Wednesday, May 10, 2006

Alternative health or medical subspecialty?

Should we consider homebirth midwifery a form of alternative health since many mainstream providers do not agree with its objective? Or should we more properly consider it just another medical subspecialty because it clearly emulates traditional medical practice in its use of medications, prenatal testing, risk assessment and referrals to doctors and hospitals?

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Should we consider homebirth midwifery a form of alternative health since many mainstream providers do not agree with its objective?

Newsflash: midwifery is already considered an alternative health care choice thanks to a century of effort to curb the practice. Perhaps if so many so-called mainstream health care providers --ACOG-- would stop breaking their backs to marginalize midwifery we could further advance the standards of education, licensure, and the profession as a whole. What service does the mainstream do for the general public when going on campaigns to malign midwifery?

By Anonymous MetroMidwife, at 10:32 PM  

Metromidwife:

"Perhaps if so many so-called mainstream health care providers --ACOG-- would stop breaking their backs to marginalize midwifery we could further advance the standards of education, licensure, and the profession as a whole."

If mainstream obstetricians were trying to marginalize midwifery (which they are not), they couldn't be doing a very good job.

According to a press release from the American College of Nurse Midwives in 2002:

"The popularity and acceptance of nurse-midwifery increased dramatically in the 1970s and 1980s. The number of CNMs practicing jumped from 275 in 1963 to 1,723 in 1976, to 2,550 in 1982, to over 4,000 in 1995.

Certified nurse-midwives ... were no longer only caring for indigent women and children. More affluent consumers discovered the benefits of the personalized, holistic health care that the modern-day nurse-midwives had to offer. Birthing centers began springing up around the country offering prenatal counseling, extensive personal care during birth and close collaboration with physicians ...

CERTIFIED NURSE-MIDWIVES IN HEALTHCARE TODAY

Today, approximately 6,200 certified nurse-midwives practice in all 50 states and many developing countries. In 2002, CNMs attended 307,527 deliveries, mostly in hospitals. This accounts for over 10 percent of all vaginal births that year. Furthermore, certified nurse-midwives continue to be highly regarded in the health care community. Two reports by the Institute of Medicine and the National Commission to Prevent Infant Mortality, praise their contributions in reducing the incidence of low birthweight infants and call for their increased utilization."

Does that sound like a campaign to malign midwifery?

By Blogger Amy Tuteur, MD, at 10:49 PM  

Does that sound like a campaign to malign midwifery?

As if you didn't know, that is a press release from the ACNM which speaks only for CNMs and CMs, not CPMs. In almost any state where direct-entry midwifery is working on legislation to regulate it you'll find ACOG there will bells on.

By Anonymous MetroMidwife, at 10:52 PM  

"In almost any state where direct-entry midwifery is working on legislation to regulate it you'll find ACOG there will bells on."

Sure. ACOG believes and I certainly believe that direct entry midwives are not comparable to CNMs or competent to deliver medical care.

No one is allowed to be even a direct entry beautician, why on earth should we countenance direct entry midwives? The entire idea is absurd. I have not seen many direct entry midwives in my state, but all whom I have seen are grossly incompetent. They don't even know how very much they don't know.

I don't mean to insult you personally; I don't even know you. However, the training of direct entry midwives is marginal at best, and some of them have no training at all. Anyone who wants to be a midwife should have a graduate degree from an accredited CNM program. Anything less in unacceptable.

By Blogger Amy Tuteur, MD, at 11:15 PM  

I'm sorry your state is filled with grossly incompetent direct-entry midwives. Instead of insulting them perhaps you could work with their organization to improve their education rather than to continue marginalizing them. That would require you step outside your scientific data box and I'm not sure you're comfortable with anything less than mainstream.

By Anonymous MetroMidwife, at 11:27 PM  

What do you object to in the NARM credentialing process? Are you talking about CPMs?

By Blogger Jamie, at 11:33 PM  

Should we consider homebirth midwifery a form of alternative health since many mainstream providers do not agree with its objective?

That is your criterion for the definition of alternative health? That doctors don't like it??!

Home from my third birth in 16 hours, one at home, two at the birth center, one under water... just lovely!

By Anonymous maribeth, CNM, at 3:07 AM  

there are many midwives who would argue that midwifery is not the practice of medicine. doctors before they named themselves OBs were "male-midwives"
I find it interesting that you are so ignorant of the history of midwifery and obstetrics that you think that it should be some form of "sub" speciality- when clearly the practice of surgery is the sub-speciality and that people who practice obstetrics frequently know little about normal physiologic birth.
I realize that you think that there is no attempt to marginalize midwifery but I think that you are wrong- have you read any of the state political sites have you talked to lobbyists for ACOG or even AMA? I have seen them in action restricting, twisting... something that just this week happened in Az there was a bill already thought the house and nearly through the senate the purpose --- limit how docs and CNMs could be sued by previously sight-unseen to their practice birthing women if they appear at the hospital and need care -- they successfully lobbied against the CNM portion of the bill and had them removed! so docs are protected if this bill is signed by the Gov but by deliberate exclusion the words certified nurse midwife was dropped - not to mention what has been done on a Federal level to try and limit payment to CNMs or any midwives
i would also like to know what you base your assessment of the midwives you have met on? and how did you communicate with them?

By Anonymous Anonymous, at 6:32 AM  

"What do you object to in the NARM credentialing process?"

First, it is my understanding that any woman can call herself a direct entry midwife. Those who have no specific training insist that no specific training is needed. NARM obviously thinks that specific training IS needed, but the requirements for certifications are (in my opinion) not nearly rigorous enough. Greater background education should be required to get into the program. More classroom experience should be required, and most importantly, much more clinical experience should be mandatory. Of course, then it would likely resemble a CNM program, not direct entry midwifery.

I briefly glanced at the complete list of standards and at the requirements for specific accredited schools. What struck me most forcibly is this: The paltry number of deliveries required for certification. I am not joking when I say that I delivered more babies in my first week of residency than is required by NARM. I did not feel (and was not in reality) remotely qualified to do anything after that first week.

Why does someone hire a midwife (or obstetrician) anyway? Anyone can deliver a baby if everything goes normally. The husband could do it. All you have to do is make sure the baby doesn't fall on the floor. Many different kinds of people can and do offer labor support. Think doulas, for example.

A midwife is only as valuable as her clinical judgment. The midwife is only necessary because things can and do go wrong. Her job is to identify what is wrong, fix it if she can, or recognize when she cannot and speedily transfer the patient to someone who can fix the problem.

Unless you have seen a substantial number of deliveries (hundreds), you can't develop any sense of what can go wrong and the many subtle signs that something is about to go wrong. If you can't offer that level of judgment, than you are offering nothing more than labor support.

While doing some research on line, I came across an article lamenting the changes in practice that occured when a direct entry midwife became a CNM. (I am trying to find the article again so I can quote from it directly). The author claimed that direct entry midwives who became CNMs lost their "heart" and began to practice differently. She viewed this as a betrayal of the values of direct entry midwifery.

I found the article ironic because what the author failed to understand was these women had changed by acquiring more experience and better clinical judgment. They were now more sensitive to subtle signs of problems. Simply put, they knew more than they knew before.

By Blogger Amy Tuteur, MD, at 7:50 AM  

Personally I put CNM is the same category as OB's... they overmedicalize both the pregnancy and birth...
Lay midwifes, those who use true alternative methods, no unnessesary pre-natal testing, use traditional herbs and tinctures, no medical instruments at all besides a fetoscope should be concidered not "medical subspecialty" but a "specialist" all together.

By Anonymous melissa, at 7:53 AM  

Anonymous:

"I find it interesting that you are so ignorant of the history of midwifery and obstetrics that you think that it should be some form of "sub" speciality- when clearly the practice of surgery is the sub-speciality and that people who practice obstetrics frequently know little about normal physiologic birth."

Really? I can assure you that everything you ever read about physiologic birth was discovered by doctors. There has never been a tradition of research in midwifery (unfortunately). All the discoveries that you depend upon to provide care, all the tests you use, all the assessment methods you use, all the drugs you carry, all the instruments you might touch, everything you know about infant resucitation, all the infant resucitiation equipment you carry, all were discovered or invented by physicians.

That's why I asked the question in the first place. To the extent that being a midwife is more than being a doula, it is because of consciously and deliberately incorporating modern obstetrical methods and techniques.

"I would also like to know what you base your assessment of the midwives you have met on? and how did you communicate with them?"

I communicated with them in the same way I would communicate with anyone; I spoke to them.

What did I base my assessment on? I based it on the fact that I was called to fix the problems that they had caused and that they clearly had no idea of what was going on. I was absolutely astounded by the lack of basic knowledge and the lack of experience.

By Blogger Amy Tuteur, MD, at 8:04 AM  

Let me acknowledge again that this isn't my field, so I don't really know what it takes to develop sound clinical judgment. But I have a couple of thoughts. If you caught 40 babies in your first week as a resident, it was probably a pretty different experience from attending 40 births as a midwife. Part of the difference with a midwife is her presence throughout most of labor.

My college roommate tells about tearing down the hall to do forceps deliveries during her residency. She was the one attending those births, technically, but I'm curious about what led up to the forceps, you know? My guess (and people with more experience, please confirm or deny) is that staying close by a woman going through labor helps a midwife assess her progress and anticipate problems before they become emergencies.

Another consideration is there's always a learning curve in developing clinical judgment. I'm remembering patients I saw early in my first job, times when I couldn't quite put all the pieces together. In hindsight the diagnosis is obvious, but they can't benefit from my hindsight. It was perfectly legal for me to see those patients; I was adequately trained for my level of experience. But they would have been better served by the 1997 version of me than by the 1995 version. Slightly OT -- I love Atul Gawande's book Complications, about learning curves and decision-making in medicine.

I don't know much about direct-entry midwives but I'm intrigued by this abstract. (No, I haven't read the full text!) It's cited in the Pang study as showing "an elevated risk of neonatal death in intended home births delivered by professional providers," but the abstract says the increased death risk was chiefly at births attended by "lesser trained attendants." It looks like the lay midwives registered with the Missouri Midwife Association had good outcomes and the risk came with the unaffiliated midwives. So I'm curious -- what training did the MMA midwives have? (I'm also curious about whether it was appropriate for Pang to cite this article as showing increased death rates for home birth, since the abstract suggests that the increase wasn't statistically significant.)

Do you think the nursing aspect of CNM training is important? I know nursing training isn't required for UK midwives -- don't know about the rest of the world.

By Blogger Jamie, at 9:37 AM  

I can assure you that everything you ever read about physiologic birth was discovered by doctors. There has never been a tradition of research in midwifery (unfortunately). All the discoveries that you depend upon to provide care, all the tests you use, all the assessment methods you use, all the drugs you carry, all the instruments you might touch, everything you know about infant resucitation, all the infant resucitiation equipment you carry, all were discovered or invented by physicians.

What is your objection exactly? It seems to me you should be jumping for joy we pay attention and implement these things into practice. No one denies the research of physicians, non-physician researchers, etc.; I thank them for making my job identifying risk factors and abnormalities even easier.

I based it on the fact that I was called to fix the problems that they had caused and that they clearly had no idea of what was going on. I was absolutely astounded by the lack of basic knowledge and the lack of experience.

What sorts of problems? Have you never been called to fix the problem that your colleagues, physicians, had caused?

By Anonymous MetroMidwife, at 10:25 AM  

"Do you think the nursing aspect of CNM training is important? I know nursing training isn't required for UK midwives -- don't know about the rest of the world."

this is also a good point because CNMs in many countries that have better stats than the US - but there duties and jobs are very different- the person who monitors your labor in or out of hospital is a midwife- no nurses- the intentional historic plan in the United States was to be better than that system and be a doctor-nurse pair. the majority of care providers in a US hospital rely on the clinical judgment of nurses and tecs - I want you to really stop and think about that now- how many hrs of OB education does a nurse get? and lets look at what if any education a tec has to have- talk about direct entry --- and in this state tecs are first assists as well !!!
I additionally suggest you look at the births required to be a CNM- in the US (25 observes and 25 catches) and compare to CPM .

By Anonymous Anonymous, at 10:25 AM  

---Really? I can assure you that everything you ever read about physiologic birth was discovered by doctors. There has never been a tradition of research in midwifery (unfortunately). All the discoveries that you depend upon to provide care, all the tests you use, all the assessment methods you use, all the drugs you carry, all the instruments you might touch, everything you know about infant resuscitation, all the infant resucitiation equipment you carry, all were discovered or invented by physicians."

this reminds me of the "Discovery of America by Columbus". -- or maybe the father in My Big Fat Greek Wedding- who thinks that every word comes from Greek.
Very basic preventive care like hand washing was done by women / midwives long before Semmelwise. The plant based medicines which were used for hemorrhage in use long before docs got into the business- infact the first male-midwives also bled their patients--- not that they still don't Barber Surgeons you know... and the early scientific double blinded studies were done by Eclectic Physicians- who were not school of medicine that the current AMA comes from --- and it took a long time before they actually picked up and figured out to do study in that way- the inventors of many of the things you are talking about were almost all direct entry docs--- when you signed up for medical school you paid to matriculate ahead of time and you took the test- even if you didn't attend lectures. Just because women were limited in how they could communicate does not mean that they were not observant, intelligent nor skilled- and to pass along that trade- until outlawed--- I have read accounts by midwives and one doctor doing mouth-to-mouth resus used long before the modern version-

By Anonymous Anonymous, at 10:42 AM  

When comparing CNM to CPM then, Let's list the experience requirements for both, for those of us who don't know. It looks like 20 observes, 20 catches for CPM and 25/25 for CNM. Is that right?

By Blogger Cherrie, at 10:46 AM  

Anonymous:

"Very basic preventive care like hand washing was done by women/ midwives long before Semmelwise. The plant based medicines which were used for hemorrhage in use long before docs got into the business ..."

I'm not sure what point you are trying to make here. Perhaps you are trying to compare doctors before 1850 to midwives before 1850. You can't be suggesting that midwives discovered the germ theory of disease or the cause and effective treatment of obstetric hemorrhage.

The fact still remains that it is absurd to accuse doctors of not knowing about physiologic birth when everything you (and everyone else) know about it comes from doctors.

By Blogger Amy Tuteur, MD, at 12:26 PM  

"The fact still remains that it is absurd to accuse doctors of not knowing about physiologic birth when everything you (and everyone else) know about it comes from doctors."

Doctors excel at treating pathological birth. Who knows the most about normal birth? I would argue that midwives do, especially homebirth midwives. Certainly this is the obvious place for midwives to be, within the scope of mainstream practice.

I wish doctors supported this structure. They could still practice their craft, seeing high-risk labors and dealing with complications, but we would certainly have a higher outcome of healthy moms and healthy babies.

By Anonymous Anonymous, at 12:41 PM  

Jamie:

"My guess (and people with more experience, please confirm or deny) is that staying close by a woman going through labor helps a midwife assess her progress and anticipate problems before they become emergencies."

It was my understanding from what I read that you could graduate from a NARM accredited school with far less than 40 deliveries to your credit, but whether its 8 deliveries or 40 deliveries, it makes you a better support person, but if you've only seen 8-40 normal deliveries, you haven't seen much in the way of abnormalities, and that's the point.

Most of the time, vaginal deliveries go very smoothly and no assistance (or judgment) of any kind is needed. You have to see a lot of deliveries in order to see a wide variety of complications. You should see abruptions, cord accidents (if possible, these are pretty rare), pre-eclampsia, different types of abnormal fetal heart rhythms, stalled labor, maternal hemorrhage, it's a pretty long list.

The only reason you need the midwife is for her judgment and how good could her judgment be if she has never managed (or possibly even seen) a neonatal resucitation or the management of a post partum hemorrhage?

Furthermore, doctors learn not just from the babies they personally deliver, but from the many, many deliveries going on around them. A busy labor and delivery unit can care for more that 10,000 pregnant women each year. Even if you are not personally managing the care of a patient with an uncommon complication, you will hear about it from your colleagues and perhaps be invited in to learn how it is being managed.

By Blogger Amy Tuteur, MD, at 12:46 PM  

“Complications in obstetrics are common, not rare. That’s in keeping with the fact that human reproduction on the whole is an extremely wasteful process.”

“I have the highest respect for the natural process of birth and most of the time I just watch it.“
....

And today:
"Most of the time, vaginal deliveries go very smoothly and no assistance (or judgment) of any kind is needed. You have to see a lot of deliveries in order to see a wide variety of complications."

Amy, how can all these statements come from the same mind? How do you reconcile these opposing ideas?

By Anonymous Anonymous, at 12:50 PM  

"Doctors excel at treating pathological birth. Who knows the most about normal birth? I would argue that midwives do, especially homebirth midwives..."

No, no, no. Obviously doctors excel at treating pathological birth, but, in addition, they are the people who discovered virtually everything you know about NORMAL birth and virtually every tool you use.

"I wish doctors supported this structure. They could still practice their craft, seeing high-risk labors and dealing with complications,.."

First of all, many doctors do support this model. During the years I practiced obstetrics, I always worked with this model. I never worked in a setting that did not have CNMs. Very few doctors object to the midwifery model of care, but most believe that direct entry midwives are not sufficiently qualified to deliver appropriate care.

"we would certainly have a higher outcome of healthy moms and healthy babies."

There is no evidence for that and there is no reason to think that it would be so. The main causes of poor outcomes are social and economic, not medical. For example, there is no evidence that midwives decrease the incidence of prematurity, the major cause of neonatal mortality.

By Blogger Amy Tuteur, MD, at 12:54 PM  

how good could her judgment be if she has never managed (or possibly even seen) a neonatal resucitation or the management of a post partum hemorrhage?

These are of course the two basic skills anyone attending a birth as a practitioner should have. Anyone working with laboring women - midwives, doctors, and nurses - ought to have NRP certification and know how to respond to hemorrhage.

A close friend's daughter has cerebral palsy because she was born at the hospital (uncomplicated delivery) not breathing, and not one person present knew how to intubate. She waited for 8 minutes for a qualified person to arrive and intubate her baby. This is unacceptable at any location, home or hospital.

I don't think that anyone here is arguing for unqualified midwives to practice.

By Anonymous Anonymous, at 12:58 PM  

Anonymous:

"Amy, how can all these statements come from the same mind? How do you reconcile these opposing ideas?"

Let me walk you through it.

Complications are common. They are often measured in percent. In other words, if you do more than a hundred deliveries, you are bound to have several significant complications.

On the other hand, they are not so common that if you participate in only 40 deliveries, you would see an abruption AND pre-eclampsia AND a post partum hemorrhage AND a neonatal resucitation, etc. Yet a direct entry midwife holds herself out as someone who could manage all these complications if they arose.

By Blogger Amy Tuteur, MD, at 1:03 PM  

Obviously doctors excel at treating pathological birth, but, in addition, they are the people who discovered virtually everything you know about NORMAL birth and virtually every tool you use.

Does that mean that doctors respect normal birth? Do they support unmedicated birth? Or do they end up seeing the birthing process itself as pathological and treating all births as high risk?

Understanding, as always, that doctors practice defensive medicine, not wanting to get sued for not performing that c-section...

Anyway, the point is, no one is discrediting doctors for their impressive medical knowledge. Midwives acknowledge that doctors understand far better than they do how to treat complications.

But it is a rare doctor that can resist interfering in a labor that's going perfectly well.

By Anonymous Anonymous, at 1:05 PM  

I strongly disagree that OBs are experts at physiological birth. I think that statement sounds good, but rings hollow and Amy probably knows it. Many residents graduate without having ever seen a natural birth. Many have never once spent more than an hour total with a woman in labor (and an hour is likely stretching it). Most actually believe in things like Friedman. Most think the 28% c/s rate is needed. Most would be terrified to catch a baby in any other way than with a mother flat on her back with the bed broken. Residents would rather sit at the desk waiting for the nurses' beck to come rather than sitting in a room watching and learning, because they are uncomfortable in a role where they are not needed to DO something.

As you've admitted, most of the time birth goes easily and no one is needed to do much of anything at all. I have 8 years of hospital experience and a lot of talking with both residents, OBs and nurses to confirm this.

I don't disagree that there are some great OBs. But most are pretty lousy at attending anything other than the complex. Most don't even really WANT to! That's where the real opportunity for change exists. We need less OBs and more midwives. OBs could sleep more and focus on high-risk OBs and GYN surgery. Midwives could attend normal birth, women would be happier, outcomes would be better.

By Anonymous maribeth, CNM, at 1:18 PM  

Furthermore, doctors learn not just from the babies they personally deliver, but from the many, many deliveries going on around them.

You make the assumption that the minimum NARM clinical component is all that is achieved. I have had an active hand in almost 200 births, not including in the at least 200-300 more pregnancies, labors, postpartums, neonatal care, and well-woman care cases. Thanks to busy practices, I have handled neonatal resuscitation and pp hemorrhage and experienced along with supervising midwives as a team fetal arrythmias, HELLP, meconium plug syndome, diaphragmatic hernia, congenital heart defect, liver disease detected by VKDB, metabolic disorders, preterm labor, and clinical postpartum depression among things I can't recall off the top of my head.

In my area I don't know a single supervising midwife who will release her apprentice for NARM testing by just meeting the minimum requirements.

By Anonymous MetroMidwife, at 1:28 PM  

"The fact still remains that it is absurd to accuse doctors of not knowing about physiologic birth when everything you (and everyone else) know about it comes from doctors."
-------------------------------

no - everything any of us know about birth comes from women and babies.

-------------------------------
tecs that are left to close c-sections don't even have the benefit of anatomy classes and certainly not 100's of births under their belt- nurses that graduate from nursing school have never inserted an IV, put a catheter in or any number of essential skills and these are the people who are in the hospital - waiting in triage to assess you patient- and pass on information to docs like you-

By Anonymous Anonymous, at 1:39 PM  

Yep. Residents, and most docs, do not know when things go right or wrong unless nurses tell them it's so. I am attending my ladies one on one. Which safety net do you prefer? Amy, do you admit that... what, 98%?... of labor care is done by someone other than the doc?

By Anonymous maribeth, CNM, at 2:27 PM  

This comment has been removed by a blog administrator.

By Blogger sailorman, at 6:47 PM  

" maribeth, CNM said...
Yep. Residents, and most docs, do not know when things go right or wrong unless nurses tell them it's so. I am attending my ladies one on one. Which safety net do you prefer?


Well, if you are in a hospital then you have a L&D nurse, and they're pretty well trained. They are pretty much in there all the time.

That's a pretty good safety net, don't you think?

And, of course, if something DOES go wrong, you have an oncall surgical staff.

That's a pretty good safety net too, don't you think?

Amy, do you admit that... what, 98%?... of labor care is done by someone other than the doc? "

Yes, she's essentially already said that, elsewhere.

This makes your above statement sort of moot. SOMEONE is attending, who is experienced--isn't this a "safety net" even in your eyes?

And if you're going to claim that a bevy of trained nurses, backed up by an OB sleeping down the hall. backed up by a surgical staff and an ICU, isn't a "safety net", what about YOU?

DO you still get to claim the proverbial "hospital down the road" is your safety net if things go very wrong? Or do you plan to install a surgical suite and learn to use it?

Home birth has quite a few things going for it. But a better "safety net" isn't one of them.

By Blogger sailorman, at 6:50 PM  

Sailorman, I refer you to NeoDoc's post on the inexperienced nurse causing the death of a preemie. I refer you to my local tertiary care hospital who has an average age of about 24 for their L&D nurses. I ask you to spend some time on L&D floors and see what percentage of the time women have ANYONE attending them in labor (since the advent of central monitoring). Very, very few have 1:1 patient to nurse ratios. And, as I've mentioned before, many hospitals do NOT have OBs (or surg teams or anesthesiologists) sleeping down the halls. Exactly how many times have you been on an L&D floor sailorman?

By Anonymous maribeth, CNM, at 9:16 PM  

A bunch of questions for you, Dr. Amy -- maybe material for future posts. If you were in charge, how would you structure health care for pregnant women in this country? Do you think OBs should be the default providers? (And BTW, do you have reservations about family practitioners providing obstetric care? They have so much else to cover in residency that surely they don't get a ton of time handling complicated OB cases either.)

I'm also interested in hearing more about your assessment of the risks associated with out-of-hospital birth. How much, in your estimate, would a homebirth with a qualified CNM raise the perinatal mortality risk for a low-risk woman with a vertex singleton?

Are you uncomfortable with all homebirths? I'm thinking about my situation in particular -- I'm typing half a mile from a good-sized hospital. If a planned homebirth went awry, I expect I could get into an OR faster than a woman planning a hospital birth at one of the small-town facilities in the surrounding area. Do you think that I was taking an unreasonable risk to have my son at home?

By Blogger Jamie, at 10:45 PM  

Jamie:

"A bunch of questions for you, Dr. Amy"

Yes, I am going to post your questions separately on the front page and answer them there. However, I will answer one now.

"Are you uncomfortable with all homebirths?"

I want to be very clear that every woman is entitled to choose homebirth. It is a personal judgment. The risks are small, and people take many greater risks every day.

My concern is that patients have the information they need to make an informed decision. As far as I can tell (from websites and books promoting homebirth), women are continually told that homebirth is "as safe or safer than hospital birth." That is simply not true.

I would not be satisfied until homebirth advocates admitted in official publications that there is a small but real increase in neonatal death at homebirth.

By Blogger Amy Tuteur, MD, at 7:19 AM  

"maribeth, CNM said...

...Exactly how many times have you been on an L&D floor sailorman?


Sigh. You're not going to let the personal stuff drop, are you?

OK: I've worked in hospitals, and 2 of my sisters are L&D nurses, one of whom was previously a midwife before getting her nurse training.

I personally have only 2 children.

However, I've spent plenty of time on the floor.

But back to my earlier question (I note you seem to demand a lot of answers, but you don't like to give answer often:)

If you're going to claim that a bevy of trained nurses, backed up by an OB sleeping down the hall. backed up by a surgical staff and an ICU, isn't a "safety net", what about YOU?

DO you still get to claim the proverbial "hospital down the road" is your safety net if things go very wrong?

By Blogger sailorman, at 9:07 AM  

Sailorman, I wasn't asking to pry into your personal life, I was asking because (as I've mentioned) I think you over-estimate the 'safety net' of your average American OB floor and I've never had a response to that.

So, let's compare my personal safety net at a homebirth to the hospital nearest my community:

Let's say I have a cord prolapse (and this has happened). I put mom in knee-chest position, displace the head off the cord, while calling 911 with my free hand. My assistant first gives terbutaline and then gives mom 02 via face mask, while dialing the (only) OB at this hospital, who is sleeping 25 minutes from the hospital. I inform him of the cord prolapse and the need for emergent c/s. He calls the OR team (all sleeping at home) and the Pediatrician (who is the furthest away) and everyone hurries in. Next phone call by my assistant is to L&D, who wil begin to prepare the OR. All this is accomplished within a minute or two of the cord prolapse. Ambulance comes. En route IV is started, bolus given, and foley is inserted. Mom remains in knee-chest with me displacing the head, and listening to FHTs. We arrive at hospital, move directly from the ambulance to the OR (where we waited for everyone to arrive for a few minutes). They arrive and c/section is performed. Baby is delivered and is fine.

The ONLY difference if we had been in the hospital is that we would have had to wait longer for the docs and the OR team to arrive.

Not to mention that the risk of cord prolapse OOH is SIGNIFICANTLY lower than compared to in hospital (where the bag of water is often broken much too early). I don't have research to support this but I stake my life on it being a fact.

(I note you seem to demand a lot of answers, but you don't like to give answer often

Is that so? And here I am thinking I'm writing more than anyone.

By Anonymous maribeth, CNM, at 6:40 PM  

"I want to be very clear that every woman is entitled to choose homebirth. It is a personal judgment. The risks are small, and people take many greater risks every day."

Ah, that is music to my ears! I live in a state where the physicians are actively working to retain laws which make it illegal for CNMs AND professional Midwives to attend home births. Home birth advocates are fighting hard against the medical establishment to have access to the Midwives Model of Care in the home setting. We don't even have birth centers available to us.

I don't agree with you that there is proof that home birth is more dangerous than hospital birth. I think the scientific literature can't actually answer the question definitively at this point. I believe the mortality statistics are very close. But there is more to consider than mortality. Even if you are correct that hospital birth on the whole is slightly safer than home birth, it is not enough of a difference to justify the medical establishment fighting so hard to prevent home birth. They are most definitely doing so in my state. I don't really want to convince you or any other doctor that home birth is safer. I just want to have the freedom to make the decision about where to have my baby. I am the one best qualified to make that decision for my individual circumstances.

By Blogger Mama Liberty, at 8:46 PM  

commenting on 2 statements:
"Today, approximately 6,200 certified nurse-midwives practice in all 50 states and many developing countries."

The number of midwives that existed 30 years after the war on midwives began-- about 47,000 so I do think that the numbers that now exist in the US very small and that the small numbers that do exist have not been because of any benevolent behavior on the part of physicians- but by hard, hard work of consumers and midwives themselves-
------------------- the other thing I wanted to address-----------------
"You can't be suggesting that midwives discovered the germ theory of disease or the cause and effective treatment of obstetric hemorrhage."

I don't think I suggested exactly that I did say however that midwives washed their hands--by the simple fact that they were cleaner than men (probably due to roles women served- going from child tending to food prep to other household duties) wearing aprons to protect their clothing that they washed , regardless of what was found later- the fact was they had did something safer than contemporary docs.
NEXT yes I will say that ergot that midwives were recorded using since at least the middle ages brought about it's scientific investigation and development into crude and refined drugs firstly by Professor Stoll in 1917 and he isolated ergotamine-trade name Gynergen used for hemorrhages and migraine( this was not pure and degraded quickly and bad side effects)- while still working at Sandoz he hired Albert Hoffman in the 1930's he started working with ergot alkaloids namely lysergic acid combined with amines> ergobasine marketed under the name Methergine the first substance he derived -- you would probably recognize Albert Hoffman from his discovery of LSD-25 (1938) something that came out of the same research time period but taking a different direction

By Anonymous Anonymous, at 1:49 AM  

>>" much more clinical experience should be mandatory"<<

Excuse me but CPMs are required to have much more hands on birth experience and continuity of care with one woman throughout her pregnancy than ACNM certified midwives and CNMs.

This ACNM webpage used to have a number by number comparison but I see it's been altered to make the ACNM not seem so lopsided in fewer actual birth numbers. http://acnm.org/display.cfm?id=191

With all due respect to the many wonderful home birth CNMs, I have t point out that almost all nurse-midwifery training is hopsital based and only about 1 or 2% of all CNMs (nationally even if you have more in your local area) attend home births. So the question about "home birth midwives" is surely referring to something this blogger obviously knows precious little about -- DEMs (which I agree can be of mixed quality which begs for regulation standards like the CPM).

Please don't slander CPMs. Your postings and comments are inaccurate.

>>"I would not be satisfied until homebirth advocates admitted in official publications that there is a small but real increase in neonatal death at homebirth."<<

I would not be satisified until the mainstream hospital birth staffs become educated on the physcial differences between a woman having an undistiburbed birth (best acheived at home) and a woman who is having her birth medically managed. and then make drastic changes to faciliate undisturbed birth.

Just because you can't see the forest for the trees of your created emergencies that tend not to occur at home with a competent midwife. You have no knowledge base to judge home birth because you don't understand how much less violent home birth is.

Do you realize that babies born in the hospital are altered by the experience compared with their generally calmer home born counterparts? Yes, I consider the gentler, undisturbed home birth the norm. Read what the World Health Organization says about birth in industrialized nations. The U.S. has it all backward. OBs managing healthy womens' birth is a timebomb that explodes with regularity and results increased injuries in babies and phsycial trauma for the birthing pair.

This is a bizarre upside down country when birth is considered a major emergency, women are placed in the worst physical positions and babies enter the world in such a violent fashion.

amy, Your post in which you doubt that women who say they did, really suffered psychological trauma during hospital birth is emblematic of your ignorance. Your comparison of natural childbirth to a hysterectomy shows us what you probably don't even realize yourself. Your focus us pathology. That's okay but don't get on a high horse about something you don't understand natural birth -- which you admit you rarely attend uneventful birth b/c of the hosptial midwives, and I contend aren't really so "natural" with the woman in an foreign enviornment and most likely in a suboptimal labor and birthing position.

Plus, your focus solely on the day of the birth regarding the birth shows your lack of understanding of real midwifery. Peventive lifeystyle guidance is one of the most valuable things a midwife provides. Bonding and trust so that the primal part of a woman's brain can do it job to open up for the birth is of primary importance. If that's not in place before the birth, and if it's been neglected throughout the pregnancy (how can you provide that with get 'em in, get 'em out ob statisitics of short office visits), it acts in a cascade effect.

So, take the midwife out of the prenatals and increase the woman's psycho-spiritual issues surrouinding birth and increase the emergencies that the midwife might have headed off months ago (not to mention the hands on personal care throughout labor).

Now I'm really rambling. I know you mean well. You just don't even know what you don't know. And spare me the gory anecdotes. That can go both ways.

By Anonymous Queen of Run On Sentences, at 8:14 PM  

queen:

"Now I'm really rambling. I know you mean well. You just don't even know what you don't know. And spare me the gory anecdotes. That can go both ways."

I know you mean well too. However, you apparently don't know that research shows that homebirth midwifery has a higher neonatal death rate than hospital delivery for comparable low risk populations.

I don't think that I have offered even a single anecdote, although I could offer quite a few. I have offered research. I did not notice any reference to scientific research in your post. It is 100% opinion, and, as such, does not carry very much weight in a discussion about science.

By Blogger Amy Tuteur, MD, at 11:11 PM  

research shows that homebirth midwifery has a higher neonatal death rate than hospital delivery for comparable low risk populations

Your arguements towards this end have still not convinced me that it's true. Again, I think you and sailorman play the data, as you accuse others of doing.

By Anonymous maribeth, CNM, at 10:25 PM