they do have more home births than other practices but in no way is her practice exclusively homebirth- there could be more midwives in Canada but there are doctors already in practice so they only allow for just so much hospital admitting privledges I won't pretend to know all the ins and outs but over all even the docs are less involved in the way things are done here in the US - so unlike here if the mws transfer in they are or someone in their practice is doing the admitting and the clients will see what ever doc is on if that is the need- it may be that they are transferring for pain meds or agumentation then they can establish that themselves and consult... very very different than any of the situations we have here-
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#68 of 98 Old 07-05-2010, 12:09 AM
 
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although it may not be totally smooth in Canada if the mws have a job then they are not holding back transfer - as far as I know there are no licensed midwife practices that are strictly homebirth- the mws have to be able to attend a woman in hospital as well as home and that is where the bridge program comes in, they have to know how do do the typical medical things like meds in hospital - I have an ex-pat friend who did the bridge program and the midwifery group she is in hired her because they do have more home births than other practices but in no way is her practice exclusively homebirth- there could be more midwives in Canada but there are doctors already in practice so they only allow for just so much hospital admitting privledges I won't pretend to know all the ins and outs but over all even the docs are less involved in the way things are done here in the US - so unlike here if the mws transfer in they are or someone in their practice is doing the admitting and the clients will see what ever doc is on if that is the need- it may be that they are transferring for pain meds or agumentation then they can establish that themselves and consult... very very different than any of the situations we have here-
I'm not 100% sure I completely understand your post, so please correct me if I've missed anything... it's past my bedtime

My point wasn't really that they couldn't transfer women or see women in the hospital. I was more arguing whether the system was really any better for *some* women because they can. Here women are "punished" for being a transfer. Both in how they are emotionally treated and also in the quality of care they receive. You better believe that affects how quickly we choose to transfer. Depending on which midwife you have with you it could mean that you are transferring before there is a real need because they are trying to please the OBs by not really doing homebirths except for the 100% perfect ones (and I am not talking risk factors like breech etc, those are already risked out, I mean some of the same things I see talked about on MDC as pros to having a midwife at your birth because having her there makes the birth as safe as it can be by using her training and tools). It also means for some women staying home longer than they would otherwise desperately trying to not get put through the hell that comes from even having midwifery care let alone transferring. There is outright hostility from almost every OB that you run into at our local hospital.

It's not right. It does not provide the best care for women or the safest. Yes there are things that can be improved on in the US, I have not and will not argue that. I was just making the point that sometimes it seems that there is a picture being painted of what it is like in "Canada" even though it's not consistent province to province let alone city to city.

FWIW what is and isn't a transfer of care isn't consistent throughout the province even. There are things that become a "mandatory transfer" even though the College of Midwives says it's just a consult because if you are in a midwife friendly area they can say either concurrent care or else continuing care with the midwife but if you are in a midwife hostile area the OB demands transfer and by and large that is what happens.

I think it would be wonderful if everyone could work together better. I understand how far there is to go with that, but it really would be in the best interest of the women and babies.

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Mama to Toad (08/06), Frog (01/09)... and new baby Newt born on his due date, Sep. 8, 2010
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#69 of 98 Old 07-05-2010, 02:18 AM
 
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here when you transfer you are completely out - the most you can do is stand by a woman and hold her hand - very often they will not take report.
and in some hospitals doctors will not come in to see the mom until the midwife has left the room- mws generally do not have admitting prevlidges at hospitals CNM or no- even for the birth center there is an admitting physician now a CNM may attend the birth or care for the mom under sufferance of the doc/or group of docs that the midwife has a practice agreement with and that doc/group of docs calls the shots as far as protocols even though CNMs in my state are completely independent providers the leverage being who has admitting rights at a hospital and it seems to be the case in Texas too if there are CNMs who do home birth but do not have back-up docs -- and if you look at New York the one hospital that had docs who signed a back-up agreement stopped doing that so now no legal way for those mws to practice--
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#70 of 98 Old 07-05-2010, 08:56 AM
 
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again-i am not saying athing about taking away choices, mearly A. making choices either safer or B. making the true safety known , or both.

i had no idea how ill trained my midwife was, she came highly reccomended. i also had the foolish notion there was accountability in the world of midwifery- like midwives who are responsible for babies dying have actual consiquences. It would have been great to know ahead of time i should not waste my time even voicing complaints, since it quickly lost me several friends and gained me MANY enemies.
what i have recieved ( here and ITRW) is comments about how A. i am trying to take away other woman's rights, and B. my baby would have died in hospital too (or "babies die in hospitals too)..llike either statement has any bearing in what i am actually saying?
my point is my baby would not have died in a hospital. I was not high risk in any way- yet my daughter is dead. not all homebirths are safe-not all midwives are good. Woman should not be telling other woman to put there fingers in thier ears so they dont hear what is true, allthough not nice to hear.
i want accurate studies, available to all woman about the safety of homebirth ~in America~ and i want regulating bodies that actually do there jobs. that is what i want.
A couple things:

1. I don't know your mw, obviously. Yet-- if you are saying that because she could not intubate, she is 'ill-trained', I must disagree. As someone pointed out way earlier in this thread, learning intubation is not enough; a person has to be able to practice it, to become good and *remain* good at it. It's a delicate process--not like riding a bicycle at all. Homebirth mws just don't get opportunities to intubate neonates--and I for one would not want someone intubating me or my baby if they did not get to practice it but once every several years. Even yearly certifying in this skill is not going to be enough since you don't get to practice on live babies.

Now, perhaps you found that your mw was lacking in other areas as well, I don't know. I will say that I have met and heard about some fairly unskilled mws that I thought should not be practicing--a mw's popularity can have little to do with her skill, JUST THE SAME as with OBs and all other docs/practitioners...unfortunately, personality plays far too large a part in things. But when it comes to things like intubation, this is something that a family just has to decide whether or not it is an acceptable risk to *them*, if their mw does not have this skill. Having a baby at home, with any practitioner, involves a set of such risk-assessment for families....because you also can't get a blood transfusion, or surgery or some other medical things at home. Lacking some of these things does not make a mw unskilled or insufficiently skilled. And it's no different at the hospital--families have to make these 'acceptable risk' assessments for themselves in ANY setting, because every setting, every kind of practitioner carries certain skills and certain risks. Not to mention that all practitioners are merely human, and all too capable of arrogance, fatigue, mistakes of all kinds.

2. You clearly believe that your baby would definitely have survived if only your mw could intubate. I don't know all the facts and don't need you to go into it--but I will say this: upon any sort of transfer of care, most especially if there is a loss or urgent/emergent situation for mom or baby, you are often going to have docs/nurses tell you that if only you had been in the hospital all along, everything would have been better. Necessarily and certainly better for mom and baby.

This does not happen for every family, every transfer...but it is VERY COMMON. And it is nothing short of shameless emotional abuse of the family when they are at their most vulnerable, in most cases--and it's shamelessly cruel 'plugging' of medical maternity services. I have heard the most mean-spirited, not to mention purely idiotic things come out of the mouths of OBs and nurses upon transfer (tho I have also seen very respectful and kind treatment of families to be sure). Again, I don't know about your daughter's birth/death, and I sure don't mean to step on your toes here with such an extremely tender topic in your life. Still I wonder--is it really, truly, certainly known that intubation *would have* saved her life--or only *possibly* true, but just as possibly *not*? (purely rhetorical question, meant to provoke thought in everyone here).

I hate to go here this way, and yet I feel this point must be raised. I *have* seen cruel behavior toward parents from med staff, usually couched in 'kindness' along with smart-sounding terms (and sometimes with purely malicious/angry tone and intent). And I suppose some of them even truly intend to be kind--to spare parents future grief--but are themselves ignorant (of the all the facts of a case and how things might have been different medically speaking, not just ignorant about how to treat shocked, possibly grieving parents). People who work in hospitals usually do so because they truly believe that it offers the best and safest care--of course! Just as homebirth mws believe that hb is safest/best for most families--nothing wrong with either party for having made their considered choices. What is wrong is that tendency to say things that may be true or not, but often are just the doc/nurse's expression of their basic belief that what they offer is necessarily and unquestionably 'better'. And that is quite the mind game, to me: abusing their position in most people's minds as The Ultimate Authority on all things 'health/birth'--leaning on people's fragile feelings at a time of loss/emergency in a self-aggrandizing way.

3. As someone who has activated for transparency and accountability in the mw/hb community here, I well know the mean tactics that can be employed--the exiling, gossip and backbiting. I even have seen one family essentially harrassed for their complaints against their mw--in the weeks following the mother's near-death from a pp infection fairly certainly caused by her mw's mismanagement. It was terrible for them--and nothing but terrible behavior from the community of that mw's supporters. And that family was NOT trying to get their illegal mw arrested--they only wanted her held accountable within the community, to stop doing births til she had more training. Anyway, that is only one example to show that I have both seen, and experienced myself, the mean and plain stupid behavior of families and mws alike in defense of mws. I know too well that it is true that many don't want to see the facts, they only want to support someone they like and 'support homebirth', not being able to see that a) 'liking' a mw does NOT mean that she is sufficiently trained, and b) 'supporting hb' must include advocation of mw accountability and transparency if families are to be as safe as possible.

Still--as mwherbs has pointed out, this is not by any means confined to the hb mw communities! If anything, docs have it even easier when it comes to complaints and accountability--even when 'something is done' by the licensing board, it doesn't mean that consequences will actually be paid by the doc. I looked into IL stats on this, a few years back: I discovered that there were 10s of thousands of complaints against docs (of all kinds) every year--but only about 20% of them *even got investigated*. Further, it was very rare for an investigation to result in sanctions. I'm not saying this is ok, not at all! Not saying hb mws should be afforded the same leniency for any reason. I'm saying that you *seem* to think this tendency is confined to hb mws/communities, but is probably worse in the med community (generally, not just OB)--because they DO have a much more developed 'good ol boys' network as mwherbs gave one example of; they do receive far more respect and protection from each other and the public in general, than mws do (yet). From what I've seen, this element is not 'worse' among hb mws than it is among docs.

Not that we should stop trying to help both groups be more responsible and better trained. Only that you seem to have decided that OBs are safer, and that their licenses offer the public some sort of protection--and neither of these things is generally true.

Again--you have chosen OBs and hospital births, according to your own considered searches of soul and info. And that is fine by me. I just hope for you to see the Big Picture more fully, because it seems to me that in making your choice you have granted med maternity care a kind of grace that is earned no more (or less) than hb midwifery. You seem to have a special axe to grind against hb mws...understandable, for sure, but I hope to encourage your more balanced view of these issues on the whole. I'm sure that is difficult in view of your loss and what followed when you tried to seek redress! But necessary, I think--for your own healing and peace, and for your own best clarity as well, in making all future birthing choices.

Just my opinion of course--with advance apology if I overstepped--no patronizing or other offense intended.
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#71 of 98 Old 07-05-2010, 10:55 AM
 
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A couple things:

1. I don't know your mw, obviously. Yet-- if you are saying that because she could not intubate, she is 'ill-trained', I must disagree.

Just my opinion of course--with advance apology if I overstepped--no patronizing or other offense intended.
no offense!
i should not have assumed you would go read my story (on birth stories here and my blog) . i was not saying my midwife was ill trained because she does not know how to intubate. i did say that i wish midwives were trained in it, and it probably would have helped my baby. But by the time intubabtion was needed Aquila had not had a beating heart for a few minutes- she had her lungs filled with blood from my placenta abrupting - which the midwife missed (despite obvious signs). The midwife did not even take my blood pressure or pulse during labor-and did not show up until 14 hours after my water broke. my full birth story is here. The board did find her guilty of a few violations and said she did not have adequate knowledge and made poor judgment calls. My whole birth was a series of mistakes that should not have been made- and in almost any hospital in the country- and certainly any in my city Aquila would have been an emergency C section at least an hour before she died. And she would be alive. Even if we had transferred when i asked to , she would be alive. Even if the midwife had called 911 when my doula suggested it it, she would probably be alive (thanks to intubabtion and Epi)

And i understand what you saying about hospitals saying hurtful things about one's baby's death being the fault of a homebirth- but for me this was not the case. no one said anything ugly to me. I had to pry people to tell me truth. they were very kind and considerate-every one. Where i have gotten this from is the homebirth community. i have had countless numbers of people tell me (people who don't have any idea medically what happened at my birth) that Aquila would have died at the hospital too. That is hurtful, because it is untrue.

and thank you for this
"a) 'liking' a mw does NOT mean that she is sufficiently trained, and b) 'supporting hb' must include advocation of mw accountability and transparency if families are to be as safe as possible."
it is well said!

mdcblog5.gif   Liz mama to DS 10, DSS 9, DD 6, DS 3, DD 2 , Aquila- dec 19th 2009 died at my homebirth, and....welcome Willow born 9-16-10 (9 weeks early)  nut.gif
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#72 of 98 Old 07-06-2010, 01:21 AM
 
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The issue/problem isn't that "high risk births are intentionally being included in the homebirth outcomes" The issue is that high risk births are being managed out of hospital in the first place. We know high risk inclusion will increase incidence of mortality and significant morbidity. Successful international home birth models that have demonstrated positive outcomes screen out all high risk with ONGOING risk screening. US CPM/DEM/LDMs must follow suit or will have unacceptable mortality and morbidity rates.
I just want to point out -- the way I read these study results, the high risk birth outcomes are being included REGARDLESS of whether or not they were transferred to hospital management. The way I understand the report, if the woman INTENDED to give birth at home at the beginning, the outcome is included in the home birth group even if changes in her status caused her to deliver in the hospital.
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#73 of 98 Old 07-06-2010, 08:12 AM
 
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liz-hippymom--

You're right, I didn't go to your blog--so thanks for sharing those details. Yes, it is pretty clear that your mw was not prepared for what happened at your birth. Because you had said "my baby would not have died in the hospital", I assumed you were speaking of intubation alone--my bad. Yes, I do know there really are hb mws out there who simply do not take the Life and Death nature of birth seriously enough in getting trained and hanging out a shingle for services--this is unfathomable to me but I have seen it so I don't doubt it.

The lure of Ego--of being the Much Admired Helper, when it comes to HCPs--is so powerful for most people. It is also something that it so extremely difficult to control by any outside source--even one as seemingly powerful as a State Health Board. While I like to believe that the majority of HCPs (in any area of care) are both humble and sensible enough to avoid the worst pitfalls of ego, it's pretty plain that (in any area of care) there are those whose egos run their lives to the great detriment of others--and who have highly developed 'personality skills' (whether charm, or overt domination, other...) and psychological self-defense mechanisms to allow them to blithely continue down that trail.

And while you and me do disagree about the study that initiated this discussion, and (as you have seen ) I myself have tried to minimize the value of that study, I am very glad you posted. Not only do we agree about certain things, like making sure your mw knows enough, but an experience like yours can't help but nudge other hb-families to being more careful about their choice of mw...and just generally becoming more fully informed about the risks of hb and how to work toward healthy birth and minimizing/eliminating those risks (some can't be eliminated, only minimized; some can be eliminated by healthy parent choices throughout pregnancy. In any event, fully informed decisions about a mw is one important element to be sure!).

Thanks again. While I have never lost a baby, I have certainly had experiences in this life that were very difficult. And while it may be easier to focus on moving forward, not thinking about those things, I know that with some experiences it can be so helpful to others to share about them. In this way, we can help others avoid such difficulties if possible, or at least be better prepared to get through them than we may have been when it happened to us. I appreciate your presence on this thread
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#74 of 98 Old 07-06-2010, 08:14 AM
 
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I just want to point out -- the way I read these study results, the high risk birth outcomes are being included REGARDLESS of whether or not they were transferred to hospital management. The way I understand the report, if the woman INTENDED to give birth at home at the beginning, the outcome is included in the home birth group even if changes in her status caused her to deliver in the hospital.
Hmmm...I don't know...but I wonder if these transport cases are being counted on both sides: in the homebirth stats as being 'intended hb', as well as hospital stats since birth occurred there. Any way to find out?
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#75 of 98 Old 07-06-2010, 09:48 AM
 
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some of the home birth data used in the study is 36 years old (1974)- and comparing that with hospital care in the 2000's is very different. if you were to compare hospital data from that time till now there would also be a considerable difference in rate-
in 1982 when I went to my first hospital based newborn resuscitation class- we were still talking determining primary and secondary apnea - and even pretty recently the thinking was vigours suctioning was recommended and thought that it would make a difference if there was meconium in the lungs- now they know that deep suctioning will not pull that out and can actually compromise a baby further- the lungs are already exposed and are inflammed or will be inflammed due to the exposure- which is why delivery via intubation of epinephrine is used in order to reduce the inflammatory response to foreign stuff in the lungs

and again we are dealing with the Washington data where the provider is unknown-

-----------------
on the topic of intubation here is a Ped's study evaluating how proficient Pediatric residents are and how many intubations they perform on average in order to achieve better than 50% proficency- it is alot - the primary thing we need to be able to do is if it ever got that far is deliver epinephrine to the lungs - the risk would be we could cause permanent damage or kill a baby trying - 10% of babies are thought to need some resuscitative effort from drying off and suction to a few puffs, babies than that need further efforts like chest compressions or more is about 1% of all births - the % that will need intubation is a smaller number than that- the ability to do that and to keep the skills up so as to not harm concerns me- I do think that epinephrine can be administered another way..
http://pediatrics.aappublications.or...ull/112/6/1242
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and another article
http://pediatrics.aappublications.or...full/117/1/e16
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#76 of 98 Old 07-06-2010, 12:31 PM
 
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Hmmm...I don't know...but I wonder if these transport cases are being counted on both sides: in the homebirth stats as being 'intended hb', as well as hospital stats since birth occurred there. Any way to find out?
"Crucially, it looked at where the woman had planned to give birth, rather than the actual birthplace. The researchers argued that the safety of home births may have previously been overplayed by the fact that when there are complications and a woman is rushed to hospital, any adverse outcome is recorded as a hospital birth."

I took the above statement to mean that in THIS study, those cases were still reported in the homebirth group, presumably to counteract the supposed "overplaying" of safety of homebirths...
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#77 of 98 Old 07-06-2010, 01:12 PM
 
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"Crucially, it looked at where the woman had planned to give birth, rather than the actual birthplace. The researchers argued that the safety of home births may have previously been overplayed by the fact that when there are complications and a woman is rushed to hospital, any adverse outcome is recorded as a hospital birth."

I took the above statement to mean that in THIS study, those cases were still reported in the homebirth group, presumably to counteract the supposed "overplaying" of safety of homebirths...
I read it the same way. But in response to the bolded isn't part of the "safety" of homebirth that when something goes wrong enough to warrant a transfer that you can and do transfer.

Negative outcomes can and do happen regardless of place of birth. Just because there is a transfer with a negative recorded outcome doesn't mean that it would not have happened any way in the hospital (although maybe it wouldn't, I'll fully agree, depending on what we are talking about... just as there are negative outcomes in the hospital that likely would not have happened at home). On the flip side a transfer to hospital with positive outcomes for Mom and babe is recorded as a "good" statistic for hospital birth usually, which it is... but it's also a "good" statistic on the side of homebirth to know when to transfer and do so in a time and fashion that results in positive outcomes when possible.

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Mama to Toad (08/06), Frog (01/09)... and new baby Newt born on his due date, Sep. 8, 2010
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#78 of 98 Old 07-06-2010, 03:33 PM
 
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I don't think it has to be homebirth/midwife vs. hospital/every-intervention-known-to-man.
Right now, where I live, practice, serve and birth, it does. There's no in between. In a vacuum, or in some parts of the country with lower litigation rates, more educated populations, and more open minded doctors, maybe it doesn't have to be, but in the right-here-right-now, we are all working with what we have. If I told you some of the things I compromised on in my last two hospital births, you'd be astounded. And they were "good" considering the alternatives here. In cases where you are more outside of the norm than minor things like pre-e (which is why my last two were born in the hospital), you can't find anyone to work with you. I had a woman drive over six hours in labor for a trial of labor with a vaginal breech. She and I both would have preferred a hospital trial of labor, but she couldn't get that anywhere else. She ended up having a beautiful, complication-free vaginal birth.

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as a provider I tend to be conservative and don't do the high risk births intentionally at home but I also think that women/families have a right to pick where they want to give birth
Yes, patient choice is what is being left out of the equation, here, there, everywhere. Women and their families are backed into corners by non-evidence based care from OBs and come to out of hospital midwives desperate for a choice in their care. The last two inquiries I've received via e-mail were titled "I hope you can help me." The desparation oozed off of the page.

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An ACOG plot? Unlikely.
Really? Because ACOG, the AMA and their state organized equivalents have been standing in the way of midwifery legislation and lobbying against it for years now. Most recent example: New York's Midwifery Modernization Act. But also, MO and TX, for sure in the last 10 years. I don't think it's unlikely at all.

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LOW risk. Inclusion of high risk will result in higher incidence of adverse outcome
By whose definition? A local doc once told me that any woman who hasn't had prenatal care by 20w is "automatically" high risk and therefore not a candidate for her care. Our state medical board doesn't allow midwives to attend labors in which the membranes are ruptured but the baby remains unengaged because it's "high risk." Given that study after study has shown that VBAC and vaginal breech have lower mortality and morbidity than c-sections, why are they considered high risk? Who gets to define high risk? And while we're talking about it, why does everything have to be either "high" or "low"? Where is the inbetween? Because while VBAC is highER risk, it's not the same as a say...type 1 diabetic pregnancy. And while breech is highER risk, it's not nearly as high risk as oblique or transverse. Why does it get tossed into the same category?

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The only way they can leave the margins is to kick women in need to the curb. You may think that's a good outcome. I don't.
THANK YOU! I either take the "high risk" woman who hasn't seen a doctor before 20w because she's had three normal pregnancies and doesn't see the need (and am marginalized because of my willingness to take "high risk" women) or I leave her to the residents at the local teaching hospital. Is that what you would have me do in the name of legitimacy?

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In my mind, State licensed and reimbursed midwifery implies certain safeguards: evidence based standards of practice, oversight and regulation, mandatory data collection.
But only for midwives, not for OBs. Because I've NEVER seen an OB practice evidence based care. And I've never seen you criticize them for their lack of evidence based care, which, incidentally, is what sends all of those ignorant high risk women to this ignorant, high risk midwife, who then puts herself on the line to offer an option that isn't available anywhere else, even when the EVIDENCE SAYS ITS SAFER than surgery.

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And let me assure you that US hospital birth consumers are likely even more greatly 'misled' than you claim homebirth consumers to be!
Thank, you, Mrs. Black!! Again, we are criticized for "selling" something unsafe, whilst the OBs tell bold faced lies to women and the women are blamed for not asking the right questions or getting the right education. I smell a double standard here.

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And also respectfully, there is nothing about homebirth or midwifery that I would ask an OB about--there's nothing an OB had to say about these things that I would take seriously. Well, maybe a select few OBs (Michel Odent comes to mind), who actually know something about homebirth and midwifery--but most do not. And their ideas about training are necessarily based upon their OWN training, which really does not apply.
I agree. Just as most midwives are "out of their element" when it comes to management of (truly) high risk birth situations (and should freely RECOGNIZE and ADMIT that!), an OB is out of his/her element when discussing the out of hospital management of a normal vaginal birth. Midwifery and obstetrics are completely different professions and neither can speak as an expert on the other's realm of expertise. It's like asking a decorator to paint or a painter to decorate. They both sort of do the same thing, but not really at all.

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When we talk about legislating a need for collaboration between OBs and MWs, that legislation should lean on the OBs, who are the ones with the power in this situation. If it leans on the MWs, it will just put us out of business.
:applause Well said. As a resident of a state that requires MIDWIVES (or worse) the CLIENTS to seek the collaboration of a physician, I can't agree with this statement more. It is the primary reason I don't practice in my home state.

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not all homebirths are safe-not all midwives are good. Woman should not be telling other woman to put there fingers in thier ears so they dont hear what is true, allthough not nice to hear.
And the inverse it also true. Not all hospitals are safe. Not all doctors (even the highly "recommended" ones) are good. And the regulating bodies for doctors don't do their jobs, either. Women and babies are the losers all around. A study saying homebirth isn't safe is just another way that women and babies lose.

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Women/midwives who use interventions "didn't trust birth enough." Part of the problem in the hospital birth community is to believe that medical interventions always make birth safer and should therefore be used with every mom/baby. In either extreme, moms and babies get hurt.
I love what you are saying here. I really do. I've often said (in person, not online...because I know there will be backlash) that I don't "trust birth." I'd much rather trust that "birth is as safe as life gets." Life isn't safe and I don't trust that it will allow me to be here tomorrow. In some cases, birth can be made safer by swift and judicious intervention and in other cases, it can be made less safe. The ultimate goal for me (and my clients) is always a safe birth in which they know that any medical interventions were necessary interventions.

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I think UC is a viable option for some women and some births but it does not make for safe birth to make a decision like that out of fear or lack of options that aren't also dangerous (a non medically necessary cesarean for instance).
I've been preaching this sermon for years. Women backed into a corner will take drastic measures and that's scary. Taking choice away will result in more UCs, which will result in an increase in mortality and morbidity, especially when women choose them because of a lack of options due to a "high risk" situation.

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it's also a "good" statistic on the side of homebirth to know when to transfer and do so in a time and fashion that results in positive outcomes when possible.
Agreed.

Charlotte, midwife to some awesome women, wife to Jason, and no longer a mama to all boys S reading.gif('01), A nut.gif ('03) S lol.gif ('08) and L love.gif ('10).
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#79 of 98 Old 07-06-2010, 03:35 PM
 
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It actually might be of some value to look at statistics regarding birth outcomes including intrapartum transfers... in the sense that theoretically things could have gone wrong (or right) at home before the transfer contributing to the outcome. However, i think it would be a mistake to include the outcomes of pregnancies that became high risk BEFORE labor began and were thus "risked out" of homebirth. It seems that this study MIGHT have included such cases in its outcomes under the label of "planned homebirth" meaning that was originally the plan. Included these cases would mean including higher risk patients who had no intention of birthing at home as things transpired throughout the pregnancy. It is unclear from what I can find if those types of cases are included, I cannot access the full text of the article, just the abstract.
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#80 of 98 Old 07-06-2010, 03:44 PM
 
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I took the above statement to mean that in THIS study, those cases were still reported in the homebirth group, presumably to counteract the supposed "overplaying" of safety of homebirths...
Except that this isn't actually a new study, it is a meta analysis of 12 other studies. So, this is a combination of some well done studies with some poorly done or outdated studies that are quite old.

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#81 of 98 Old 07-06-2010, 05:46 PM
 
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Unfortunately, whenever we talk about making homebirth transfer situations safer, the focus falls somehow on legislating midwives. Requiring that midwives have agreements makes life more difficult without improving the situation. What we need is some way to improve the way we are received at the hospital, and to remove the stigma against doctors who consult with us.

When midwives feel like their reception is going to be less than friendly, they consult less often and transfer later. I've seen this firsthand, working with a CNM with hospital priviledges, CPMs with very friendly relationships with doctors and hospitals in their area, and CPMs with shaky relationships with doctors and hospitals in their area. The issue wasn't the skill or safety of the practitioners, it was the political climate re: homebirth and midwives. In fact, the CPMs with the shakiest relationship practiced in the most conservative way of anyone I worked with. Poor reception at a hospital/ poor professional relationships aren't usually about how good or bad midwives are.

The unfortunate fact is that doctors are leaned on from several angles to avoid developing positive relationships with midwives. From ACOG, from their malpractice carriers, from hospital admin. From what I've seen in trying to hammer out smooth transfers is that the biggest problem is actually the malpractice carriers and hospital administrators, who insist that doctors not formally consult with midwives because they view it as opening the doctors up to liability. The fact is, we may then later have to transfer blind to one of those same doctors with a train-wreck-in-the-making...how is that any better?

When we talk about legislating a need for collaboration between OBs and MWs, that legislation should lean on the OBs, who are the ones with the power in this situation. If it leans on the MWs, it will just put us out of business.

And yes, FFS, how could anyone not believe that ACOG has it out for homebirth midwives after multiple issue briefs to that effect?
I am a avid homebirth supporter and chose hb for my second pregnancy. Ultimately, complications led my midwife to transfer me during labor to the hospital. There isn't that "good" relationship here that I agree with you is much needed. Fortunately, my midwife isn't swayed in a direction that would lead her to provide less than adequate care because of this kind of thing. I can see where the fear comes from absolutely, and I hate that it is present. I agree, legislation should focus on OBs providing backup care as needed, and hospitals accepting homebirth transfers as necessary without it being a "situation". Also, I think those providing in home maternity care should register with a board that would provide trainings on important things like neonatal resuscitation. I think a universal law legalizing midwives in all 50 states is crucial to making hb as safe as possible.

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#82 of 98 Old 07-06-2010, 10:28 PM
 
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And what changes were brought about by this study, released four years ago, which showed a twofold risk of neonatal death with c-section? The rate has continued to rise, even with EVIDENCE that it's "not safe" or "higher risk" or whatever catchphrase you want. So I wonder...if a mother who would have a c-section in the hospital has a vaginal birth out of the hospital...don't the two "risks" cancel each other out and her risk is back to 1?

All of the meta analysis in the world doesn't change the state of birth care in this country. And arguing amongst ourselves about more regulation won't change it either. What needs to happen is the providers, the insurance companies, the legislators, the regulators, the boards, and the entire society need to value the lives of mothers and babies. THAT will change the state of maternity and birth care. Until then, we all have to do the best we can with what we have, which is a very imperfect, flawed, and sometimes dangerous system of care.

Charlotte, midwife to some awesome women, wife to Jason, and no longer a mama to all boys S reading.gif('01), A nut.gif ('03) S lol.gif ('08) and L love.gif ('10).
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#83 of 98 Old 07-07-2010, 12:55 AM
 
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I cannot believe it they used the Pang study again!!!!!! insane
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#84 of 98 Old 07-07-2010, 01:31 PM
 
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And what changes were brought about by this study, released four years ago, which showed a twofold risk of neonatal death with c-section? The rate has continued to rise, even with EVIDENCE that it's "not safe" or "higher risk" or whatever catchphrase you want. So I wonder...if a mother who would have a c-section in the hospital has a vaginal birth out of the hospital...don't the two "risks" cancel each other out and her risk is back to 1?

All of the meta analysis in the world doesn't change the state of birth care in this country. And arguing amongst ourselves about more regulation won't change it either. What needs to happen is the providers, the insurance companies, the legislators, the regulators, the boards, and the entire society need to value the lives of mothers and babies. THAT will change the state of maternity and birth care. Until then, we all have to do the best we can with what we have, which is a very imperfect, flawed, and sometimes dangerous system of care.
Anyway, we are talking about 3%, 0.2% increases in risk. Even if it was a perfect meta-analysis, does it really point to increased legitimate risks? Birth in and of itself is not something that goes perfectly all the time. Sure with a well trained professional, "situations" can be handled. But, when I see single digits, I counter it with the double digits of things like c-section and induction and risks associated. Being someone who has experienced c-section for no real reason, and c-section as a homebirth transfer, I have to say that my 2nd c-section was a safer surgery with better outcomes than my first and I have to say I think it was because of the patience and expertise of my midwife. What needs to be addressed absolutely is the hierarchy placed into the maternity care of this county and the horrible situations women are placed in because of this approach to caring for us.

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#85 of 98 Old 07-07-2010, 04:05 PM
 
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I think that Gail Hart's article (which was just posted online today), Midwifery Today Responds to Study Questioning Homebirth Safety, is an awesome rebuttal to the conclusions that were drawn by this flawed meta-analysis. Gail Hart!


And as an aside, I just have to respond to this:
Quote:
Originally Posted by Charmie981 View Post
I've often said (in person, not online...because I know there will be backlash) that I don't "trust birth." I'd much rather trust that "birth is as safe as life gets." Life isn't safe and I don't trust that it will allow me to be here tomorrow. In some cases, birth can be made safer by swift and judicious intervention and in other cases, it can be made less safe. The ultimate goal for me (and my clients) is always a safe birth in which they know that any medical interventions were necessary interventions.
I feel like disparaging the term "Trust Birth" is almost like a personal attack on Carla Hartley and the whole Trust Birth movement. Both as a friend of Carla's and as a midwife who does trust birth, I'd just like to provide some clarification about Trust Birth. Written by Carla herself (and quoted with permission): "I am wondering, why those who are so riled up about Trust Birth take such an interest in slamming what we do and what we believe. How are we hurting you? Or more to the point, how will it hurt you if women take their births back and start trusting that they know how to do this? If they make the rules? If they un-invite you?
-Insert big sigh here-
I personally wish that there was no need for a Trust Birth movement. I wish I could just help women become authentic 'with woman' midwives. But wherever there are lies, there is the need for truth. The idea that birth is a medical event, or even one fraught with danger, is a lie. It doesn't matter who is telling it. Yes, midwives in any setting are usually better than OBs. Home birth is safer than hospital birth. But the truth has not quite been told if you stop at home birth and midwives. To tell women part of the truth and not all of the truth borders on criminal, in my opinion. Tell the whole truth: Birth is MORE safe than not. Interference is MORE risky than not. Birth belongs to the women giving birth and they have the right to choose who is there or not there. PERIOD. Women should be acknowledged, and deferred to, as their own authority and everyone else should agree to be in service to her....not to tell her what to do or give her permission to do what her body knows how to do.

Now, to you women reading this who are not midwives. Everything the Trust Birth Initiative does is for you and your babies. Even though the bulk of the criticism of the Trust Birth movement comes from midwives with a little slice or two from Dr. Amy, midwifery is peripheral to what we are about. Trust Birth is about helping you. No payment required. No need for titles or officialness. If you want someone to believe in you and help you research and prepare for birth..... or walk with you at any stage of your pregnancy, labor and birth, Trust Birth is here for you. We will help you find the facts and find your power. We want you to fully embrace your ownership of birth. We want to tell you the whole truth, not just the part that serves birth attendants. You were made to do this. That is truth."
~Carla Hartley, mother of the Trust Birth Initiative
http://www.facebook.com/carla.hartle...d=411391578603
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#86 of 98 Old 07-07-2010, 07:00 PM
 
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Ah, and there's the backlash. I didn't attack Carla Hartley. I said that "trust birth" isn't what works for me in my practice and I'm happy to offer something different to my clients. I do wonder, after reading that, what Carla Hartley's response would be to women who have found, as some have on this very thread, that birth was not worthy of their trust.

Charlotte, midwife to some awesome women, wife to Jason, and no longer a mama to all boys S reading.gif('01), A nut.gif ('03) S lol.gif ('08) and L love.gif ('10).
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#87 of 98 Old 07-07-2010, 07:16 PM
 
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The idea that birth is a medical event, or even one fraught with danger, is a lie. It doesn't matter who is telling it. Yes, midwives in any setting are usually better than OBs. Home birth is safer than hospital birth. But the truth has not quite been told if you stop at home birth and midwives. To tell women part of the truth and not all of the truth borders on criminal, in my opinion. Tell the whole truth: Birth is MORE safe than not. Interference is MORE risky than not. Birth belongs to the women giving birth and they have the right to choose who is there or not there. PERIOD. Women should be acknowledged, and deferred to, as their own authority and everyone else should agree to be in service to her....not to tell her what to do or give her permission to do what her body knows how to do.


If birth was not safe, the human race would've died out a long time ago.

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#88 of 98 Old 07-07-2010, 08:09 PM
 
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Not to derail the thread too much but I do hope that as professionals anyone reading this thread will consider how horrendously hurtful it is for those of us who "trusted" our birth and ended up losing our babies or in seriously compromised positions to hear this trite way of describing a finely balanced biological and physical process.

I realize I haven't posted my birth story but I was pushing my daughter against her cord for four and a half hours until her heart stopped. I trusted the women around me who were telling me this is just part of being a woman. And it was awful to feel the dreadful weight of those lying reassurances, and to have bought into them. I had panicked about an hour before my daughter's heart stopped but I grit my teeth and refused to ask about a c-section because I trusted that "my body was made for this." Well that was a flat-out lie. It is brutal to watch people perpetuate it.

As for the human race would have died out long ago - lots of people and children did die, and continue to die around the world because they don't have access to medical intervention when they need it. The reason losing a child in childbirth in this day and age is so isolating is because it is not common. Even a few generations ago it would have been quite normal. I had older woman who understood around me, because they had lost children. But very few of my peers have.

I am a supporter of natural childbirth and homebirth, and I agree that many hospitals over-intervene and that change is needed. But this kind of oversimplification not just drives me nuts personally, it is extraordinary hurtful and you lose me as a political ally when you insist on trite phrases. I am sharing this in the hopes that some people might stop.

~ Mum to Emily, March 12-16 2004, Noah, born Aug 2005, Liam, born January 2011, and wife to Carl since 1994. ~
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#89 of 98 Old 07-07-2010, 10:42 PM
 
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Charlotte, I usually agree with your posts, but you left yourself open to that when you used that phrase. Trusting birth does not mean that nothing will ever go wrong. It simply means that a mother is the ultimate authority over her birth. Anyone else involved is just a consultant, and to me, one of the main parts of my job is to help women find that ability to trust their own intuition. Even if things seem to be progressing quite normally during a birth, if a mama says, "Something's wrong" or something else along those lines, I listen to her. Sometimes it's just a matter of needing some reassurance, but a woman who is truly attuned to her body should never be made to feel like she doesn't know what is going on inside that body. The common thread in the stories of the women who have lost babies during homebirths seems to be that at one point, they *felt* like something was wrong, and their concerns were either dismissed by their caregivers or they felt afraid to speak up about their fears. Again--midwives are not the authorities on a woman's body. She is, and that should be respected by all caregivers above all else.

And I would also like to add that I am still dealing with a 2nd trimester loss of a baby that happened just a few weeks ago. Not the same situation, but my own grief still knocks me over. My comments were addressing a specific quote, and were noted as such.
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#90 of 98 Old 07-07-2010, 10:44 PM
 
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My heart goes out to all the mamas who have lost babies. I can't imagine the anguish. I want to clarify how I (and I think many others) interpret the phrase "trust birth". I don't think it's a matter of believing that birth is 100% safe all the time, or that there is always a happy outcome. For me, it is about trusting the motherbaby, and listening to the instincts of the mother, and being tuned in but not interfering unless necessary. In both of the tragic stories shared on this thread, it appears that the midwife was not trusting the mother's intuition and that can be a terrible (and in these cases, fatal) mistake. IMO a midwife's default should be trust that the process of birth will unfold naturally, but to also have the skills and sense to realize when something is amiss. I'm so sorry that there are mamas hurting because of those two simple words: trust birth. Words that were intended to protect you and your baby from unnecessary meddling and harm. I'm sorry that your gut was not trusted.
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