Risk factors and homebirth - a general discussion for supporters of HB. - Mothering Forums
1 2 
Homebirth > Risk factors and homebirth - a general discussion for supporters of HB.
IdentityCrisisMama's Avatar IdentityCrisisMama 07:24 AM 04-25-2013

I'm wondering if we can have a general discussion among those who support homebirth about the issue of risk factors.

 

Because our own experiences with HB (whether you are a care provider, someone who has had a HB or is considering a HB, or perhaps was risked out of HB, or even your spiritual affiliation and etc.) is an important factor in how we formulate our opinions about this subject, please share a little about you and your relationship to HB. And then share your feelings on risk. Specifically things like:  

 

  • Should risk factors and HB be regulated 
  • What are the ethical considerations when a MW takes a client with risk factors? 
  • Do we consider risk to be on a spectrum? Or would we like to see some hard lines about what is considered risk and what is not? 
  • How does the issue of lack of availability for care options in the hospital impact this issue. For instance, is the lack of availability for VBAC in a local hospital justification for HVBAC? 
  • What role (if any) does choice regarding testing impact risk? 
  • Do you think that a woman choosing HB in the presence of risk factors is primarily driven by the mother or by MWs? What are the ethical implications of this difference? 
  • What about consent? Are mothers who choose HB with risk factors given adequate information about HB and risk factors? What would/does this look like?  
  • What do you think about the term "variation of normal"? 
  • How do groups like the Amish, for instance, impact this issue if at all? 
  • How do your own experiences with HB impact your opinion this issue? 
  • What other topics do you think relate to this issue? Please share! 


rachelsmama's Avatar rachelsmama 08:11 AM 04-25-2013

Good idea for a thread! 

Quote:
Originally Posted by IdentityCrisisMama View Post

I'm wondering if we can have a general discussion among those who support homebirth about the issue of risk factors. Specifically things like:  

 

  • Should risk factors and HB be regulated 

 

I'm not sure.  I think that regulations could prevent midwives from pushing women into homebirth who might be better off in hospital, but at the same time, making it impossible to find a MW will drive some women to choose UC who would have preferred a MW attended birth, or would force them into unnecessary surgery.

 

  • What are the ethical considerations when a MW takes a client with risk factors? 

 

Just like when a MW takes a low risk client, or an OB takes a client, there needs to be informed consent.  There needs to be honesty about what the risks are, and what the care provider's skills are, and whether there is another care provider who might be a better fit.  All care providers have an ethical obligation to keep updating their skills, and trying to improve. 

 

  • Do we consider risk to be on a spectrum? Or would we like to see some hard lines about what is considered risk and what is not?

 

Yes, I consider it to be a spectrum.  While I think there are births that are definitely too high-risk to be a planned homebirth, I think there are a lot that fall into a grey area. 

 

  • How does the issue of lack of availability for care options in the hospital impact this issue. For instance, is the lack of availability for VBAC in a local hospital justification for HVBAC? 

 

Yes.  And some hospitals that support VBAC in theory aren't very supportive in practice.

 

  • What role (if any) does choice regarding testing impact risk? 

 

In my experience, I got really shoddy care from one care provider who was inflexible about testing, but couldn't keep me straight from other patients, and I got fantastic care from another care provider who was more than willing to skip or substitute tests based on how relevant they were to me.  I think the individualised testing was more useful for assessing risk, and that removing choice doesn't really have much benefit.

 

  • Do you think that a woman choosing HB in the presence of risk factors is primarily driven by the mother or by MWs? What are the ethical implications of this difference? 

 

I suspect that it's mother driven more often than gets recognised.  Much of the time, when HB risks are discussed, the tone of the conversation implies that us women are hapless victims of the whims of midwives, but in real life, most of the moms I know who have aimed for HB did their research first, and hired a midwife second.  (I realise there are a few really unethical midwives out there, I'm not trying to dismiss the experiences of women who were misled or mistreated.)

 

  • What about consent? Are mothers who choose HB with risk factors given adequate information about HB and risk factors? What would/does this look like?  

 

I think that depends a lot on the care providers. 

 

  • What do you think about the term "variation of normal"? 
  • How do groups like the Amish, for instance, impact this issue if at all? 
  • What other topics do you think relate to this issue? Please share! 

eltongomez's Avatar eltongomez 08:42 PM 04-25-2013

These are excellent questions, and monumentally important.  My experience with OOH birth was at a freestanding birth center where risks were not adequately explained, there were no risking out protocols, and our baby did not survive injuries sustained at delivery.  My responses to these questions will most certainly be affected by that experience.  That being said, I very much value choice and OOH options, I simply think they could be much, much safer and more consistently so. 
 

  • Should risk factors and HB be regulated 

Every other country that has professional, university trained midwives within a national health care system, also has specific risking out criteria and screening measures.  We often say HB is for low-risk mothers, but we don't want to define what that means or looks like.  The purpose for screening isn't to rob anyone of their choice, it's to prevent preventable deaths and injuries.  If we don't define or regulate what risk factors put mom and baby in danger, how can we say a pregnancy is indeed "low risk"?  Too many times assessments are disregarded as unnecessary, and risk factors downplayed.  Mothers sign waivers because they trust that their midwives have "informed" them.  It's my personal opinion that some risk factors should minimally require a collaborative care visit with an OB, and that a balanced board of highly educated midwives and docs should establish guidelines for both assessments and transfer of care for HB midwives. 
 

  • What are the ethical considerations when a MW takes a client with risk factors? 

I believe that if midwives want to be licensed, educated, professional care providers, they have a tremendous responsibility to keep their clients (mom and baby) safe above all else.  If a mother is asking her midwife to support her in a knowingly dangerous/risky situation, she still has a professional obligation to protect the life of that baby.  I suppose it always depends on the circumstances, but wanting a candle lit home birth in a tub doesn't overrule judgements by a professionals that would put mom or baby in harm's way.  The midwife is the paid leadership, and has an obligation to make it clear to her client long before labor starts, that choices have limits in the professional world.  I don't know any mother who would argue with true informed consent in a high risk situation...if her midwife looked and her and said, "I know you don't want a cesarean, but you/your baby may not survive if we don't get help."  Our ideals cannot trump safety.  A midwife can help the situation by helping the mother find appropriate care, or perhaps considering dual care to support the mother in her journey.  A midwife's philosophy also influences this a great deal.  If the midwife believes and teaches women to "trust birth at all costs" and tells them that things just work out the way they are meant to be, then it is extremely difficult for a mother in a high risk situation to see the need to consider alternatives.  A healthy perspective from the beginning of prenatal care would go a long, long way. 
 

  • Do we consider risk to be on a spectrum? Or would we like to see some hard lines about what is considered risk and what is not? 

There is room for a spectrum and hard lines.  There are so many complications.  That's why if each state had a board of midwifery composed of highly educated midwives and docs who could navigate guidelines for "consultation", "Collaboration", Risking out, and transfer of care, the water would be less muddy.  ACNM already has suggested guidelines for HB...some choose not to follow them.

 

  • How does the issue of lack of availability for care options in the hospital impact this issue. For instance, is the lack of availability for VBAC in a local hospital justification for HVBAC? 

Another example I often hear is that there aren't OBs trained in breech delivery.  Our baby was breech.  Our midwives told us we were as safe, if not safer outside the hospital.  There was no effort to connect us with a consulting physician, even though (as we found out later) there are OBs in our area who offer breech TOL.  I don't think lack of availability is an excuse for taking advantage of a mother's vulnerability.  It needs to be made very clear that choosing HB in these kinds of situations could very much end up in disaster.  Women deserve to know they are risking the lives of their babies and themselves by not seeking the care that is available, and too often it's not explained that way.  Instead, it's about being a "variation of normal".  Don't get me wrong here, I think options are often limited and that absolutely needs to change...but in the meantime, taking huge risks with lives (especially when those risks aren't explained upfront) doesn't fix the problem, it creates a lifetime of heartache.  Midwives aren't doing any favors by taking on high risk situations b/c we don't like what's available to us.

 

  • What role (if any) does choice regarding testing impact risk? 

I touched on this briefly earlier.  Women cannot make a "choice" when the care giver they trust is telling them the test isn't necessary in the first place.  If the midwife downplays or doesn't understand the importance of assessments, that will transfer over in her care and greatly influence the client.  Often women who choose HB have a very special bond and level of trust with their midwives.  They believe them when they tell them "there isn't any research that says ultrasounds are safe"  "Babies come when they are ready" "GD testing is often false", and on and on...The assessments are key in monitoring a woman for risk.  If the assessments are skipped, there is no way to ensure "low risk".  Avoiding assessments is like putting on blinders to risk, and just hoping all goes well.  There is a distinct difference between making an "educated choice" and being indoctrinated, and it's hard to tell the difference when you're in the thick of it. 

 

  • What about consent? Are mothers who choose HB with risk factors given adequate information about HB and risk factors? What would/does this look like?  

I can only speak from my own experience, and I absolutely was NOT informed adequately about risk factors.  No one explained that even under the best circumstances and with a low risk pregnancy that OOH birth brings a 2-3 times greater chance of death.  No one explained that with a breech baby those numbers increased dramatically.  We asked what potential complications might be and never was there discussion that our baby may not survive.  Instead, risks were downplayed, and we were told about "research supporting vaginal breech delivery" and that they would know what to look for and when to get us help if we needed it.  It was the opposite of being informed of risks, it was being sold on the idea that it was somehow the safest route.  I think this question could be answered many different ways, depending on the individuals involved.  I still believe though that it is the professional's responsibility to say no to situations she knows to be dangerous, and help find the mother safer care.  I would like to see boards of midwifery (as mentioned above) write state-wide informed consent criteria so that mothers can be informed consistently and thoroughly.  Certain elements should be present in every informed consent document.  Risky situations should also require direct consultation or dual care with an OB. 

 

  • What do you think about the term "variation of normal"? 

The phrase "variation of normal" is misleading.  Everything is a variation of normal, but to what degree and how far of a variation means danger?  This is a phrase being used to down play risk and it leads mothers to believe things are always just fine, when in fact they may not be. It feels more like manipulation that truth.  


MyLilPwny's Avatar MyLilPwny 09:41 PM 04-25-2013
I had a home birth with my 5 year old daughter and from my research I determined that a hospital birth is way more risky than home birth.
phathui5's Avatar phathui5 11:24 PM 04-25-2013

Here's my story (well, one of them). I was seeing a CNM when I was pregnant with my fourth baby, planning to have a homebirth with her. At 38 weeks, she called me at home to let me know that because my iron was low, she wasn't able to attend my birth at home. I'd had low iron with the pregnancy before that (to the point that the birth center where I was going kept telling me that it was borderline and I might not be able to birth there) and things had gone well with the birth.

 

So at 38 weeks, I decided that I was not willing to birth in the hospital despite the increased chance of hemorrhage from the low iron and found a midwife who would be willing to attend my birth at home. Dh and I discussed our options (hospital birth with CNM, unattended birth, home birth with CPM) and decided that we were the most comfortable taking on the risks of staying home vs the risks of birthing in the hospital. We chose home birth, The midwife agreed to come, she didn't encourage us to stay home but she didn't refuse to be there. She didn't tell me that my low iron was normal.

 

For me, the birth went fine. I did not hemorrhage. My postpartum recovery was not adversely affected. I felt that I sucessfully avoided the risks of hospital birth. If something had happened, I feel like it would have been my responsibility, not the responsibility of the midwife who agreed to attend my birth so that I wouldn't be home alone. 


krst234's Avatar krst234 01:05 PM 04-26-2013

I think these are great questions - though each deserves its own thread! So many topics for discussion - I don't know where to start.
 

Quote:
  • Should risk factors and HB be regulated 
  • What are the ethical considerations when a MW takes a client with risk factors? 

 

I'm not a hard black and white thinker - but I do think some risks should be regulated out of OOH birth - BUT - I know this will not prevent these types of births from happening OOH. But I think there needs be guidelines - and if both the client and the MW are willing to take risks and accept the risks - and knowingly go outside of the parameters of safety and normalcy and legality- they should be able to make that decision. It gives the decision a weight that is not there when it is all 'permitted.'

 

The problem comes when certain risk factors or conditions are not legally deemed inappropriate for OOH birth, and parents are led to believe that because it is not explicitly contraindicated, it must be safe. Or it may be safe. Why would the state license providers (MWs) to attend risky births at home? I'm actually not totally against risky birth OOH - but I do believe everyone involved should be made fully aware that the 'deviations of normal' presented by certain risk factors actually increase the chance of something bad happening. Awareness of the risks is key.

 

Ethically - midwives have the responsibility to convey the risk of any conditions that may increase risk to the mother and baby, and provide alternatives to OOH birth - I believe it is the professional midwife's responsibility to help the clients navigate through challenging health/pregnancy conditions, provide unbiased information, and help the clients have the safest and most satisfying birth experience. I don't believe midwifery care means OOH birth is superior in all situations. I do believe midwifery care encompasses more than just the physical needs of the client. When clients become too high risk for OOH midwifery care, I believe the most ethical thing to do is to provide personalized, midwifery care in a supportive role in the safest environment for the client. And yes, sometimes that is in the hospital.


Gena 22's Avatar Gena 22 01:13 PM 04-26-2013

It is unethical to force a person to have medical procedure without their consent, as it is unethical (less so) to force a provider to do things to which they don't consent.  So while I can understand a provider saying they would not attend a VBAC for instance, it is similarly wrong to force women into surgical births to which they don't consent. 

 

Hospitals are limited in the options they can present women with.  Limited as business models and by liability.  Plenty of women don't want the birth hospitals offer.  Because of that, as a society we have an interest in assisting women choosing to birth at home.  Does that mean licensing?  Maybe.  Personally I don't think so.  Licensing means hard lines on the women HB midwives can attend.  When those are the very women who won't go to the hospital because of what means.

 

I was a primi-para carrying di-di twins.  Family history of late, long labors and a local hospital with a 20% vaginal birth rate for twins.  I felt I had to have a HB to prevent surgery I didn't need.  Thankfully I live near Amish communities served by a wonderfully experienced CPM.  And I had a great birth.

 

Because of the way we're structured our hospitals, "high risk" women are just the ones looking for homebirths in many instances.  And we should make that a good choice.


IdentityCrisisMama's Avatar IdentityCrisisMama 05:32 AM 04-29-2013

I have removed a post on this thread. Members are welcome and encouraged to correct information they feel is inaccurate but doing so must follow our UA and avoid name calling: 

 

 

Quote:
We expect our members to keep conversations civil and on topic, and uphold the integrity and diversity of the community. We value the honest and supportive exchange of ideas and opinions, and we ask that members avoid negative characterizations and generalizations about others.

fairydoula's Avatar fairydoula 11:26 AM 04-29-2013
Quote:
Originally Posted by phathui5 View Post

Here's my story (well, one of them). I was seeing a CNM when I was pregnant with my fourth baby, planning to have a homebirth with her. At 38 weeks, she called me at home to let me know that because my iron was low, she wasn't able to attend my birth at home. I'd had low iron with the pregnancy before that (to the point that the birth center where I was going kept telling me that it was borderline and I might not be able to birth there) and things had gone well with the birth.

 

So at 38 weeks, I decided that I was not willing to birth in the hospital despite the increased chance of hemorrhage from the low iron and found a midwife who would be willing to attend my birth at home. Dh and I discussed our options (hospital birth with CNM, unattended birth, home birth with CPM) and decided that we were the most comfortable taking on the risks of staying home vs the risks of birthing in the hospital. We chose home birth, The midwife agreed to come, she didn't encourage us to stay home but she didn't refuse to be there. She didn't tell me that my low iron was normal.

 

For me, the birth went fine. I did not hemorrhage. My postpartum recovery was not adversely affected. I felt that I sucessfully avoided the risks of hospital birth. If something had happened, I feel like it would have been my responsibility, not the responsibility of the midwife who agreed to attend my birth so that I wouldn't be home alone. 

Are you a midwife now, phathui5? I am asking, because you seem uninformed. And I'm concerned because you don't seem to understand basic physiology. The risk when a woman has low iron is not hemorrhage, but a lack of ability to recover FROM a hemorrhage. Do you know the difference? If you do not, that is concerning if you are in fact a midwife, serving other women. You should know that low iron means that O2 (oxygen) has difficulty entering the bloodstream, because of the way in which it travels. Therefore, if a woman has LOW iron in her blood, that means that for each pass through the lungs, the blood is unable to pick up as much oxygen as normal, because of the lack of iron. But by no means does low iron mean a higher risk of hemorrhage. It means a struggle to recover from blood loss, which is a different thing altogether. Even mild blood loss can be much more damaging to a woman with low iron levels, because she is not as able to compensate. There are also studies that show that low iron is problematic for infants during pregnancy and that low iron is generally associated with a higher risk of death for the pregnant/laboring mother. This is more evident in countries with much worse perinatal care than ours... there are lots of different sources to study.. I would hope you would look into it further, if you are providing care to others. Low Iron levels, or anemia, is a problem that should not be dismissed out of hand, in pregnancy, or indeed, in any woman of childbearing years. It contributes to many different health problems. Please consider getting some further education to offer even better care for mothers and babies. Thank you.


mothercat's Avatar mothercat 12:21 PM 04-29-2013
Quote:
Originally Posted by fairydoula View Post
But by no means does low iron mean a higher risk of hemorrhage. It means a struggle to recover from blood loss, which is a different thing altogether. Even mild blood loss can be much more damaging to a woman with low iron levels, because she is not as able to compensate. There are also studies that show that low iron is problematic for infants during pregnancy and that low iron is generally associated with a higher risk of death for the pregnant/laboring mother. This is more evident in countries with much worse perinatal care than ours... there are lots of different sources to study.Low Iron levels, or anemia, is a problem that should not be dismissed out of hand, in pregnancy, or indeed, in any woman of childbearing years. It contributes to many different health problems.

As a midwife the thing I always worry about is how the woman who has just given birth will be able to care for herself and her baby after a blood loss. For some women, it doesn't take a lot of blood loss for them to have trouble getting out of bed. Others can lose what I think is a lot and they seem to be fine. My job as a midwife is to check their hemoglobin (or better a CBC) to be sure it is in a decent range and help them keep it there. The other part of my job is to minimize blood loss after the birth so she can enjoy the baby. We never know how any amount of blood loss will affect any given woman, but we do know that a postpartum hemorrhage can damage the pituitary gland and seriously effect her milk supply, possible never recovering even for another pregnancy and a baby who nurses well.

 

Always better to err on the side of caution and have a couple of back up plans in case the first line of treatment doesn't work. Having access and knowing when to administer  Pitocin, methergine, and cytotec is key, as well as knowing when too much blood loss is too much and transferring in to the hospital.


IdentityCrisisMama's Avatar IdentityCrisisMama 05:19 AM 05-01-2013

I have removed a post because although it addresses risk it is more appropriate on its own thread. Choosing the original source material as the link (rather than the link provided on this therad), I started a thread on the new AAP policy statement on HB: http://www.mothering.com/community/t/1382637/new-policy-statement-on-hb-from-the-aap


phathui5's Avatar phathui5 01:39 AM 05-02-2013
Quote:
Originally Posted by fairydoula View Post

Are you a midwife now, phathui5? I am asking, because you seem uninformed. And I'm concerned because  you don't seem to understand basic physiology. The risk when a woman has low iron is not hemorrhage, but a lack of ability to recover FROM a hemorrhage. Do you know the difference? If you do not, that is concerning if you are in fact a midwife, serving other women. You should know that low iron means that O2 (oxygen) has difficulty entering the bloodstream, because of the way in which it travels. Therefore, if a woman has LOW iron in her blood, that means that for each pass through the lungs, the blood is unable to pick up as much oxygen as normal, because of the lack of iron. But by no means does low iron mean a higher risk of hemorrhage. It means a struggle to recover from blood loss, which is a different thing altogether. Even mild blood loss can be much more damaging to a woman with low iron levels, because she is not as able to compensate. There are also studies that show that low iron is problematic for infants during pregnancy and that low iron is generally associated with a higher risk of death for the pregnant/laboring mother. This is more evident in countries with much worse perinatal care than ours... there are lots of different sources to study.. I would hope you would look into it further, if you are providing care to others. Low Iron levels, or anemia, is a problem that should not be dismissed out of hand, in pregnancy, or indeed, in any woman of childbearing years. It contributes to many different health problems. Please consider getting some further education to offer even better care for mothers and babies. Thank you.

 

Wow. I posted my experience with my fourth baby as a mother. The midwife I was seeing (a CNM) risked me out because my iron was just under the cutoff for her protocols. I decided for myself that since it wasn't dangerously low (in my opinion), that I was comfortable birthing at home.

 

I'm going to bold the parts of your post where you jump to conclusions about my knowledge base without actually knowing me and then I'll address anemia and PPH.

 

You said:

 

 

Quote:
 The risk when a woman has low iron is not hemorrhage, but a lack of ability to recover FROM a hemorrhage.

 

That's part of the risk, but not completely accurate.

 

 

 

Quote:
But by no means does low iron mean a higher risk of hemorrhage.

 

That's not what the research shows.

 

"Anemia is associated with debility, which is a more direct cause of uterine atony." - Myles Textbook for Midwives p. 546

 

Association between anaemia during pregnancy and blood loss at and after delivery among women with vaginal births in Pemba Island, Zanzibar, Tanzania.

http://lib.bioinfo.pl/pmid:18686556

 

http://maternova.net/blog/running-empty-anemic-women-facing-labor-and-blood-loss

 

"Pregnancy puts a high demand on iron stores, and women who have had multiple pregnancies and perhaps began in a slightly anemic state are further depleted with each pregnancy. Thus a woman facing labor in a moderately or severely anemic state may be at greater risk from excessive blood loss."

 

"If we recall that the main reason for postpartum hemorrhage is uterine atony (failure of the uterus to contract properly), then the link between anemia and postpartum hemorrhage becomes more clear. Lower hemoglobin, less oxygen carrying capacity, less capacity to contract the uterus, higher postpartum hemorrhage"

 

On another note, this study found that women with mild anemia (like I had with my third and fourth pregnancies) had the best maternal and infant outcomes:

"Conclusions: Mild anemia fared best in maternal and perinatal outcome. Severe anemia was associated with increased low birth weight babies, induction rates, operative deliveries and prolonged labor."

http://www.ijgo.org/article/S0020-7292(02)00225-4/abstract


IdentityCrisisMama's Avatar IdentityCrisisMama 04:39 AM 05-02-2013

Thank you for responding, Phathui5. I suspect there may be interest in discussing anemia as a risk factors as an independent topic. Members wishing to continue the topic of this very specific risk are encouraged to start a thread on the subject. 

 

I will attempt to post today about my feelings on risk in general and HB. Hopefully we can get this thread back to the OT. orngbiggrin.gif


krst234's Avatar krst234 07:14 AM 05-02-2013
Quote:
  • Should risk factors and HB be regulated 
  • What are the ethical considerations when a MW takes a client with risk factors? 
  • Do we consider risk to be on a spectrum? Or would we like to see some hard lines about what is considered risk and what is not? 
  • What role (if any) does choice regarding testing impact risk? 
  • Do you think that a woman choosing HB in the presence of risk factors is primarily driven by the mother or by MWs? What are the ethical implications of this difference? 
  • What about consent? Are mothers who choose HB with risk factors given adequate information about HB and risk factors? What would/does this look like?  
  • What do you think about the term "variation of normal"? 
  • How do your own experiences with HB impact your opinion this issue? 

 

I think the discussion of anemia and home birth hits all of these topics listed above.

 

 

Quote:
Should risk factors and HB be regulated?

 

 

Many places, a maternal hemoglobin lower than 10g/dl is considered a contraindication to OOH birth. Is this appropriate? Or is this a risk factor that can be brushed aside as a 'variation of normal'?

 

 

Quote:
What are the ethical considerations when a MW takes a client with risk factors?

 

There are so many ethical considerations when a MW knowingly takes on a client with risk factors. Does the client understand the risks? Is the MW trained and skilled and staffed to handle any complications that may arise from this increased risk? Is the midwife influencing the client with her own comfort level with certain risk factors? What are the ethical implications when a MW openly states that she takes on clients with risk factors. Or if the MW decides that a hemoglobin of < 10g/dl is not a contraindication to OOH birth? What if the MW believes that a lower hemoglobin is actually *better* for the mother? Is this ethical?

 

 

Quote:
What role (if any) does choice regarding testing impact risk?

 

Well, if we don't perform screening or diagnostic tests during pregnancy, we can't really know which risk factors are present. Is it ethical to practice blindly - say, not knowing blood type, CBC, maternal antibodies, etc? A client has a right to refuse any and all tests - yet what is the responsibility of the MW to gather this data and base decisions on known information. If as a MW I allow my clients to refuse to have their hemoglobin checked, and the client suffers a morbid blood loss at a planned OOH birth related to undiagnosed anemia, am I not responsible as the MW for omitting this crucial assessment? Or is this solely the client's responsibility? The client refuses a standard of care, the MW agrees to this deviation of care, the client suffers, and it is the client's responsibility? No, I don't agree to this at all. At some point, refusing testing is a valid rationale to risk a client from the MW's care.
 

Choice regarding testing impacts risk quite a bit. Though too often, an 'unknown status' is treated like "WNL"

 

 

Quote:
Do you think that a woman choosing HB in the presence of risk factors is primarily driven by the mother or by MWs? What are the ethical implications of this difference?
 
What about consent? Are mothers who choose HB with risk factors given adequate information about HB and risk factors? What would/does this look like?


I used to believe that the choice to have an OOH birth in the presence of risk factors was primarily driven by the mother. After my experience with OOH births and MWs, I believe it is more driven by the MW's 'comfort' in higher-risk situations. It is very rare that a home birth client has the medical background to understand the risks of OOH birth, and the types of critical situations that could arise, and the near impossibility of OOH providers to handle certain complications without serious repercussions in the OOH setting. There are a few clients like this - but they are very few. I find that most parents/clients trust the MW's comfort level - and when a MW expresses comfort with a certain situation, they are led to believe it is safe.

 

What are the ethical implications of this? Well, it goes against the ethical principle of veracity - the duty to tell the truth. This is tricky because verbally, the MW may recite the all the risks, but non-verbally, the MW may be expressing comfort, and the biggest non-verbal cue would be the MW's willingness to continue to plan an OOH birth. WOW. What confusion for the client!

 

Consent in this situation.... needs to be clear, with no ambiguity. "This poses an increased risk to your health, your life, your baby's health, your baby's quality of life." Sorry if this sounds like fear-mongering. But too often, we want to bet our money on everything turning out 'just fine' because they probably will. This is a disservice to clients who are misled into believing their risk factors are inconsequential. Informed consent has to be pretty powerful - and let's not forget that true informed consent involves presenting alternatives. <---- that's plural. It's my responsibility to share with the client ALL the alternatives in a given situation (if there is sufficient time). Not "Well, you can go to the evil hospital and have an induction and a c-section" but "Dr A works in hospital B and can take on your care." "Dr B works in hospital C, and the OB nurses are very mother-baby friendly," or "CNM D has a great collaborative relationship with DR E, they practice about an hour away, but they also have very holistic care."

 

Informed consent from the MW would, in my ideal world, include the following:  "I am not trained or skilled in handling this situation, and in my professional judgment, you are safer in a hospital setting with access to skilled staff and emergency equipment."

 

I actually do believe in informed consent. But in certain situations, I would want the client to know that a decision to birth at home is NOT a safer one. But a riskier one. That would need to be VERY clear. No pretending that: 1) the risk factors are not meaningful, 2) the birth is appropriate for OOH, 3) the MW is equipped to handle these complications.

 

 

Quote:
What do you think about the term "variation of normal"?

 

Largely a matter of opinion. I've heard it used often to describe situations that are NOT normal. Not even close to normal. It's used to reassure clients that they do not need to transfer their care to a physician. Or it's just wishful thinking by the MW. Maybe a combination of these two things.

 

I *do* believe there are some variations of normal.... not a fan of the Friedman curve... but have seen deviations from the Friedman curve that I would consider truly 'variations of normal' and others that clearly were not. A matter of opinion.

 

If we're talking about hemoglobin. I'm not one that would take risks with an anemic mother at home. This seems to be asking for trouble. A heavy blood loss can make the most beautiful, glorious natural birth a very difficult and traumatic experience. My role as a provider is to assure the gentlest passage possible - having an anemic post-partum mother with delayed lactogenesis is not a gentle birth experience! It is a very difficult experience.

 

 

Quote:
How do your own experiences with HB impact your opinion this issue?

 

Personal opinions and experiences play HUGE roles in normalizing certain conditions in OOH birth. How many stories are out there about women with ***significant*** risk factors having *successful* homebirths?

 

I've had OOH births with risk factors, but I do not broadcast these risk factors to the world because I know they were risk factors. Telling others that my births ended up 'just fine' is misleading, and because of my professional status, I also believe it is unethical. Some of the risks I was "comfortable with" at home - others I think should have been handled in the hospital. I can't go back and change that. And I was in no mindset during labor to critically and objectively evaluate my situation. Yes, I consider myself educated and intelligent - but labor is mind-altering. Only in retrospect can I think clearly about the decisions that were made (not by me, but on my behalf!) during my OOH labors.

 

I know enough to know that my personal experiences and opinions are not sufficient reasons to reassure others that risk factors can be ignored or minimized.

 

Even with significant increased risk, most births will turn out 'just fine'. This creates a very distorted picture of risk.

 

Should I tie this back to hemoglobin levels? If I decide that 10g/dl or less is an acceptable level for mothers planning OOH birth, how many women who meet this criteria will suffer under my care? How many will have difficult postpartum recoveries? How many will have uneccessary breastfeeding challenges and delayed milk production? How many will require fluid resuscitation or blood transfusions? How will their risk of postpartum transport increase - I would expect a higher percentage of anemic mothers to have to transport for PP complications than the non-anemic mothers. Is this acceptable practice?

 

---------

 

HUGE topic, here. Hard to keep it short. Thank you for letting me express myself here.


IdentityCrisisMama's Avatar IdentityCrisisMama 10:32 AM 05-02-2013
Quote:
Originally Posted by krst234 View Post

HUGE topic, here. Hard to keep it short. Thank you for letting me express myself here.

Thank you very much for sharing your thoughts!  There's so much good information and thoughtfulness in your post!  


I want to get back to quoting you and continuing the discussion but that may have to wait until after the weekend for me.

 

I wanted to pop on and address what seemed like a question or comment on my request about how we discuss important issues while remaining reasonably on topic. I think getting into specific risks will happen if this discussion evolves and obviously there will be some discussion and disagreement even over some of the medical issues surrounding those risks. If we end up really focusing and debating over one particular risk factor, however, I do think that is better hosted on another thread for two reasons. 1.Because it would take us of course for the general conversation and 2. Because that discussion is super important and will be of interest to members who may not be interested in  the more philosophical type conversation we're having here. I love the idea, for instance, of a discussion topic of anemia, homebirth and risk but think it better hosted as a topic in its own right. I hope that makes sense. 


mothercat's Avatar mothercat 12:47 PM 05-02-2013

I'm currently following a conversation on a home birth midwifery board. The question revolves around the licensing laws and the effect it has had on midwifery practices in that state. Interesting comment from one of the midwives was that the clear criteria about who is risked out has made her life easier.  Turns out that midwives also suffer from peer pressure. Before licensing midwives felt they needed to help every woman who asked for an OOH birth. The feeling was that even if the midwife was sure the woman should not have an OOH birth, there were other midwives who would have done the birth. And, no midwife wants to be thought of as being "too medical". However, midwives seem to spend a lot of time worrying about those women who have risk factors that are pushing the boundaries.

 

Now , the midwives can point to the state licensing laws and  say that they aren't allowed to provide OOH birth care for those women. I had never thought of it this way. Kind of like being a kid and finding yourself in a sticky situation. You can just say that your parents will ground you, take away the keys, whatever, and it gets you out of that situation.


mothercat's Avatar mothercat 12:50 PM 05-02-2013

BRAIDED is the acronym used to guide the process of informed consent. If all of the elements are not included in a balanced way, then it is not informed consent.


BRAIDED: The Elements of Informed Consent
   Benefits: What are the benefits of the proposed treatment?
   Risks: What are the risks? How likely are they to happen to me?
   Alternatives: Are there any alternatives to the proposed treatment? What factors led the doctor to select the option he/she chose for me and eliminate the others?
   Inquiry: any other questions, including referrals for second, third opinions
   Decision to withdraw okay: It’s okay to say no to any treatment offered; and what’s likely to happen if you decline treatment.
   Explanation: How does the proposed treatment work?
   Documentation: A consent form read and signed by both parties. Ask for a copy to take home and read, reflect on if not an emergency situation.


The Role of the Caregiver
   Help the patient find a physician he/she trusts.
   Before the appointment, discuss and write down the patient’s goals, wishes, and preferences for care: not just the what, but also the why.
   Do the driving, and go along for moral support.
   If the physician does not ask, help the patient state his/her goals, wishes, and preferences for care.
   Ask questions based on BRAIDED & write down the answers.
   Ask the physician, nurse to translate any medical jargon you don’t understand.
   Ensure that informed consent is being given: check off each BRAIDED item.
   Encourage the patient to take all the time needed to consider the options and feel confident that the decision is the best one.
   Mind the details: get all the information in writing, take good notes, and bring all paperwork home with the patient.
   Focus on the patient’s goal for treatment: let the trusted physician determine how best to achieve that goal, based on wishes, preferences for care.


pillowy's Avatar pillowy 11:59 AM 05-03-2013

I think these are really great questions and this is a great idea for a discussion.

 

Should risk factors and HB regulated?

Personally, yes, I think they should be. I think that there should be official risking-out criteria for home births, that midwives and doctors follow. High-risk means high-risk for a reason; there are some situations that are better dealt with in hospitals, and midwives shouldn't feel pressured to accept high-risk births because they're afraid the woman will attempt an even riskier birth without any help. I know the argument against this is exactly that - "Well, what about the women who will still won't go to the hospital, and will just attempt a high-risk unassisted birth (or something similar)?" Truthfully? I don't know. I don't know what we can do about that situation.

 

Do we consider risk to be on a spectrum? Or would we like to see some hard lines about what is considered risk and what is not?

Both. Some risks are spectrum-type risks, and some are hard-line risks. I thought this chart was really interesting - it compares the Dutch risk criteria vs. Oregon risk criteria. It distinguishes between "absolute risks," which require transfer to a medical doctor, and "non-absolute risks," in which the midwife must consult with and the patient must see a medical doctor. The chart is very complete, and I found it interesting to go down the list and look at what was considered absolute or non-absolute.

 

How does the issue of lack of availability for care options in the hospital impact this issue? For instance, is the lack of availability for VBAC in a local hospital justification for HVBAC?

This is a tough one. I think what needs to happen here is a change in hospital policies, so that women do have more care options at the hospital and don't feel that they're having to choose between a rock and a hard place. I'm not sure how this would happen - federal regulation, maybe?

 

What role (if any) does choice regarding testing impact risk?

Again, this is such an interesting question. Women do have the right to refuse testing, but refusing testing can mean that risk factors go unidentified and that what may appear to be a low-risk birth is actually a high-risk one. Take, for example, GBS. If a woman refuses to be tested for GBS, she may or may not have it - but neither she or her midwife knows. If she doesn't have it, great. But if she does have it, and it's not treated with the appropriate antibiotics because they fail to realize it's there - this "low-risk" home birth suddenly became a high-risk one.

 

Do you think that a woman choosing HB in the presence of risk factors is primarily driven by the mother or by the MWs? What are the ethical implications of this difference?

and

What about consent? Are mothers who choose HB with risk factors given adequate information about HB and risk factors? What would/does this look like?

I think people above me in this conversation have already answered these questions really well. krst234 said it better than I could have:

 

Quote:
Originally Posted by krst234 View Post


After my experience with OOH births and MWs, I believe it is more driven by the MW's 'comfort' in higher-risk situations. It is very rare that a home birth client has the medical background to understand the risks of OOH birth, and the types of critical situations that could arise, and the near impossibility of OOH providers to handle certain complications without serious repercussions in the OOH setting. There are a few clients like this - but they are very few. I find that most parents/clients trust the MW's comfort level - and when a MW expresses comfort with a certain situation, they are led to believe it is safe.

 

What are the ethical implications of this? Well, it goes against the ethical principle of veracity - the duty to tell the truth. This is tricky because verbally, the MW may recite the all the risks, but non-verbally, the MW may be expressing comfort, and the biggest non-verbal cue would be the MW's willingness to continue to plan an OOH birth. WOW. What confusion for the client!

 

Consent in this situation.... needs to be clear, with no ambiguity. "This poses an increased risk to your health, your life, your baby's health, your baby's quality of life." Sorry if this sounds like fear-mongering. But too often, we want to bet our money on everything turning out 'just fine' because they probably will. This is a disservice to clients who are misled into believing their risk factors are inconsequential. Informed consent has to be pretty powerful - and let's not forget that true informed consent involves presenting alternatives. <---- that's plural. It's my responsibility to share with the client ALL the alternatives in a given situation (if there is sufficient time). Not "Well, you can go to the evil hospital and have an induction and a c-section" but "Dr A works in hospital B and can take on your care." "Dr B works in hospital C, and the OB nurses are very mother-baby friendly," or "CNM D has a great collaborative relationship with DR E, they practice about an hour away, but they also have very holistic care."

 

Informed consent from the MW would, in my ideal world, include the following:  "I am not trained or skilled in handling this situation, and in my professional judgment, you are safer in a hospital setting with access to skilled staff and emergency equipment."

 

I actually do believe in informed consent. But in certain situations, I would want the client to know that a decision to birth at home is NOT a safer one. But a riskier one. That would need to be VERY clear. No pretending that: 1) the risk factors are not meaningful, 2) the birth is appropriate for OOH, 3) the MW is equipped to handle these complications.

 

Sorry for quoting so much, I just think this is all so good! I also really like the "BRAIDED" elements of informed consent that mothercat posted. Also excellent!

 

What do you think of the term "variation of normal"?

I think it's okay if it's used when discussing non-absolute risks, but I think that it's often used to make absolute risks seem more okay. Like krst234 said about comfort, I think that this phrase can be used to express comfort about serious issues, emotionally clouding the matter.


mothercat's Avatar mothercat 10:08 PM 05-10-2013

This story illustrates the difficulty with home birth in higher risk cases. The doctor said home was not appropriate and the mom chose to ignore that advice. The midwife also said it should be a hospital birth, but appears to have couched her advice in more biased and political terms, providing the mother with a false sense of security about her choice. The midwife was supporting the mother and following her wishes. This has resulted in a call for more oversight and regulation of home birth in Australia. Baby died and mom has a ruptured uterus.

 

Australian home birth death.


aquanis's Avatar aquanis 10:31 PM 05-10-2013
wrt the Joseph Thurgood-Gates case it seems like the hospital tried very hard to work with the mum to have her give birth at the hospital but the mum was absolutely against it under any circumstances. meanwhile the midwife failed to properly communicate her concerns to the mother, and certainly lacked the strength to put her foot down and refuse to attend a homebirth. the mother now blames the hospital and the midwives for what happened. what stands out in the coroner's findings is how well the hospital team documented their efforts and concerns, whereas the mid wife's records were incomplete, her recollection of events was faulty and her documentation during the labour was shown in the video to be inadequate. it also seems as though she let personal sympathies overwhelm her better instincts that this was not a low risk home birth.
mwherbs's Avatar mwherbs 09:59 AM 05-12-2013
The more i think about it , the more it comes to no.
Are the CNMs proposing that they are part of this regulation? No
Are the Naturopaths? No Are the MDs? No.
The regulation is on midwives who are not nurses.
as a mother , because of "fads" in regulation was a componet of why I did have a UC with my last child. I would not ask a midwife to break a rule for me.


Right now we have as rule a strict freedman's curve- of 1cm/hr primip and 1.5cm/hr multip , even though there are plenty of studies showing that women take longer to birth now .and most likely no one has really looked at freedman's bellcurve--- what is more likely to be a problem are labors that fall outside 2 deviations of normal, either way.

As for comparing the rules in Oregon to the Rules in the Netherlands, that is not in legislation the midwives make their own rules, midwives in the hospitals and midwives out of the hospital, doctors are directed by midwives.
And some of them although not addressed may still in all be something a midwife would pass on.
And to be frank i have worked with several CNMs and a couple NDs in out of hospital births, they have all gone well beyond what I would ever think of doing at home, i can recall the instances where they stepped outside my comfort zone. Or even MD back-ups , when misoprostol was first being used for induction, there were docs who would place the misoprostol observe in the office a few hours and then send mom home to have a home birth with midwives, we gave feed back that this was not normal labor and warned clients to not allow doc to do this in office... The CNMs and the NDs all have used and still use misoprostol as an induction at home.
mothercat's Avatar mothercat 10:18 PM 05-12-2013

This article, which was linked from One World Birth, asks a long list of questions about birth at home and what is appropriate. These are the questions we should be asking about the safety and appropriateness of birth OOH.

 

"A coroner has found a baby's death after a home birth went wrong could have been prevented if the labour and delivery had been carried out in a hospital.

Coroner Kim Parkinson said the hypoxic brain injury suffered by Joseph Thurgood-Gates happened during labour before the birth.

Ms Parkinson said a contributing factor to the baby's death was his mother Kate Thurgood's failure to attend at the hospital when contractions began.

The coroner said this had "resulted in inadequate monitoring of the course of the labour, removed the opportunity to identify any complications arising and prevented early intervention".

Ms Parkinson said midwife Fiona Hallinan had indirectly contributed to the baby's death by failing to tell the mother of the risks of home birth which had "sustained the misguided views of the mother, contributed to her disregarding the advice provided by obstetric medical clinicians and facilitated in her a level of confidence that she may safely proceed to home birth".

The coroner said Ms Thurgood was determined to have a home birth after researching the topic on the internet and found the risks were negligible.

Had she known there was a risk to her baby she would have had a caesarean at 40 weeks.

Ms Parkinson said Ms Thurgood’s use of the internet to research home birth was ‘‘sadly an example of the danger of untrained users utilising raw data or statistical information to support a premise as to risk, without knowledge and understanding of the complex myriad of factors relevant to the risk’’.

‘‘To disregard the obstetrician’s advice on the basis of a mantra founded in the uncertainty of statistical data obtained from the internet is a dangerous course to follow,’’ the coroner said.

The coroner recommended the Health Minister consider regulating the practice of providing home birth services and develop a source of information to help prospective parents be fully informed of the issues associated with various birthing options.

Ms Parkinson pointed out the inquest into Joseph's death had not been an inquiry into the appropriateness of home birth because the circumstances of the case were such that "home birth was never a safe or appropriate option".

But the coroner said it became apparent during the inquest that the community had lost an appreciation that childbirth had inherent and unpredictable risk and the debate was currently largely directed towards denial of the risk, particularly in the context of home birth.

There appeared to be little current discussion that managing the risk or identifying complications may be more difficult during home births when the technology used in a hospital obstetric unit is not available.

"The time would appear to be right for a proper and informed public discussion about these issues, not merely focused upon home birth and how it can be facilitated, but also the possible benefits and advantages of hospital birthing in some cases," Ms Parkinson said.

The coroner said there also appeared to an absence of legislative standards and practical supervision and regulation of private midwifery practice and home birthing in particular.

The midwifery guidelines under the Australian College of Midwives were unclear and uncertain as to the circumstances in which care should be transferred to a medical clinician and at what point the midwife should withdraw from providing care.

Ms Thurgood and her partner, Dwayne Gates, had had three children all born by caesarean section before Kate discovered she was pregnant again in March 2010.

On December 13, 2010, when Kate, 41, was 42 weeks pregnant, she attended Monash Medical Centre with what she described as a heavy bleed.

She was seen by obstetrician Peter Neal and scans revealed both baby and placenta were fine except the baby was in the breech position.

Dr Neal suggested Kate have a caesarean, which she declined.

Due to the bleeding, Kate was admitted to hospital for two days and went home to Clayton on December 15.

She went into labour the next day about 4pm and her midwife Fiona Hallinan arrived about two hours later.

Kate's labour intensified quickly so Ms Hallinan contacted a second midwife, Jan Ireland, to attend and assist.

The fetal heart rate was found to have dropped to 80 beats per minute at 9.15pm but it wasn't until 9.35pm Ms Hallinan said Ms Thurgood had to go to hospital.

Joseph was born at 10.16pm but was floppy, not breathing and had no heart beat.

Kent Kuswanto, who delivered Joseph, gave evidence that Ms Ireland had been blocking the staff's access to the cardiotocography (CTG) machine to monitor the fetal heartbeat.

"The reason given for this obstruction was for Kate to have as little intervention as possible," Dr Kuswanto said.

At one stage Ms Ireland asked, "Why does she need that?", the obstetrician said.

Joseph died on December 21 when his life support system was turned off.

Ms Thurgood and Ms Hallinan were not in court today.

Ms Ireland declined to comment."


mwherbs's Avatar mwherbs 11:38 PM 05-12-2013
I still would be hard to say how much the OZ midwives were to blame, it sounds as if the midwife referred her to the hospital numerous times. That it took 20 minutes to leave, hard to say what all occured, including the possiility of convincing the mom they needed to go.
I dont know if they are having the same malpractice issues in OZ that they have here but it can undercut everyone's credibility when c-sectiions are done frivoulously , and for self-serving reasons.
mothercat's Avatar mothercat 07:36 AM 05-13-2013

I think (MHO) that the midwives were quite a bit at fault. In other parts of the coroner's inquest report the midwives were asked why they didn't take a firm stand and transport the laboring woman. Their response was that they didn't want to upset the woman and feared she might decide to "freebirth".

I have had women tell me that if I didn't take on their high risk pregnancy and attend them at the birth, then that is what they would do also. That is their choice, but I won't be manipulated into attending a birth that has identifiable risk factors or known complications. I won't enable someone to make those choices. If she feels that strongly that she doesn't want a hospital birth, then she can take full responsibility for it. I am responsible for my professional decision making.

 

OTOH, the coroner's inquest did place blame on the internet sources and the influence they had on this woman's decision making. This column delves a bit more deeply into why those sources also bear responsibility in the baby's death.


mwherbs's Avatar mwherbs 12:23 PM 05-13-2013
Just because we are reading it in the papers doesnt mean they are accurate in their accounts. And yes it did look like they were cautious with her in how they approached information. She was in the hospital the day before she gave birth... Do you think nothing was said to her there? They have a bit of a different system in that midwives do attend, even when a woman will refuse everything. We are not there and not part of any peer review, the news can be reasonable and true or could be sensationalizing we dont know. I do know that some women can be very set on what they want to do . In reading over the accounts it did seem that there was a time after the midwife recommended to go to give birth at the hospital during prenatals ,that maybe she didnt even see the midwife.
You know that a heart rate of 80 can be a normal dip, during pushing, and that it would take a second and third listen as well as assessment as to how soon the baby would be born... And who knows if after when she was documenting that she really did delay or if it was just an approximate time when they walked out the door.

On the other hand , internet information can be really challenging and I could take your point on that.
Vbac alone would be my personal variation from normal 1 thing, is my limit and any additional stuff would just mean transfer, there is no way to even simply caclulate all the risks involved - everything could have been ok but there is an risk a higher than average risk that the baby would die or that mom would have a ruptured uterus or that both would be compromised ,
We have vbac x 3 with a risk of placental abnormalities - including previa, which the bleeding makes me feel like maybe a marginal placenta
We have breech baby. Higher risk of infant death, with an unproven pelvis... What was the reasons of her csections? Cpd???
We have post dates
Uncooperative mom---- i put this because it is a risk all the way around
rachelsmama's Avatar rachelsmama 02:54 PM 05-13-2013

I didn't read any links, only what was presented in post 22, so I appologise if my questions have been answered elsewhere, but I wonder what information the mother was presented with before her 3 c-sections?  And if she had shown up at hospital, would a VBAC attempt have been considered, or was the hospital environment hostile towards that idea?  My point is that while the midwife's choices and the mother's choices were probably the primary factors in the baby's death, the hospital policies and culture, and previous doctors' actions also could have contributed in very meaningful ways.  For example, did the OB practice she was seeing discuss the risks with her in a meaningful way, or just lecture and expect her to agree?  Were her c-sections all necessary, or was she just told after the first one that once a c-section, always a c-section with no discussion of options?  Was her reluctance to go to hospital partly the result of previous bad hospital experiences?  
 


mothercat's Avatar mothercat 08:26 PM 05-13-2013

If any one needs these statements, the ACNM, AAP, and ACOG statements relating to having a safe home birth. In all cases, these organizations pretty much say the same things. This is from Safer Midwifery for MI about how to have a safe home birth.

 

Only low risk women should be having home birth.

They should use a well educated, licensed health care professional: CNM, CM or physician attending the birth.

 

Their reasoning is thus: Licensed HCP have a more consistent and high quality education.

They are integrated into the larger maternity system, making transfer, if needed, easier to accomplish and communication is more consistent.

 

SMM feels that although the woman should ask questions of the midwife or HCP she chooses, sussing out qualifications and education, and how those things will affect her and baby's care in the event of complications, is quite complicated. Why add a layer of complication to the whole process? When attorneys and legislators need to be educated about the different sorts of midwives, their education, skills, and capabilities, how can we expect women to learn all that in such a short period of time.

 

Hopefully the MERA working group will be able to develop standards for ALL midwives that are consistent with ICM standards. Once every midwife can meet those standards there will no longer be the need for these statements or discussions. However, that is a long way down the road.


phathui5's Avatar phathui5 12:19 AM 05-14-2013
Quote:
the hospital policies and culture, and previous doctors' actions also could have contributed in very meaningful ways. 

 

Absolutely! I think that more women would choose to have their VBAC in a hospital if the hospitals were trying to get them to come there for a VBAC. Instead, the OBs and hospitals push women away by not letting them try for what they want in a setting where medical intervention is readily available.


mothercat's Avatar mothercat 12:41 PM 06-14-2013

This is germane to the discussion of home birth safety. I also posted it in the very long thread about death among home birth babies.

 

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

 

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

 

 

This is the part we need to replicate here:

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

 

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

 

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


thesilence's Avatar thesilence 01:12 PM 06-14-2013

I don't have time to answer all of this, but I wanted to add a few comments.

 

I do think risk is a spectrum and it's quite unfortunate when state regulations don't allow midwives to regulate themselves. For example, I have a condition that is well handled with safe medication. I've spoken with several midwives in this state and they are all quite comfortable with taking me as a client since the condition is controlled and doesn't actually pose a problem with the pregnancy. But the state won't allow them to take me as a client. It's ridiculous. I think if a midwife feels comfortable treating a client with certain risk factors that should be up to them. If one doesn't, she doesn't have to take that client. 


1 2 

Up