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#61 of 116 Old 09-09-2006, 02:18 AM
 
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although vaginal birth isn't a medical procedure to be consented to, hiring a doctor to attend it IS! By choosing that providor and that setting, you are choosing a bundle of risks and benefits- medical and otherwise. And making an informed selection ought to include being informed of all the statistically likely outcomes of that bundle.

It makes total sense to me that a doctor would say "here is the package of risks/benefits for cesarean. for a hospital OB delivery. for a hospital midwife. for homebirth midwife. for unassisted" and then you'd have the information you'd need to consent to any of the above. After all, vaginal birth is not equally safe everywhere/with everyone you may do it with!

Allowing a Dr to attend you, or a midwife, may not make birth a "medical porcedure" but it should still be an informed, consenting decision, so I think it's very relevant to the topic at hand.

Besides, how could you informed-consent to a C/S without seeing data on the alternative?

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#62 of 116 Old 09-09-2006, 02:23 PM
 
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Originally Posted by eilonwy
A few years ago, my mother had surgery after which she was not permitted to cough for (72?) hours. She managed to stop herself; it was difficult, but she managed. I have also managed to stop myself from coughing during asthma attacks and while I had bronchitis and pneumonia. Please don't tell me that it's impossible; I've seen it done and have done it myself.
So, that means anybody who isn't able to stop themselves from coughing just isn't trying hard enough? I have, on occasion, been able to stop myself from coughing. On other occasions, I haven't. It's partly how hard I try, but there are other factors involved, too. If it were just a matter of trying hard enough, I'd never have coughed in the first few days post-op from a c-section, yet I've done so twice. And, there was a weird bug going around here a few years ago that made me cough constantly, and I never once managed to stop it.

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Loving my amazing dh, James & forever missing ribbonpb.gif Aaron Ambrose ribboncesarean.gif (11/07) ribbonpb.gif

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#63 of 116 Old 09-09-2006, 02:32 PM
 
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Originally Posted by cchrissyy
although vaginal birth isn't a medical procedure to be consented to, hiring a doctor to attend it IS! By choosing that providor and that setting, you are choosing a bundle of risks and benefits- medical and otherwise. And making an informed selection ought to include being informed of all the statistically likely outcomes of that bundle.

It makes total sense to me that a doctor would say "here is the package of risks/benefits for cesarean. for a hospital OB delivery. for a hospital midwife. for homebirth midwife. for unassisted" and then you'd have the information you'd need to consent to any of the above. After all, vaginal birth is not equally safe everywhere/with everyone you may do it with!

Allowing a Dr to attend you, or a midwife, may not make birth a "medical porcedure" but it should still be an informed, consenting decision, so I think it's very relevant to the topic at hand.

Besides, how could you informed-consent to a C/S without seeing data on the alternative?
Apparently because vaginal birth is the way nature intended things, it makes all of the risks commonly associated with the entire process not worthy of mention.

I think it's more about scaring women into NOT having a section than really making an INFORMED decision
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#64 of 116 Old 09-09-2006, 03:12 PM
 
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Originally Posted by valeria_vi
Tylenol has a drug information sheet that includes all kinds of potential side effects. But how many people actually take it seriously?
How many people read the side effects for the BCP?

RE: tylenol. How many people have had liver problems or transplants, not knowing years of indiscriminate tylenol use could be a contributing factor to their problem.
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#65 of 116 Old 09-09-2006, 03:15 PM
 
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Originally Posted by wifeandmom
I think it's more about scaring women into NOT having a section than really making an INFORMED decision
In my 54 years of life, of birthing, teaching CBP classes, doula-ing, and working with midwives, I have NEVER known this to happen. A cesarian is considered "'delivering' from above", a heavenly experience!

Obstetricians/Gynecologists are trained surgeons who sell the cesarian delivery and never, ever consider there to be any reason not to do a section.
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#66 of 116 Old 09-09-2006, 05:12 PM - Thread Starter
 
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Originally Posted by miriam
In my 54 years of life, of birthing, teaching CBP classes, doula-ing, and working with midwives, I have NEVER known this to happen. A cesarian is considered "'delivering' from above", a heavenly experience!

Obstetricians/Gynecologists are trained surgeons who sell the cesarian delivery and never, ever consider there to be any reason not to do a section.
I'm sorry that this has been your experience. That's seriously depressing.

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#67 of 116 Old 09-09-2006, 08:00 PM
 
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Originally Posted by eilonwy
A few years ago, my mother had surgery after which she was not permitted to cough for (72?) hours. She managed to stop herself; it was difficult, but she managed. I have also managed to stop myself from coughing during asthma attacks and while I had bronchitis and pneumonia. Please don't tell me that it's impossible; I've seen it done and have done it myself.
This is a little like saying, "Please don't tell me vaginal birth is impossible. I've seen it done and have done it myself." :

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Again, please pay attention to what I'm writing: I have not said that vaginal birth is inherently risky, I've simply said that for some people, there is indeed risk and those women should be aware of that risk.
Yes, women should be aware of the risks of vaginal birth. They should also be aware of the risks that their choice of practitioner and birth location have on their births. They should be made aware of how those risks can be lowered. That is *not* standard procedure. Again, you cannot consent to something your body does naturally. It is different than having a procedure performed on you. And people should be made aware of the risks of having a procedure performed vs. letting things happen naturally. (If possible. I understand that not everyone in the universe can give birth vaginally.)

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Even so, the risk involved with a vaginal delivery of a child with a prolapsed cord was too much for me. Perhaps I'm just weak minded, I wasn't intent enough on a vaginal delivery to go through with it? Maybe my daughter's life and my own weren't actually in any significant danger? You can argue all you like, but I'm not gonna buy it. That c-section *definately* saved my daughter's life, and it probably saved mine, too. The risk associated with a vaginal delivery was, in my mind, unacceptable.
I have not seen one person here say that your particular C-section was unnecessary. You started this thread about "informed consent," not about whether your C-section was necessary. You don't need to prove that your particular operation saved your baby's life. I am talking about informed consent as a matter of policy, and not in your particular birth.
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#68 of 116 Old 09-09-2006, 08:52 PM
 
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Rynna,

Well, I haven't read all of the replies, but have to say, I'm sorry, this does happen all the time with medical model of care. Really, don't have anything else to add that isn't there.
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#69 of 116 Old 09-09-2006, 10:01 PM
 
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Originally Posted by eilonwy
I'm sorry that this has been your experience. That's seriously depressing.
I do not know if you are being serious or just mocking one of my previous posts.

An obstetrician/gynecologist is a surgeon, plain and simple. They are trained to do surgery. They like to do surgery. They see surgery as the answer to all of your ills because that is what they do.

Therefore, to paraphrase the late, great medical heretic, Dr. Robert Mendelsohn, if you do not like to get bit, stay away from snakes. If you do not want surgery, stay away from surgeons/obstetricians/gynecologists. If you need surgery, that is who you should see.
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#70 of 116 Old 09-09-2006, 11:58 PM
 
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Originally Posted by miriam
I do not know if you are being serious or just mocking one of my previous posts.

An obstetrician/gynecologist is a surgeon, plain and simple. They are trained to do surgery. They like to do surgery. They see surgery as the answer to all of your ills because that is what they do.

Therefore, to paraphrase the late, great medical heretic, Dr. Robert Mendelsohn, if you do not like to get bit, stay away from snakes. If you do not want surgery, stay away from surgeons/obstetricians/gynecologists. If you need surgery, that is who you should see.
If what you say is true, and ALL OB/GYN's are interested solely in operative delivery, can you explain why the national average for surgical delivery is 25-30%? Why on earth are these so-called surgeons 'allowing' 70-75% of their patients to skip surgical delivery if that's ALL they are interested in doing?

If OB/GYN's were *only* interested in doing surgery, seems to me their surgical delivery rates would be much, much higher than what they are.

FTR, the first hospital I delivered in, where NO midwives were allowed to attend deliveries at the time, so we're talking ALL OB/GYNs here had a section rate of just under 10%.

Second hospital allowed midwife attended births, however they were not common at all, thus the vast majority of patients were delivered with an OB/GYN in attendance. Guess what? Their c-section rate was just under 20%.

The OB/GYN I am currently seeing has a primary section rate of 8%. EIGHT PERCENT.

So I dare say that not ALL OB/GYNs, or even MOST, are as you describe. When an OB/GYNs section rate approaches 80% or more, I might give your statements more weight. Otherwise, the stats simply do not back up what you are suggesting. At all.
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#71 of 116 Old 09-10-2006, 12:41 AM
 
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May I direct you to a book entitled How to Lie with Statistics, by Darrel Huff, an oldie but a goodie.

The cesarian rate varies from surgeon to surgeon, from hospital to hospital, from city to city, and from region to region. The 25-30% cesarian rate in this country is an average of stats from all of the country; how that number is figured depends on the hospital protocol for reporting. When a hospital reports a cesarian rate, it is usually a primary cesarian rate, that is, a mother having her first cesarian birth. If a woman has a repeat cesarian birth, she is not figured in the final statistics, depending on the department protocol, laws of the local medical society and rules of the hospital.

I think if all of the births were reported, as they should be, the total number would be more like 50% of the total births in this country. So the reporting, IMHO is skewed and dishonest.

The same with neonatal deaths, stillborns, and premature babies. The hospital, being a profitmaking entity, will fudge numbers to attract their customers.

When I visited the largest medical center in my town (Los Angeles) to visit a friend twenty years ago, there were twenty-eight babies in the nursery and only one was delivered vaginally. That baby was eleven pounds. The rest were delivered by cesarian section. I doubt every single one was justifiable, but there it is. I doubt any doctor was sued for doing surgery.

As for doctors doing *only surgery*, as you put it, what do you think an episiotomy is? That is surgery, and it is done by a surgeon, ie, obstetrician, which as I said is their primary training. The cesarian is simply more surgery and puts more people to work and of course, co$t$ the patient and insurance more.
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#72 of 116 Old 09-10-2006, 01:10 AM
 
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How about this-I was transferred from a birth center hemorrhaging to the local ER. I had not signed a single paper. The nurse proceeded to start shoving cytotec pills up my bum while I was screaming no at the top of my lungs, because cytotec doesnt work for me and it hurt! They kept doing it anyway. Once the OB got there she said she was going to do a D&C, I said ok, I kind of figured that part out, but then she said she may have to do a hysterectomy. I said no, you will not be doing a hysterectomy, I would rather die (seriously, esp at that time, I probably would have commited suicide). She said yes, she would be. Again, I had not signed a single paper, I was still awake and perfectly capable of signing, but no one had me sign a thing-not even my dh signed anything. And they proceeded to do the D&C, they gave me two transfusions, they did all of this without a single paper on file. I have verified this-I have my medical records. Granted it isnt the same as a cesarean, but I am sure it happens. I know that when I refused to sign the consent form for my first to be sectioned, the doctor threatened to do it regardless. He didnt, but he said he would.
As far as cesarean stats go, it varies so much from doctor to doctor. I have yet to meet one with a rate lower than 20%, but most of the docs I have met have a 35-60% rate. I even know a doc that admitted to having close to a 75% rate! He actually said to me that he prefers to do cesareans because he can schedule them and he feels more involved, because, after all, when a woman has a natural delivery, she is doing all the work. My midwives on the other hand, who do take high risk patients, have a 4% cesarean rate. And then look at the midwives at the farm, they have extremely low cesarean rates as well and they routinely do multiples and breech. Its a small miracle that I have been able to have 4 babies without a cesarean. Of course, if my sOB had had his way with my first, I would have probably had 4 cesareans instead.

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#73 of 116 Old 09-10-2006, 01:31 AM
 
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In general, cesarean rates reported by US hospitals are percent totals of all births. As part of our accreditation process, we are required to report cesarean rates and primary vs. repeat rates as well as VBAC rates and number of "failed" VBACs, although I understand that the VBAC rate will no longer be considered as part of the quality measures used to assess hospitals, so probably we won't have to report them much longer. The nationally reported cesarean rates of just under 30% are for all cesareans, not a primary cesarean rate.
Nevertheless, it is hard to argue in favor of such a rate, and there is much individual variation with some hospitals/surgeons having much lower rates and some having much higher rates. In my little community, my hospital hovers around 20%, with a primary rate of less than 10% - but the hospital in the next town is closer to 40%, and no longer offers VBACs, even if the mom in question has already VBACed successfully in the past. My own total cesarean rate has stayed around 11% total, with a primary rate around 4-5%. Of course I'm a family doc, and have to consult for a cesarean, which I think influences my rate.

I think this thread has deteriorated to "Well I've seen this." and "Oh yeah, well I've seen this."
I don't think there is any question that while some docs provide good, thorough, informed consent, many women have experienced poor consent processes, and worse, poor consent processes after poor care in the first place. If even one woman is coerced or mislead into surgery, that is too many in my book.
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#74 of 116 Old 09-10-2006, 10:12 AM - Thread Starter
 
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Originally Posted by miriam
I do not know if you are being serious or just mocking one of my previous posts.
Why would I mock you? That is depressing.

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An obstetrician/gynecologist is a surgeon, plain and simple. They are trained to do surgery. They like to do surgery. They see surgery as the answer to all of your ills because that is what they do.
1) I don't believe that's necessarily true.

2) What about all the women who see family practice doctors? Do they also, in your opinion, "like to do surgery" and "see surgery as the answer to all of your ills?" Because that's not (necessarily) what they do.

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Originally Posted by miriam
I think if all of the births were reported, as they should be, the total number would be more like 50% of the total births in this country. So the reporting, IMHO is skewed and dishonest.
I have a really hard time believing this. Do you honestly believe that 50% of total births in this country are c-sections? There's no way. I personally know hundreds, if not thousands of women who have had babies, and I can only think of a handful who had c-sections, primary or otherwise. In fact, I have a hard time believing that 30% of births in this country are c-sections, but I recognize that my sample is quite limited by the fact that the overwhelming majority of women in this area either have homebirths or birth at one of *three* hospitals in the area, one of which has an overall c-section rate of 15% (about 9% for primary sections).

I'm not buying the episiotomy argument, either; I only know two women who've had episiotomies (irl). Everyone else either tore naturally or didn't tear at all. The whole episiotomy-happy doctor thing is a myth in my experience. In fact, on the "fill-in-the-blanks" birth plan that they gave me, it listed episiotomy as an option, so I asked about it; my doctor told me that they only do an episiotomy if the delivery will require forceps and they're unable to get in without it, but that the overwhelming majority of the time it wasn't necessary and that he could only remember doing one in the 20-odd years he'd been practicing medicine.

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Originally Posted by MsElle07
This is a little like saying, "Please don't tell me vaginal birth is impossible. I've seen it done and have done it myself."
Not quite-- it's more like saying, "I believe that it is possible, if difficult, to keep one's body from delivering vaginally should extenuating circumstances dictate."

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Originally Posted by MsElle07
Yes, women should be aware of the risks of vaginal birth.
Okay. That's all I was saying. If they can be made aware of said risks, then shouldn't it be required that they consent?

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Originally Posted by MsElle07
They should also be aware of the risks that their choice of practitioner and birth location have on their births. They should be made aware of how those risks can be lowered. That is *not* standard procedure.
That really sucks. I'm having a hard time believing that, though. The statistics are there for anyone to see. Any woman should be able to ask her care provider what their stats are, and should be able to find other women who've seen said provider and ask them about their experiences. Doctors are like anyone else who provides a service-- you really ought to shop around until you get the best one you can.

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Originally Posted by MsElle07
Again, you cannot consent to something your body does naturally. It is different than having a procedure performed on you. And people should be made aware of the risks of having a procedure performed vs. letting things happen naturally. (If possible. I understand that not everyone in the universe can give birth vaginally.)
Of course you can consent (or fail to consent) to something that your body does naturally. It's difficult, but it's not impossible to stop your body from certain things, including birth. The human mind is capable of all sorts of things. The way I see it, if you're going to consent to one, you've got to require consent for all.

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#75 of 116 Old 09-10-2006, 10:26 AM
 
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Not quite-- it's more like saying, "I believe that it is possible, if difficult, to keep one's body from delivering vaginally should extenuating circumstances dictate."
Only with medical intervention.

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Okay. That's all I was saying. If they can be made aware of said risks, then shouldn't it be required that they consent?
I think we have a fundamental disagreement about what consent means. What does it mean to you? Should women then have to consent to become pregnant? Because pregnancy in and of itself carries extreme risk for a small percentage of women. Should women have to go to their doctor and sign a consent form to get pregnant in the first place?

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I'm having a hard time believing that, though. The statistics are there for anyone to see. Any woman should be able to ask her care provider what their stats are, and should be able to find other women who've seen said provider and ask them about their experiences. Doctors are like anyone else who provides a service-- you really ought to shop around until you get the best one you can.
I disagree; the stats about many routine hospital procedures are NOT available for everyone to see. Women usually have to hunt for them on their own. Also, if the stats are there for everyone to see, why don't you believe them? (For example, the stat that nearly 30% of the women in this country give birth via C-section is not a statistic made up by the women on this board.) http://www.usatoday.com/news/health/...sections_x.htm

Women are NOT told the difference between having a midwife attend their birth vs. a family practice doctor vs. an obstetrician. When you go see your OB, does he/she tell you, "It's nice to meet you, but I need to inform you that if you see a CNM instead of me, your chances of C-section drop dramatically. (The birth center C-section rate is less than 5%.) If you have your baby in a birth center instead of at the hospital, your chances of dying or having a dead baby are significantly smaller? Do OBs give you copies of the National Birth Center Study? http://content.nejm.org/cgi/content/short/321/26/1804

In terms of episiotomy, this study found that private practice doctors perform them up to 67% of the time: http://www.acog.org/from_home/public...nr12-31-03.cfm

Being informed of risk means being informed of alternatives and the risks they carry as well. Most doctors are not doing this.
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#76 of 116 Old 09-10-2006, 11:13 AM - Thread Starter
 
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Originally Posted by MsElle07
I think we have a fundamental disagreement about what consent means. What does it mean to you? Should women then have to consent to become pregnant? Because pregnancy in and of itself carries extreme risk for a small percentage of women. Should women have to go to their doctor and sign a consent form to get pregnant in the first place?
Yes, women should have to consent to become pregnant, but no, they shouldn't necessarily have to sign a consent form with a doctor. If getting pregnant doesn't involve a care provider, of course they don't need said cp's consent. That's like saying that you're going to see doctor A for all your care, but you should have to sign an informed consent statement for doctor D, who probably won't be anywhere near you.

Quote:
I disagree; the stats about many routine hospital procedures are NOT available for everyone to see. Women usually have to hunt for them on their own. Also, if the stats are there for everyone to see, why don't you believe them?
The 50% stat? I've never seen that anywhere but here, and I can't for the life of me figure out how it could be true; No, I don't believe it. I didn't say that I don't believe the 30% stat, I said that I have a hard time believing it *but* I recognize that my sample is skewed by the fact that most women I know who have had babies have done so locally, in a hospital with a low percentage of surgical births.

[quot]Women are NOT told the difference between having a midwife attend their birth vs. a family practice doctor vs. an obstetrician. When you go see your OB, does he/she tell you, "It's nice to meet you, but I need to inform you that if you see a CNM instead of me, your chances of C-section drop dramatically. (The birth center C-section rate is less than 5%.)[/quote]

Yes.

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If you have your baby in a birth center instead of at the hospital, your chances of dying or having a dead baby are significantly smaller? Do OBs give you copies of the National Birth Center Study? http://content.nejm.org/cgi/content/short/321/26/1804
I don't think we have a birth center locally, but if we did I'm sure I'd get that information from my doctor, especially if my insurance gave me that choice.

Quote:
In terms of episiotomy, this study found that private practice doctors perform them up to 67% of the time: http://www.acog.org/from_home/public...nr12-31-03.cfm
That's horrible. Still, I have to say that I can only think of a handful of women who have had episiotomies. I didn't think I lived in a particularly progressive area, either.

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Being informed of risk means being informed of alternatives and the risks they carry as well. Most doctors are not doing this.
That's just not acceptable, and it's difficult for me to fathom. Doctors are people who provide a service; I can't understand why they wouldn't inform women about the options, particularly in our lawsuit-happy climate. It just doesn't seem logical to me.

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#77 of 116 Old 09-10-2006, 02:41 PM
 
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I have had 2 unplanned and unwanted c-sections, and neither time was I told one single risk. I heard all sorts of risks while planning a vbac of course.
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#78 of 116 Old 09-10-2006, 05:49 PM
 
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Women are NOT told the difference between having a midwife attend their birth vs. a family practice doctor vs. an obstetrician. When you go see your OB, does he/she tell you, "It's nice to meet you, but I need to inform you that if you see a CNM instead of me, your chances of C-section drop dramatically. (The birth center C-section rate is less than 5%.)
Quote:
Yes.
If doctors are doing this, what explanation is there for women choosing their care 90% of the time? If women were truly informed of the risks of hospital birth with your average OB vs. the risk of a homebirth of birth center birth, why would 90+% still choose that care route? Frankly, I have a hard time believing that doctors are telling their patients "You could get better care elsewhere" and 90% of those women still go with their doctor anyway.

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I don't think we have a birth center locally, but if we did I'm sure I'd get that information from my doctor, especially if my insurance gave me that choice.
And did you also get homebirth information? Did they tell you that homebirth was safer for the mom and baby as well?

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That's just not acceptable, and it's difficult for me to fathom. Doctors are people who provide a service; I can't understand why they wouldn't inform women about the options, particularly in our lawsuit-happy climate. It just doesn't seem logical to me.
Most doctors do not practice evidence-based medicine, despite the lawsuits. Because women are uninformed, and they are often kept that way by their practitioners. If obstetricians practiced evidence-based medicine, they would say, "I am not the best care provider for your low risk pregnancy. Here is a referral to a midwife."

I'm not sure what else you want from this thread. You asked if doctors informed people of risk, you have four pages worth of evidence that they don't. Is there some piece of information you're still looking for that someone can provide? I'm glad YOUR doctor informed you of the risks and obtained your fully informed consent -- that's the way it should be. I'm glad your C-sections were good experiences. But that is clearly not the universal experience -- quite the opposite, in fact.
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#79 of 116 Old 09-10-2006, 11:19 PM
 
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If doctors are doing this, what explanation is there for women choosing their care 90% of the time? If women were truly informed of the risks of hospital birth with your average OB vs. the risk of a homebirth of birth center birth, why would 90+% still choose that care route? Frankly, I have a hard time believing that doctors are telling their patients "You could get better care elsewhere" and 90% of those women still go with their doctor anyway.
'You could get better care elsewhere' is certainly not factual in the least. Perhaps 'You could get DIFFERENT care elsewhere' might be more appropriate. There are RISKS to homebirth. There are RISKS to midwife/birth center births. There are RISKS to hospital births. NONE of the choices are risk free, and perhaps a great majority of women feel more secure knowing they are delivering in a place where they will have immediate access to surgical intervention vs. being however many minutes away by ambulance or car should transfer become necessary.

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And did you also get homebirth information? Did they tell you that homebirth was safer for the mom and baby as well?
You left out quite a few qualifiers there.

First, it's research backed to say it's safer for LOW RISK pregnancy. Second, it's research backed to say it's safer when ATTENDED by a licensed midwife.

Two big issues there, don't you think? The second even more so considering the ONLY way research has shown (to my knowledge, please correct me if there is some huge study out there I am missing) that homebirth is safer is when it is attended by an experienced, licensed midwife. Women have to have access to midwives that do homebirths to make this work. And of course, there's the issue of whether or not (usually NOT, which is a shame and a whole different debate) such care would even be covered under the woman in question's insurance.

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Most doctors do not practice evidence-based medicine, despite the lawsuits.
A great many practices currently used (continuous EFM comes to mind) are NOT based on evidence, rather based on defensive medicine, something any intelligent OB who would like to continue practicing in their chosen profession quickly learns to do well...BECAUSE of the lawsuits.

Think about it. Doc says 'Well, research doesn't support continous EFM, so I'm going to go against the vast majority of my fellow colleagues and forego continuous monitoring.'

That's all well and good...til something goes wrong...and doc can't produce that lovely continuous monitoring strip to 'defend' himself. So the question of course becomes 'Well, if doc HAD done continuous monitoring, would he have known baby was in trouble sooner, therefore been able to intervene earlier?'

There IS NO WAY TO ANSWER THAT QUESTION, and because doc didn't 'do all he possibly could', guess who wins that case? It sure isn't the doctor.
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Why would it be that difficult to find a licensed midwife? I know in some areas there are only CNM's/birth centers, but in those states that allow homebirth, it is not at all difficult to find a licensed midwife. In fact, I am on medicaid and had my homebirth covered, no questions asked. And there is no doubt that homebirth with a qualified birth attendant is SAFER than hospital birth.
I saw an OB for my first. I remember mentioning that I would like to homebirth. He never said that was an option and, being that I was 17 and had no clue, I assumed it wasnt. In addition, when I was told I should be induced for being 2 weeks overdue, no one ever said there was a risk involved with Cytotec, nor the Pitocin. Then when I got an epidural, again, no one spoke of any risks. I was horrified when I read up on it later....its no wonder I almost ended up with a cesarean! Good thing I had the foresight to refuse. I am a firm believer that babies come when they are ready and my ds wasnt ready since he had a tight nuchal cord.
As far as cesarean rates go, as a pp said, it really varies by area, hospital, and doctor. Around here it seems that every other woman delivers by cesarean. I know that most of the women I have met outside of my midwives office ended up with a cesarean. Most of the cases were at least partially due to intervention.

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#81 of 116 Old 09-11-2006, 12:00 AM
 
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Why would it be that difficult to find a licensed midwife? I know in some areas there are only CNM's/birth centers, but in those states that allow homebirth, it is not at all difficult to find a licensed midwife. In fact, I am on medicaid and had my homebirth covered, no questions asked. And there is no doubt that homebirth with a qualified birth attendant is SAFER than hospital birth.
Safer for low risk women.

Since I was never low risk to begin with, I'm sure my inability to locate a midwife willing to do a homebirth is not all that unusual.

I have also read quite a few stories from women here who say it was not possible for them to convince their insurance carrier to cover a homebirth at all. I don't think that particular issue is uncommon, but again, I was never low risk to begin with, thus homebirth was never the safest option for me and I didn't look into the matter further once I discovered this fact.
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Originally Posted by wifeandmom
.

A great many practices currently used (continuous EFM comes to mind) are NOT based on evidence, rather based on defensive medicine, something any intelligent OB who would like to continue practicing in their chosen profession quickly learns to do well...BECAUSE of the lawsuits.

Think about it. Doc says 'Well, research doesn't support continous EFM, so I'm going to go against the vast majority of my fellow colleagues and forego continuous monitoring.'

That's all well and good...til something goes wrong...and doc can't produce that lovely continuous monitoring strip to 'defend' himself. So the question of course becomes 'Well, if doc HAD done continuous monitoring, would he have known baby was in trouble sooner, therefore been able to intervene earlier?'

There IS NO WAY TO ANSWER THAT QUESTION, and because doc didn't 'do all he possibly could', guess who wins that case? It sure isn't the doctor.

so the doctor who has sworn an oath to do no harm... concludes it is better for his career to use practices not supported by research (even though he knows better) and let women bear the consequences of the harm these practices can cause in order to try to keep his record suit-free... how is this an ethical choice?

Doc practices based on policy and the fear of lawsuits instead of evidence based medicine... guess who wins in that case? It sure isn't mothers and babies. I understand a dr has a lot to lose, a career they have trained for for many years. But guess what. When we don't get the evidence based care we need, we have more than a career at risk.
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#83 of 116 Old 09-11-2006, 02:02 AM
 
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'You could get better care elsewhere' is certainly not factual in the least. Perhaps 'You could get DIFFERENT care elsewhere' might be more appropriate. There are RISKS to homebirth. There are RISKS to midwife/birth center births. There are RISKS to hospital births. NONE of the choices are risk free.....
Cesarean birth was left out of the RISK paragraph above, so I thought I'd add it here, for balance

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and perhaps a great majority of women feel more secure knowing they are delivering in a place where they will have immediate access to surgical intervention vs. being however many minutes away by ambulance or car should transfer become necessary
And perhaps a great majority of women would feel more secure if they knew that they are NOT safer in the hospital (and I'm not speaking about women who for whatever reason need to have their babies by c/s..so that's not what we're discussing From the Mehl Study (an oldie but interesting anyway, at least to me):

Neonatal Outcomes:

In the hospital, 3.7 times as many babies required resuscitation.
Infection rates of newborns were 4 times higher in the hospital.
There was 2.5 times as many cases of meconium aspiration pneumonia in the hospital group.
There were 6 cases of neonatal lungwater syndrome in the hospital and none at home.
There were 30 birth injuries (mostly due to forceps) in the hospital group, and none at home.
The incidence of respiratory distress among newborns was 17 times greater in the hospital than in the home.
While neonatal and perinatal death rates were statistically the same for both groups, Apgar scores (a measure of physical well being of the newborn) were significantly worse in the hospital.

Mehl, L., Peterson, G., Shaw, N.S., Creavy, D. (1978) "Outcomes of 1146 elective home births: a series of 1146 cases." J Repro Med.
19:281-90


Quote:
First, it's research backed to say it's safer for LOW RISK pregnancy. Second, it's research backed to say it's safer when ATTENDED by a licensed midwife.
Actually, I don't believe the research specifies "licensure," does it?

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Two big issues there, don't you think? The second even more so considering the ONLY way research has shown (to my knowledge, please correct me if there is some huge study out there I am missing) that homebirth is safer is when it is attended by an experienced, licensed midwife. Women have to have access to midwives that do homebirths to make this work. And of course, there's the issue of whether or not (usually NOT, which is a shame and a whole different debate) such care would even be covered under the woman in question's insurance.
Are you assuming all women to have insurance? IME, this is not at all the case, at least in the US. Many women I know do not have insurance, and for those who do, if homebirth was covered, even partially, this is a bonus. Off the top of my head, I know the states of Oregon and Florida legally require HB to be covered. Wouldn't that be an wonderful public policy to support in each of our states!

There are many families who value the experience of never needing to worry about signing consent forms by remaining outside of the hospital system altogether. These families, IME, are informed, educated and aware of the risks and benefits, and who do not operate under the assumption that an obstetrical emergency is going to happen. They realize it could, but assume it will not. This does not mean, in the slightest, that families who believe in the birth process to be a normal, physiological event are unaware and need constant reminders of how dangerous vaginal birth is.

Quote:
A great many practices currently used (continuous EFM comes to mind) are NOT based on evidence, rather based on defensive medicine, something any intelligent OB who would like to continue practicing in their chosen profession quickly learns to do well...BECAUSE of the lawsuits.
Just another reason to avoid selecting a surgeon to provide prenatal and labor care, IMO. If one is birthing in a hospital, perhaps utilizing a midwife would be in the mother, babies and family's best interest. Or perhaps if a mw isn't in the cards, a Family Practitioner, if one who does births is available.

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Think about it. Doc says 'Well, research doesn't support continous EFM, so I'm going to go against the vast majority of my fellow colleagues and forego continuous monitoring.'
What if a cardiologist (or insert medical specialty here) was practicing this way? Well, the research shows that I there is no reason to keep performing xyz procedure, but, heck, everyone else is doing it..and if I don't if/when I get sued, I will sure wish I did. Why do OBs get the free pass here? Why is obstetrics the seemingly only field of practice where evidence-based practice is a dirty word? The very idea that "Because everyone else is doing it" would be a reason to do something, for a medical practitioner---a trained scientist---is odd.

Quote:
There IS NO WAY TO ANSWER THAT QUESTION, and because doc didn't 'do all he possibly could', guess who wins that case? It sure isn't the doctor
But, in "defensive medicine", in most instances, who is it who loses the normal, intervention and drug-free, empowering, satisfying and rewarding birth experience? Mom andbaby.

So, you are suggesting that doctors continue to utilize inferior and/or unnecessary procedures/tests because if she didn't---she's going to be sued and lose? This, to me, is a perfect example of why normal, "low risk" births should absolutely not take place within an institutional setting with practitioners who believe that the human body is somehow defective and the miracle of technology and the power of the doctors can somehow save us all from our inherently risky bodies :

I have retired from administration work, so if you have a question about anything MDC-related, please contact Cynthia Mosher. Thanks!
 
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#84 of 116 Old 09-11-2006, 02:05 AM
 
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Sorry if that got rambly

Saw this Mothering Action Alert and thought it was interesting:

Good News for People Who Love VBAC News

and check out this link for more information about the advantages of vaginal birth for both babies and mothers

I have retired from administration work, so if you have a question about anything MDC-related, please contact Cynthia Mosher. Thanks!
 
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#85 of 116 Old 09-11-2006, 02:15 AM
 
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so the doctor who has sworn an oath to do no harm... concludes it is better for his career to use practices not supported by research (even though he knows better) and let women bear the consequences of the harm these practices can cause in order to try to keep his record suit-free... how is this an ethical choice?
He probably figures somebody has to pay back the $100K+ in student loans, so he'd best do what it takes to avoid losing his ability to practice medicine.

I've said it before, and I'll say it again...

When women stop suing for imperfect outcomes in childbirth, current practices set up to AVOID such outcomes at all costs will likely change as well.

Bottom line is if something goes wrong with mom OR baby, the care provider better darn well be able to show they did EVERYTHING they could to avoid that outcome. Even then, they might lose. But if they DON'T do 'everything' that could have possibly prevented a bad outcome, well, it's their livlihood on the line, and I don't blame them one bit for doing what pretty much everyone else is doing in their field.

To do otherwise is asking to lose a malpractice case.

This sort of thing works in other fields too, but obstetrics and anesthesia are the two biggest fields most likely to be sued, therefore they are the two professions that are most likely to 'go overboard' so to speak, being ultra-conservative in their approach, in order to protect themselves.

If they have to choose between NOT doing a necessary section and DOING one that is likely NOT necessary, they'll choose to do many UNnecessary sections to avoid missing that ONE that really WAS necessary. Like with continuous EFM where it's fairly accepted that out of 4 babies showing distress on the monitor, only ONE of them is really in trouble. So do they NOT section any of the four, thinking 'Well, that's THREE unnecessary sections according to research' or do they section them all thinking 'Well, I'd rather do three unnecessary sections to save that one baby in trouble.'

If the current section rate of 30% should REALLY be more like 10%, then 2 of every 3 sections aren't truly medically indicated. Nobody has a crystal ball to determine which two exactly would have been just fine laboring longer and which one would not. It's only going to get worse, that's my prediction.

I will add this:

The current OB I am seeing is VERY laid back, touted around town as VERY low-intervention, etc. I've been amazed at some of the things he allows, is comfortable with, recommends, etc. And I admit to thinking he is REALLY wide open for a lawsuit, and really that's a shame.

One such example is he encourages women to bring a video tape to any u/s appt (and he is totally cool with NOT doing u/s, makes it a choice with pros/cons which I'd never experienced before). But if you have an u/s, he'll record it and let you take that video home with you.

That is NOT common practice AT ALL anymore. Why? Lawsuits. If something is 'missed', mom then has a record of exactly what doc 'should have' seen. Of course, hindsight is 20/20, so it might very well be that he didn't 'miss' anything at all, but if another expert views the tape, knowing what defect they are looking for, it's not quite the same, kwim?

Anyhow, there are so many decisions that unfortunately are made based on the liklihood of someone suing that it's very sad, but again, it's the way things are. Until that changes dramatically, I don't see obstetrics changing much either.
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#86 of 116 Old 09-11-2006, 02:59 AM
 
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Cesarean birth was left out of the RISK paragraph above, so I thought I'd add it here, for balance
I dare say not many moms in these parts are going to be choosing a section for no reason whatsoever, but of course, if she DOES want to choose that route to deliver, I have no issue with HER choice. And she ABSOLUTELY should understand the consequences of making that choice, something I've always stressed without reservation.

Before my first section, I could recite every possible thing that could go wrong during a scheduled section, how likely it was to happen, what it meant if it DID happen, what the potential complications were to future pregnancies/deliveries, blah blah blah.

Of course, I could also tell you the risks of the other choices in my particular situation. Really, it only makes sense to me that ANY woman be able to do exactly that before committing to ANY birthing choice. The beauty of modern medical science is we DO have choices.

We can opt for birth at home by ourselves. There are pros to that choice, but there are also cons. We can opt for a homebirth with a friend, a lay midwife, a doula, a licensed midwife. Again, there are pros and cons to each of these choices. It goes on and on. Have a baby at a birth center. Pluses and minuses. Have it at the hospital with a midwife, a family practice doc, an OB. Go straight to the OR for a section. Every one of those choices carry benefits, as well as risks. Who gets to decide which benefits are most important? Which risks are acceptable vs. which ones are too much to bear?


Quote:
From the Mehl Study (an oldie but interesting anyway, at least to me):

Neonatal Outcomes:

In the hospital, 3.7 times as many babies required resuscitation.
Infection rates of newborns were 4 times higher in the hospital.
There was 2.5 times as many cases of meconium aspiration pneumonia in the hospital group.
There were 6 cases of neonatal lungwater syndrome in the hospital and none at home.
There were 30 birth injuries (mostly due to forceps) in the hospital group, and none at home.
The incidence of respiratory distress among newborns was 17 times greater in the hospital than in the home.
While neonatal and perinatal death rates were statistically the same for both groups, Apgar scores (a measure of physical well being of the newborn) were significantly worse in the hospital.

Mehl, L., Peterson, G., Shaw, N.S., Creavy, D. (1978) "Outcomes of 1146 elective home births: a series of 1146 cases." J Repro Med.
19:281-90

Those are interesting stats. Were all of the babies in each group from low risk moms experiencing low risk pg? Back in the 70's, induction and c-section were MUCH MUCH MUCH less common than today, so I'd be interested to see stats from today's birth data comparing low risk homebirth babies to low risk hospital birth babies. Wouldn't surprise me a bit if the hospital numbers were even worse with all the induction going on since that alone is known to cause distress in the baby.


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Actually, I don't believe the research specifies "licensure," does it?
Hmmm, not sure. I'd venture to say if insurance is going to pay, you'd have to use someone licensed. I'd be personally more concerned with training and experience rather than a piece of paper, although really, I'd prefer all of the above if it were me.



Quote:
Are you assuming all women to have insurance? IME, this is not at all the case, at least in the US. Many women I know do not have insurance, and for those who do, if homebirth was covered, even partially, this is a bonus. Off the top of my head, I know the states of Oregon and Florida legally require HB to be covered. Wouldn't that be an wonderful public policy to support in each of our states!
Of course not every woman has insurance. Of those that DO have it, it seems to be a common issue with insurance carriers NOT wanting to cover homebirth with a licensed provider. Maybe that issue is simply exaggerated here, but it seems to come up quite often from what I've seen.

That an insurance company would pay for more expensive hospital care but refuse to pay for a midwife/homebirth delivery is completely absurd IMO. I'd support regulations to change that without a doubt, as it can very easily take away a woman's right to choose what birth situation she feels most comfortable with if she is unable to pay out of pocket for something her insurance should be covering to begin with (assuming we're talking licensed professionals and obstetric care is already covered for the woman in question).

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There are many families who value the experience of never needing to worry about signing consent forms by remaining outside of the hospital system altogether. These families, IME, are informed, educated and aware of the risks and benefits, and who do not operate under the assumption that an obstetrical emergency is going to happen. They realize it could, but assume it will not. This does not mean, in the slightest, that families who believe in the birth process to be a normal, physiological event are unaware and need constant reminders of how dangerous vaginal birth is.
Ok...

Obviously whatever choice is made, there are risks associated with that choice, and I'd certainly HOPE that each woman knows what those risks are as she's the one who will be living with her decision should the worst case scenerio happen to her or her child.

I'd think if one were truly confident in whatever decision they made, it wouldn't be earth shattering to read about potential problems associated with said choice...cause well, they should have ALREADY read and understood what they were choosing. Of course, I'm not a fan of sticking my head in the sand and pretending like my choices don't have potential complications associated with them, so maybe I just don't get the big deal about discussing pros/cons like some other people seem to have such an issue with. (not meant in a snarky way at all) I'm all about learning as much as possible, knowing what to expect, etc etc.



Quote:
Just another reason to avoid selecting a surgeon to provide prenatal and labor care, IMO. If one is birthing in a hospital, perhaps utilizing a midwife would be in the mother, babies and family's best interest. Or perhaps if a mw isn't in the cards, a Family Practitioner, if one who does births is available.
That seems to be a good compromise for those who feel better in a hospital knowing emergency services are 'right down the hall' but without the higher rates of interventions that are likely with an OB at the wheel.

One reason I've seen/heard that such a decision is not more common is when women say they'd prefer to have an established relationship with whomever might end up cutting them open should the need arise rather than having to rely on whomever is on call that day showing up for an emergency section having never laid eyes on mom. I do know that many midwives have specific OBs that do back up for them, so that could be a possibility in calming this particular fear.



Quote:
What if a cardiologist (or insert medical specialty here) was practicing this way? Well, the research shows that I there is no reason to keep performing xyz procedure, but, heck, everyone else is doing it..and if I don't if/when I get sued, I will sure wish I did. Why do OBs get the free pass here? Why is obstetrics the seemingly only field of practice where evidence-based practice is a dirty word? The very idea that "Because everyone else is doing it" would be a reason to do something, for a medical practitioner---a trained scientist---is odd.
Perhaps you could look at it like this...

They ARE practicing evidence based medicine. Only they are relying more heavily on the evidence that says 'If you DON'T do everything.under.the.sun. to prevent a bad outcome, you CAN expect to face a very serious lawsuit that threatens your ability to support yourself, your family, and continue to practice in your chosen profession.'




Quote:
But, in "defensive medicine", in most instances, who is it who loses the normal, intervention and drug-free, empowering, satisfying and rewarding birth experience? Mom andbaby.
And if this is the birth mom desires, she'd best stay far away from an OB, preferably far away from a hospital. It's the way things are, and it's not going to change any time soon. People can work to make changes, and they absolutely should do so, however today's choices must be based on today's realities.

Quote:
So, you are suggesting that doctors continue to utilize inferior and/or unnecessary procedures/tests because if she didn't---she's going to be sued and lose?
I'm saying I don't blame them for doing so.

I understand where they are coming from. I know in the field of anesthesia, which is where my husband practices, there are choices to be made that may involve more intervention 'just to be safe' that are common place, and you bet your butt that I fully expect DH to err on the side of safety with his patients.

If he were an OB, I'd fully expect him to section a woman in an instant if he thought baby might be in trouble. It sucks that it's like that, but I would rather a woman have an unnecessary section if the alternative was DH losing his ability to support our family.
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#87 of 116 Old 09-11-2006, 06:36 AM
 
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'You could get better care elsewhere' is certainly not factual in the least. Perhaps 'You could get DIFFERENT care elsewhere' might be more appropriate. There are RISKS to homebirth. There are RISKS to midwife/birth center births. There are RISKS to hospital births. NONE of the choices are risk free, and perhaps a great majority of women feel more secure knowing they are delivering in a place where they will have immediate access to surgical intervention vs. being however many minutes away by ambulance or car should transfer become necessary.
Your tone is unnecessarily hostile.

And what I meant was, "You could get better care elsewhere for a low risk pregnancy." Did you read my link above for the national birth center study? 11,000 women. C-section rate of 4.4%. No maternal deaths. That is better care.

Here are some additional statistics:

1. The risk for neonatal mortality was 33% lower for births attended by CNMs.
2. The risk of delivering a low birth weight infant was 31% lower for CNM attended births.
3. The mean birth weight was 37 grams higher for CNM attended births.
4. The infant mortality rate was 19% lower for CNM attended births.

Tell me, why do you think it is the midwives (particularly CNMs practicing in birth centers) don't practice defensive medicine in the same way doctors do, yet they have better birth outcomes?

Doctors do not share these statistics, published in the US Journal of Epidemiology, with patients. They do not say, "As a low risk mother, you will be much less likely to die while in the care of a CNM."
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#88 of 116 Old 09-11-2006, 07:15 AM
 
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I hope this won't sound totally irrelevant, as it's a personal experience with medical care that wasn't related to pregnancy.

i was hit by a car as a pedestrian, and had excellent care for my badly broken leg at the hospital nearest the accident. The emergency orthopedist installed an external fixator, which looks kind of like an erector set--metal rods go through the affected limbs. I returned to my home and needed to see another doctor for follow-up care. My HMO assigned me an orthopedic surgeon. The surgeon decided he should remove some of the rods of the external fixator. (He didn't seem to understand how it worked.) I told him I wanted a second opinion. He tried to browbeat me into signing a surgical consent form in his office, weeks before the proposed procedure.

Risks? Schmisks. He didn't even know what he was doing. I found out that he was not board-certified. He saw me as an opportunity to get another surgery under his belt. The fact that the surgery didn't make any sense--well, that wasn't interesting for him.

That was an orthopedist. I wasn't even pregnant! Okay, that guy was a total ringer, but still. i would never assume that surgical consent forms are always done properly.

I don't have a bad feeling about all doctors. i'm just saying, they are another group of people who have power over people because they take care of them. You always have to be wary and careful about people in helping professions.

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#89 of 116 Old 09-11-2006, 09:04 AM - Thread Starter
 
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Originally Posted by MsElle07
Here are some additional statistics:

1. The risk for neonatal mortality was 33% lower for births attended by CNMs.
2. The risk of delivering a low birth weight infant was 31% lower for CNM attended births.
3. The mean birth weight was 37 grams higher for CNM attended births.
4. The infant mortality rate was 19% lower for CNM attended births.
I'm curious about the controls for these studies-- were participants matched for age, parity, and other risk factors? Does it take into account that people who choose CNM attended births are not only healthier in general, but more likely to be educated, not only about birth but in general? There are so many factors that would have to be considered in such a study, I'm just curious as to whether or not they were all considered.

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Originally Posted by MsElle07
I'm not sure what else you want from this thread. You asked if doctors informed people of risk, you have four pages worth of evidence that they don't. Is there some piece of information you're still looking for that someone can provide? I'm glad YOUR doctor informed you of the risks and obtained your fully informed consent -- that's the way it should be. I'm glad your C-sections were good experiences. But that is clearly not the universal experience -- quite the opposite, in fact.
Well, I ended my last post by saying that it didn't seem logical or reasonable, for doctors to fail to obtain informed consent or to mention risks involved with surgical birth, not by asking for more from this thread.

Rynna, Mama to Bean (8), Boobah (6), Bella (4) and Bear (2)
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#90 of 116 Old 09-11-2006, 01:25 PM
 
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Actually, my point was that even with women who are concidered high risk in certain cases-like with twins, breech, preeclampsia, GD, etc-they STILL have better outcomes with homebirth vs hospital birth.
As an example, I had preeclampsia with my 2nd. My current midwives would have continued my care. However, the CNM's I was seeing required me to deliver at the hospital. They sent me in to be induced. I had to fight to keep the CFM away, had to fight to eat, had to fight to move at all, had to fight to get into the water. Its no wonder women in situations like mine end up with epidurals. And then some of them have problems like becomming too numb or having their labor stall, which means more pit, which means baby is at higher risk for getting stressed out, which in turn means cesarean.
As another example, I hemorrhaged with my 3rd, under my midwives care (I was at a birth center). I almost died. However, that did not risk me out of a homebirth and I had one with my 4th with no problems. We were still prepared-I had planned on getting a hep lock just in case, because the time before they had a very hard time getting an IV in. Well, she just came too darn fast for that, but we were still trying to be prepared.
I have never heard of people not being able to take videos of their ultrasounds and take them home. I have been to oh...5 different ultrasound places and all of them have let me have the video to keep. 1 was my OB, 1 was another OB I was visiting, 1 was my CNMs, 1 at the fetal medicine clinic and another 1 at a different fetal medicine clinic. I know several people who also have their ultrasound videos. So maybe it isnt common where you are but then you said most of the women have homebirths so....
I cant remember where it is, but there was recently a study published on licensed midwives and homebirth/birth center birth vs OB/hospital birth. It was adjusted for risk factors and the results were that midwife attended births were much much safer then OB attended births. Also, you have to concider that many of the people doctors in the US put as high risk really shouldnt be high risk anyway. Not ALL, just some. In other countries they would not be concidered high risk and they would not automatically do a cesarean or whatever else. On top of that, doctors in this country seem to have a "big baby" complex. I cannot tell you how many women "had" to have a cesarean because their "baby was too big to fit." I'm sorry but that is soooo BS! In fact, I had this disussion with my OB while I was preggo with my first. In the 20 years he has been practicing, he has literally NEVER had a case where the baby was too big to be born vaginally. He said the only time he was worried was when the dad was samoan and the mom was this tiny little asian. The baby was a nice size but not huge. Anyway, he was talking about how it is just ridiculous that these doctors say oh, you're too small to deliver your baby. He is also a user of the Gaskin maneuver, something that most OBs either save as a last resort or refuse to do at all. It is the first thing he does in the case of shoulder dystocia and he has never had it fail-and never had a baby be born with a broken clavicle or cerebral palsy. Ok, I gotta go!

Cari-mama to Eriq, Lile, Paikea, Kaidyn, and Mieke is here!! 2/9/10
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