Thoughts on "planned home births are associated with double to triple the risk of infant death than are planned hospital births." - Page 4 - Mothering Forums

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#91 of 394 Old 03-15-2013, 02:57 PM
 
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you need to do more research :) The university programs get hundreds of applicants, it is incredibly hard to get in, in Ontario only 90 places between the three schools and over 900 apply, the same goes for MRU and UBC, they get probably 6-10 times more applicants than there are seats. This is my third year applying. We have more than enough interest the problem stems from not being able to have enough preceptors for our students and as such we cant raise the seats higher than we can support. Midwives have to pay professional fees every year as well as other business expenses, out of pocket, this is deducted off their paycheque. You are on call 24/7 and depending on where you work you either have 6-8 days off a month or 2 weeks off call, while still doing clinic work. Midwives do make decent money but they still have disparages in their pay and it's a job of passion not money or prestige.

 

electronic fetal monitoring is generally used when there is an indication

Are you positive about that? I hope to god you're wrong because I have two "friends" (on FB) who have gotten in, both on their first tries basically (by their on admissions) that they're "not good at anything else". If there are really hundreds of people lined up to get in, I have absolutely no idea how these two nitwits got accepted.

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#92 of 394 Old 03-15-2013, 03:28 PM
 
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Alan/Slackerinc, do tell the truth! You weren't banned. You were forbidden to go off-topic.

 

You derailed threads about any and every subject into endless harping about breast vs bottlefeeding.  A discussion about feminism was sidetracked by your insistent nagging about male circumcision. An when there was a thread that was supposed to be about breastfeeding, you insisted on discussing your stellar SAT-scores.

 

I'm not a supporter of Dr Amy but the way you hijacked that forum wouldn't have been appreciated on a pro-homebirth blog either. You made several hundreds of posts.

 

Besides, I am noticing  the same pattern here: why are you bringing up your shenanigans in a thread with a completely unrelated subject? 

OT: I've always been behind the 8 ball & the last to know.  Someone enlighten me to this, please?

 

Thanks,

Sus


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#93 of 394 Old 03-15-2013, 03:39 PM
 
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I don't know how helpful this is but in case it matters to anyone I can clarify re midwifery in the UK

 

We have direct entry, which is a 36 month course. This does not require you to have studied at degree level. You'd usually have A levels which I think are basically your high school diploma. Older applicants can offer alternative qualifications. It is highly competitive.

 

There is also an access to midwifery option for those who hold nursing degrees, which lasts 18 months. Again, highly competitive and you'd need to, iirc, have studied adult nursing to get on. Its being phased out. The main reason, as I understand it, for the phase out is that midwives actually don't appreciate the nursing crossover as they consider themselves a separate profession. Midwives, fundamentally, assist normal, healthy people at a particular stage of their life, and there is great emphasis on the client as in charge of their own treatment.

 

Midwifery is a recognised profession and seen as a branch of medicine in its own right. Midwives practice quite independently of both nurses and doctors and have a very distinct identity. 

 

Home births are normal, not seen as terrible outlandish, but relatively uncommon here. The midwives who cover them are also the midwives seen by all women routinely as part of antenatal care, and they also tend to cover birthing centre work so its quite normal to transfer from a home birth to a birthing centre. 

 

My understanding is that the statistics are around equal for safety for low risk women. Midwives tend to be quite proactive around suggesting home births IME, but tbh its a very flexible thing. With all three of mine a home birth was my first choice but I transferred to a ward in one case and the midwifery led unit in the other, only had one home birth, the last. It doesn't feel like a big, big deal really, certainly my midwives advised me to plan for a home birth because that was the hardest logistically for me, but were totally relaxed about any of the options.


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#94 of 394 Old 03-16-2013, 12:31 AM
 
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MotherCat... I was looking for some documentation for you. Mostly this has been personal communication with RNs... There was awhile back a doula who was in nursing school and she bloged about it- because she had tried to set up some additonal speakers for her class- unfortunate her blog is now private invites only.
Labor and delivery nurses now often have additional- professional develelopment POST basic RN cert/ licensing that has to do with EFM terminology and intrepretation, including what meds do to strips.... Stuff like that. But that does not mean that every CNM candidate has even worked Labor and Delivery other than inital roation in school. When researching CNM schools i came across an application form that allowed for RN without L&D experience to enter if they had taken a birth education course...
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#95 of 394 Old 03-16-2013, 05:31 AM
 
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Has anyone posted this yet?  Oregon mandated reporting of out of hospital birth rates in 2011.

 

The following testimony was just provided in committee for the state legislature, showing a 6-8 times higher rate of death for birth with a DEM (versus the 2 - 3 times we are discussing here). 

 

https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585

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#96 of 394 Old 03-16-2013, 06:50 AM
 
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Has anyone posted this yet?  Oregon mandated reporting of out of hospital birth rates in 2011.

 

The following testimony was just provided in committee for the state legislature, showing a 6-8 times higher rate of death for birth with a DEM (versus the 2 - 3 times we are discussing here). 

 

https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585

 



This deserves its own thread. The most compelling thing about this is that it comes from Judith Rooks, CNM. Who has published numerous articles on OOH birth. This is not coming from ACOG, or Dr Amy, or evil obstetricians somewhere - this is coming from a midwifery professional and proponent of OOH.(Though she is a proponent of safe OOH birth). It's time to start paying attention.

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#97 of 394 Old 03-16-2013, 11:30 AM
 
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I've removed several posts on this thread because MDC is not going to host discussions about member participation on other forums. Contributing to this topic is 100% welcome but how that topic plays out specifically on other forums will not be hosted. 


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#98 of 394 Old 03-16-2013, 12:54 PM
 
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With DEM's specifically?  Or are non-CNM's being assumed to be DEM's?  (Just wondering b/c often state-reported homebirths include unplanned unassisted births - like "back-alley crack babies" - and preterm deliveries, which would obviously be different from planned at-term homebirths.  I'm not saying this is one or the other, just wondering.)

Those stats certainly don't match what we see in any of the other studies done in countries that have bothered to study the stats.
 

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#99 of 394 Old 03-16-2013, 01:23 PM
 
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The link emphasizes that this is an analysis of planned homebirths/birth center births and is focused solely on the outcome for term births.

 

What the materials demonstrate very clearly is just how good hospital mortality rates are for term infants.  Also, I find it interesting that she did not specifically call out a line in the table for CNM births.  You can get there simply by subtracting the DEM attended birth information from all the planned homebirth/birth center birth information.

 

When I do that, I get 2 deaths for CNMS out of between 600 and 700 births attended. 


I support homebirth that meets the qualifications set forth in the AAP's 2013 policy on homebirth.

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#100 of 394 Old 03-16-2013, 01:33 PM
 
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Are you positive about that? I hope to god you're wrong because I have two "friends" (on FB) who have gotten in, both on their first tries basically (by their on admissions) that they're "not good at anything else". If there are really hundreds of people lined up to get in, I have absolutely no idea how these two nitwits got accepted.

Um, I'm on my third year applying and am an administrator on a facebook group of 300 people trying to get into the program, I have talked and worked with midwives and students and hopefuls for the program, so yes I am absolutely 100% sure I know what Im talking about. It is extremely hard to get into the program and the majority of people have to apply more than once to be accepted, applications range from 6-10 people applying for every seat.


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#101 of 394 Old 03-16-2013, 01:36 PM
 
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Stats are good but simple logic is too. Many complications are rare but if add up all of them, the chance of having one is not so low. 1-2% chance is high.    3-4-5% is even worse.

 

Home has no OR or blood bank or extra people to help. There is not way around it. An ambulance takes longer than 10 minutes and no one  know how to teleport patients yet.

 

The absence of technology at home is the reason why the stats are so bad.

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#102 of 394 Old 03-16-2013, 02:41 PM
 
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.6/ 1000 seems very very low. And these are the numbers for 1 year- hard to say if it was a fluke or a true trend. So what is the rate of iatrogenic preterm birth in Oregon? And what is the associated death rate with that? This is also why i included infant mortality rates in the above link because it is easy now to maintain a baby for a month or more but not forever- i recently was interviewed by a couple who had heroic measures used on their last baby and the baby lived for 6 months and they were looking for midwives who would not use extreme methods to save a life it the baby needs resuscitation at birth...
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#103 of 394 Old 03-16-2013, 03:47 PM
 
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Stats are good but simple logic is too. Many complications are rare but if add up all of them, the chance of having one is not so low. 1-2% chance is high.    3-4-5% is even worse.

 

Home has no OR or blood bank or extra people to help. There is not way around it. An ambulance takes longer than 10 minutes and no one  know how to teleport patients yet.

 

The absence of technology at home is the reason why the stats are so bad.

I disagree, look at studies for countries outside of the USA, stats look great and technology at home isn't any better than in the USA.


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#104 of 394 Old 03-16-2013, 04:31 PM
 
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I do agree that the technology at home is a very simplistic argument. Skills of the MW would be huge as well as transfer care (that we've touched on). Certainly well-baby care either by a pediatrician or a trained MW is also important.  


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#105 of 394 Old 03-16-2013, 05:45 PM
 
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I think that the europeans (i) do a better job risking out women who should not be attempting homebirth, (ii) are less hesitant to transfer and (iii) are better trained which accounts for the difference (in terms of better outcomes than here in the US -- I do not agreed that all european studies show "great' stats).

 

I still think that there are X number of women and babies who will be seriously injured and harmed without immediate access to an OR, blood products, sophisticated neonatal resuscitation, etc., but those numbers are likely fairly small where (i), (ii) and (iii), along with adequate prenatal care and appropriate midwife regulation/licensing requirements, are present.

 

Edited to add:  should have included (iv) do a better job licensing and regulating the midwives' practice.


I support homebirth that meets the qualifications set forth in the AAP's 2013 policy on homebirth.

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#106 of 394 Old 03-16-2013, 06:17 PM
 
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I just looked at the numbers again -- and it really is amazing. 

 

If you had a homebirth with a DEM in Oregon last year, you had a 1 in 400 chance of your term baby dying. If you include intrapartum deaths you had a 1 in 175 chance of your term baby dying.  One in 175!!!

 

This is versus a 1 in 1600 chance of your term baby dying while giving birth in the hospital.

 

So, do you think DEMs in Oregon will be including this information in their informed consent documents?

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#107 of 394 Old 03-16-2013, 06:51 PM
 
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I just looked at the numbers again -- and it really is amazing. 

 

If you had a homebirth with a DEM in Oregon last year, you had a 1 in 400 chance of your baby dying. If you include intrapartum deaths you had a 1 in 175 chance of your baby dying.  One in 175!!!

 

This is versus a 1 in 1600 chance of your baby dying while giving birth in the hospital.

 

So, do you think DEMs in Oregon will be including this information in their informed consent documents?

When I read these statistics, it reminds me of the presentation I saw in 2007 by Ina May Gaskin.  During it she talked about how in the US, the statistics that are kept for maternal & infant mortality are not indicative of all the actual deaths.  She talked about all the states & their death certificates, that they do not all ask if the woman had been pregnant during the last so many months of her life (some would ask in the last three months, others would ask a different # of months & some, IIRC, didn't ask at all).  Death certificates are not uniform throughout the country & vary by state.  So, while I don't disagree that a less skilled birth attendant won't likely have as good of outcomes as a more skilled one, I highly doubt that we really are doing as well over all as statistics like the one above, 1 in 1,600 chance in the hospital.

 

I have not researched the above further.  It simply made an impression upon me nearly six years ago.

 

Sus


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#108 of 394 Old 03-16-2013, 07:01 PM
 
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.6/ 1000 seems very very low. And these are the numbers for 1 year- hard to say if it was a fluke or a true trend.
That does sound low but I think it is supposed to be for a comparable population to those who are candidates for home birth (singleton, term birth, no high-risk factors).
So what is the rate of iatrogenic preterm birth in Oregon? And what is the associated death rate with that?
Probably a lot lower than 4 or 5 out of 1000. Bear in mind a lot of iatrogenic preterm births are going to be "late preterm". 35-36-37 weekers tend to do pretty well. Hospitals are not screwing up right and left and delivering babies massively early. 
This is also why i included infant mortality rates in the above link because it is easy now to maintain a baby for a month or more but not forever- i recently was interviewed by a couple who had heroic measures used on their last baby and the baby lived for 6 months and they were looking for midwives who would not use extreme methods to save a life it the baby needs resuscitation at birth...
Not really a comparable scenario. Presumably most people who plan homebirths want a living baby out of the deal. 
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#109 of 394 Old 03-16-2013, 07:37 PM
 
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This link is to the story about what started the birth/newborn death statistical review in Oregon.

Even the LM who was the director of the Board of Direct Entry Midwifery states that she now feels  that licensing should be mandatory. The lack of mandatory licensing means that there is no accountability either for education before beginning practice, continuing competencies during practice, or for accurate reporting of care during labor and the newborn death. 

I keep coming back to the point that birth OOH can be safe, but it is the provider that makes it safe. It is not always a simple matter  for women to suss out how the midwife practices and if others have reported problems that could be life threatening. Mandatory educational minimums and licensing for all midwives will help to ensure that women can make informed, educated choices by knowing who is qualified and who is not. The site maintained by Oregon Midwife Info is publicly available  information and details complaints made against midwives and the actions that the Board of Midwifery has taken with regard to those complaints.

 

IMHO this information should be available in every state, so that every woman considering home birth/birth center birth would know what she is choosing. That would make home birth safer.

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#110 of 394 Old 03-16-2013, 07:44 PM
 
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mwherbs, the reason I asked about your reference for the didactic in nursing for pregnancy and birth is that I am a midwife and have also been a clinical instructor for nursing students during their OB rotation. Nursing students education regarding pregnancy and birth comprises an entire semester or quarter (depends on the program) which is several weeks in length. These are state and national standards. It is far more than 1-2 hours of didactic.

 

erigeron: breech should also be considered a high risk condition. It is one of the conditions that Oregon is considering restricting for home birth midwives. (See the first link in my post above)


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#111 of 394 Old 03-16-2013, 09:50 PM
 
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"That does sound low but I think it is supposed to be for a comparable population to those who are candidates for home birth (singleton, term birth, no high-risk factors)."

 

Actually -- I don't think that's accurate.  As I read the materials provided, there is no distinction given as to the risk factors of the populations involved other than one qualifier -- being that only term births are included.  Further, while the OOH table pulls out the one death resulting from congenital abnormalities, the author specifically notes that the hospital number does not.  In other words -- births involving cogenital abnormalities incompatible with life are included in the hospital number.

 

In other words, as I read these materials the hospital number includes mothers with heart conditions, pre-eclampsia, multiples, breech births, etc., etc.

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#112 of 394 Old 03-17-2013, 02:41 AM
 
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the primary cause of preterm birth now is induction or c-section . So it is when ever ,yes there are desires to get a baby to 33-34 weeks but not always.... And it would be incorrect to think that midwives in Oregon do not attend breeches, twins and vbac because they do. . The controlling was for term births. So twins by medical birth/c-section are almost always preterm 34 weeks- so twin stats would probably not be included in the Oregon hospital term birth stats- but would be part of the home birth stats- And the death rates for breeches and twins is higher c- section or vaginal birth for these births compared to singleton vertex term births.
Because one of the deaths was from congenital anomaly of a BABY- She probably did not discuss those stats because it would be too far off the point that she is trying to make... And she is saying that is the thing that would not be changed by regulation or different birth place..
Since there are very staunch supporters of UC births amoung Oregon midwives it would also be hard to say if some of these losses are related to UC births- quite awhile ago we had a survey on mothering and the death rate was 1/200 or 1/300 cant remember but quite high -
The midwives that field / investigate the complaints in Oregon have no jurisdiction to act on complaints against unlicensed midwives.
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#113 of 394 Old 03-17-2013, 02:47 AM
 
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Mothercat, associates or bachelor's ? I am pretty sure these were associates RNs they have complained and complained about how little time and focus and how scared they were during clinicals...
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#114 of 394 Old 03-17-2013, 05:00 AM
 
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Who posted the Oregon article/letter? Can we get some original source material for that study? The second article linked by Mothecat is pretty good. My state (and I don't know all the nitty-gritty) is going through something similar as Oregon.  Oregon has 150 DEMs practicing? That's a lot, no? Knowing that the experience and training can vary quite a bit from DEM to DEM, I wonder if the original study shows much better results from some of Oregon's seasoned DEMs.  


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#115 of 394 Old 03-17-2013, 05:29 AM
 
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The OR document was submitted during a legislative committee hearing on Friday regarding licensing OR MWs . It's accessible through the OR state govt website.

It really does not have a lot of detail - we're left guessing what the methods were used for collecting and including data. Not saying I think it's wrong - just that it's not as thorough had it been a published review.

The point made was that there's a discrepancy between OOH and hospital births in OR - and this discrepancy is not slight.

"Why" is another whole question.
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#116 of 394 Old 03-17-2013, 05:35 AM
 
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The OR document was submitted during a legislative committee hearing on Friday regarding licensing OR MWs . It's accessible through the OR state govt website.

It really does not have a lot of detail - we're left guessing what the methods were used for collecting and including data. Not saying I think it's wrong - just that it's not as thorough had it been a published review.
 

What document? The letter? Is the original source material not available? 

 


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The point made was that there's a discrepancy between OOH and hospital births in OR - and this discrepancy is not slight.
 

I'll have to read the letter again but that wasn't the point, from my read. 

 

 

 

 


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mwherbs: I was a clinical instructor with an ADN program and a graduate of a diploma (3 yr, hospital SoN) program. Either way, there is still a lot of classroom time devoted to pregnancy and birth. It's an entire rotation. The clinical portion alone was 12 hours per week and classroom time was at least twice that. I have also taught the NCLEX review class for OB and  by itself that was an 8 hour day. This is not a fluke. These are national standards for the amount of classroom and clinical time. I am not sure how the students or nurses you spoke with could have attended an accredited program and had gotten less than this.

Your point about preterm birth seems a red herring. If babies are being born by induction or C/sec at 34 weeks there is a medical reason for that birth. PPROM, severe preeclampsia, chorio, abruption, and a dozen more.  The gestational age at birth is secondary to the medical reason for the birth.

 

IdentityCrisisMama: the original Oregon testimony is below. I couldn't get the table to copy well. I can send you the entire thing if you wish (3 pp as a pdf) as I don't have permission to create attachments. Then you can post it if you wish.

 

My name is Judith Rooks.
I’m a certified nurse-midwife, a past-president of the American College of Nurse-Midwives, and a CDC-trained epidemiologist who has published three major studies of out-of-hospital births in this country.
In 2011 the Oregon House Health Care Committee amended the direct-entry midwifery—“DEM”—law to require collection of information on planned place of birth and planned birth attendant on fetal-death and live-birth certificates starting in 2012.
Oregon now has the most complete, accurate data of any US state on outcomes of births planned to occur in the mother’s home or an out-of-hospital birth center.
This table summarizes that data (PTT slide):
On the 1st row, you can see that nine babies died during or soon after labor in homes or birth centers.
The total mortality rate for planned out of hospital births was 4.5 per thousand, as seen in the last column of that row.
I have included the number of neonatal deaths both with and without the death of one baby who died of congenital abnormalities. That death cannot be attributed to the care given by the DEM attendant.
The 2nd row shows data on deaths associated with planned OOH births with direct-entry midwives as the planned birth attendants.
The total mortality rate associated with those births – excluding the one involving congenital abnormalities – is 4.8 per 1000.
For comparison, data on births planned to occur in hospitals is provided in the bottom row of the table.
Note that the total mortality rate for births planned to be attended by direct-entry midwives is 6-8 times higher than the rate for births planned to be attended in hospitals. The data for hospitals does not exclude deaths caused by congenital abnormalities.
Many women have been told that OOH births are as safe or safer than births in hospitals. This is true in some places, including British Columbia.
2
But out-of-hospital births are not as safe as births in hospitals in Oregon, where many of them are attended by birth attendants who have not completed an educational curriculum designed to provide all the knowledge, skills and judgment needed by midwives who practice in any setting.
Most women who have OOH births with direct-entry midwives are very happy, support them strongly, and many will contact their legislators to argue that DEMs do not need more education or regulation.
Oregon needs more direct entry midwives. More and more women want to have out of hospital births, and they want direct entry midwives. But currently the collective practice of these midwives is not safe enough.
In 2012 six Oregon mothers lost their babies in births attended by DEMs. They may feel guilty about having chosen a home birth with a DEM and are unlikely to lobby their legislators.
The more than a thousand women who had good outcomes and are happy are the ones who will call you. The legislature won’t have another opportunity to make the law stronger on behalf of safety until 2015. Please keep the six women who lost their babies last year in mind as you legislate this year.
 


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#118 of 394 Old 03-17-2013, 05:43 AM
 
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Grumbling that the letter, which is based on the need for quality research, does not cite her source. 


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#119 of 394 Old 03-17-2013, 05:44 AM
 
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I realize that this letter was submitted as testimony. I wasn't talking about the original letter. I'm talking about the source of the data that she uses in the letter. 

 

She says this: 

 

 

Quote:
This table summarizes that data

 

So, what data? Why wasn't that cited? My question is whether the original source that she is citing is available? 


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#120 of 394 Old 03-17-2013, 05:58 AM
 
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And this is not to say that I don't agree with her assessment (not that I am qualified to weigh in, necessarily). I acknowledge some of the concerns of licensing DEMs but my somewhat uninformed instinct tells me that the benefits outweigh the negatives. 


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