Thursday, May 11, 2006

Confessions of a tired obstetrician

I am always amused when I read comments like these because they are so incredibly far from the truth:

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

I could not have been happier if most of my patients had spontaneous vaginal deliveries without interventions of any kind. I think most obstetricians feel the same way. We went into it to participate in the miracle of birth and it is a lot more fun to cry "It's a girl!" as a mother pulls her new daughter up for a first look, than it is to be elbow deep in someone's bloody abdomen desperately trying to stop a mother's hemorrhage.

There are other, more practical reasons to respect normal birth. It is faster and it is easier for the doctor. All you have to do is stand there and make sure the baby doesn't fall on the floor; half the time the parents think you are a genius for doing nothing. For almost all of my career, I worked at night so I could be home with my children during the day. I was required to be in the hospital, but if things were quiet, I could sleep. In addition, I was "protected" by two midwives who delivered most uncomplicated patients. So, theoretically, if all the births were uncomplicated, I could sleep all night, unless there were more uncomplicated patients than the midwives could handle by themselves. The midwives I worked with were fabulous; I can't imagine that anyone could have done their job better and their patient satisfaction was very high.

The people who refused to cooperate with my deep and abiding respect for natural birth and my deep an abiding desire for sleep were the mothers and their babies. There was always someone, or a few someones, with pre-eclampsia, with premature labor, with a shoulder dystocia, with fetal distress, with a post partum hemorrhage, or with something. So I would get up and try to fix it and hope that I could manage it without doing surgery. Surgery was a guaranteed two or more hours before I could go back to bed, but if I could put off doing surgery, I could go back to bed right away. Then when it was time for the delivery, the whole thing, paperwork included, would take me less than an hour.

It is a cherished myth of some branches of midwifery that doctors cause pregnancy complications because they enjoy them or because they can't recognize normal when they see it. Far from it. Most doctors are hoping for normal each and every time they see a laboring woman. It's the patients (through no fault of their own) who sometimes refuse to cooperate.

36 Old Comments:

Amy, again this conversation is being split. Can you participate in existing dialogues first please? You leave questions unanswered and it leaves frustrated posters about ready to quit this game.

More comments later, but you write it is a lot more fun to cry "It's a girl!" . Food for thought: I think announcing that really steals a magical moment away from parents that is rightly theirs. I always let either the dad tell the mom, or let them discover on their own time by looking. It's an extra special time out of time that rightly belongs to parents.

By Anonymous maribeth, CNM, at 2:46 PM  

Maribeth, doctors invented the phrase, "It's a ___!" along with A&P, prenatal testing and care, and delivery techniques, and everything else in sun, including how NOT to say, "It's a ___!" so as not to steal the thunder of their grateful patients so don't think you are doing something unique by giving families the opportunity for anything magical. It's just a baby.

Sarcasm from a tired midwife.

By Anonymous MetroMidwife, at 2:55 PM  

Well, 'tis time to put in my little quip.
I am the homebirther who started it all, over at neonataldoc.
I had a primary c/s after 15 hours of labour, because my son turned himself into a single footling breech. No question, he would not have come out "healthy". I went on to have two homebirths. The last one was more truamatic than the c/s (she had the cord around her neck as she grew, an NO the ultrasounds at 20 and 24 weeks did NOT pick that up, it was beyond tight so that when she tucked her chin to come out, she cut off her support). She had perfect heart tones even the one chance they had to take it while I was pushing *no one expected her to come out so quickly*. And it had NOTHING to do with the midwives, being at home etc... it had to do with the medical community. The emt's did not have the right equipment. They had the fellow trained in infant intubation meet them a few blocks from the hospital (I got the records a few weeks back). My midwives had three sets of equipement and are trained in intubation every single year. Guess that is the joy that is Canada and regulated midwifery in my Province. The neo natal neurologist was the only sane one there. She asked permission from my husband and the 2nd midwife before ever touching my daughter. She wrote me a touching note, commending me for having done the best thing for my child, a home birth.
This particular post peeved me to no end. I was so thrilled to find out on my own what my baby was. I am not sure where geographically(other than you Dr. Amy, because we are all seeing you as the absolute be all and end all of perfection in an OB) doctors love unmedicated births. I have very rarely seen a physician who didn't have the pitocin up and ready to go within minutes... let alone the cut off time on how long you can labour before you get pit or even better, lets just get baby out through your abdomen! Yes, I know I'm jaded from that first "traumatic" experience... shucks, if I'd only gone out for dinner and a movie instead!!!... but lets get real. I'd have been labeled FTP with my second child and sectioned... instead two hours later he came flying out of my "damaged uterus". IF for my third child I'd been at the hopsital with an epidural in a bed. My daughter would be dead. I have doubts that even a crash c/s would have done her any good, five minutes from -1 to out, three pushes... No amount of medical intervention would have saved her.
I'm so saddened by this forum. But like a moth to a flame..... I keep coming back. Keeps me from counting the ambulance sirens during the day.
Oh and Maribeth... there are way too many CNM's by that name (even know of two in Canada)... I keep trying to find you!!!
A homebirth mother who has NO regrets, and ironically enough neither did the neonatal doctor who saw her daughter! =)

By Anonymous Anonymous, at 3:42 PM  

Several times, in several different places, people have pointed out that docs don't spend time with women in labor. This seems to be the latest excuse why they can't have caused the complications.

Here I was, just trying to get a good night's rest, when someone somewhere complicated and I had to go fix it.

I suggest to you, that a midwife who routinely sits with a Mama from the beginning of labor, through the birth, and several hours postpartum will know better how to anticipate complications as well as how to treat them safely.

I also suggest to you that hospital rituals and routines and standing orders that are not based on individual need of the woman laboring, cause complications that you, Dr Amy, were then awakened to come to fix.

I suggest that many women such as myself, who are neither midwives nor OBs, would rather have one on one midwifery care than the hosptial treatment. We consider it safer.

When we read a 'debate' such as this (and I imagine I've stuck around way longer than the lay person) where things go around and around, and nothing every get's 'proven' or 'disproved' ... well, we get tired too, and at some point wander away.

This started as a debate over if home birth is as safe as hosptial birth. I agree that as the MD who says it ISN'T, that the burden of proof lies on you to show why.

By Blogger Cherrie, at 3:47 PM  

Dear Anonymous:

Please accept my condolences. I think a situation like yours is off limits for my comments. I would not risk the possibility of increasing your grief.

By Blogger Amy Tuteur, MD, at 3:52 PM  

Cherrie:

"This started as a debate over if home birth is as safe as hosptial birth. I agree that as the MD who says it ISN'T, that the burden of proof lies on you to show why."

It doesn't work that way. When a drug company invents a new drug it doesn't put it on the market and say "if you think it isn't safe, the burden of proof is on you."

We have tons of data showing that as deliveries shifted from home to hospital, the neonatal and maternal mortality rates dropped by over 90%. Now you want to go back to homebirth. It's up to YOU to prove that homebirth is safe, since it was never safe in the past.

One thing I keep seeing is that every time I respond to a SPECIFIC comment, someone immediately changes the topic. This thread is a SPECIFIC response to the cherished myth that doctors prefer complicated deliveries and do all in their power to cause them.

So rather than responding to what I SPECIFICALLY said and acknowledging that the original post may have been wrong, or asserting that maybe what I said only applies to me and not to other doctors, the responses have been directed to whether or not anyone should announce the sex of the baby.

Why not stick to the topic under discussion, instead of trying to change the subject?

By Blogger Amy Tuteur, MD, at 4:04 PM  

I could not have been happier if most of my patients had spontaneous vaginal deliveries without interventions of any kind.

That is fantastic!!!

I think most obstetricians feel the same way.

I wish this was true, but I just don't see it.

Problems:

Inductions. Most women in the care of OBs are not allowed to go more than one week overdue (far less in some areas), even if there is no other medical cause for induction.

OBs admit that due dates are estimates, but by the end of pregnancy, it is an iron-clad date.

Length of labor. When a laboring woman enters the hospital, she is on the clock. If she doesn't deliver within an arbitrary amount of time (10-24 hours, especially if her water has (been) broken), her risk of c-section - even without any other medical reason - increases.

Harmful hospital routines. By this I mean the protocols of most US hospitals which decrease a woman's chances of having a normal birth: constant external fetal monitoring which requires women to lie down in bed instead of moving freely - a practice that has been proven not to contribute to better birth outcomes; denying laboring women food and drink; overuse of labor stimulants (pitocin); delivery in the lithotomy position.

If I believed that most OBs felt the way you have said you do about birth, I would be choosing a different battle. But there isn't very much evidence that doctors see birth as a normal event.

By Anonymous Anonymous, at 4:52 PM  

We have tons of data showing that as deliveries shifted from home to hospital, the neonatal and maternal mortality rates dropped by over 90%. Now you want to go back to homebirth. It's up to YOU to prove that homebirth is safe, since it was never safe in the past.

OK, Amy, this is bad logic AND bad history.

Because two things happened at the same time, does not prove that one caused the other.

Sure, our current medical care is pretty darn good, but it was a long and dangerous road to get here (puerperal fever, twilight sleep, lack of antibiotics, inexperience, etc.).

Improvements in everything from education about birth to the quality of food available to us have undoubtably had an impact as well. You cannot separate out where credit is due, because everything affecting how we birth has improved.

Do you honestly think that the current risk of home birth is as bleak as maternal or infant mortality rates 100 years ago (1 in 100 MMR and 165 in 1000 IMR)?

By Anonymous Anonymous, at 5:26 PM  

Exactly what grief do I have?
I'm sad at the state of affairs in the medical world for vbac mothers... we are only marginally better off in Canada... but obviously my example of IF I'd been in the hospital was taken as truth. I was at home, my daughter had a hb of less than 100, poor tone and no respiratory effort. By the time the EMT's (useless twits) arrived four minutes later, she was pink wailing and furious at the mask hovered over her beautiful face. IF I'd been in the hospital, like a good patient with an epidural and coached pushing, her descent would have been hindered (of course interventions are not bad at all now are they?) and she would have died. A crash c/s would not have got her out fast enough. Upon speaking with the neonatal neurologist, she agrees. Which is why she believes in homebirth and midwifery for all but the most complicated of pregnancies.
My daughter is happily nursing while her brothers run wild waiting for dad to get home. I have no grief, other than for the people I meet who have been battered and beaten by the "system". I know about the system, I know that I have "baggage" in regards to the amount of c/s's done in this hemisphere... but that is my baggage. I can only hope to help stem the tide as a birth doula... hope to someday be able to be able to sign off as a midwife too.... sarcasm is a freebie!

By Anonymous Anonymous, at 5:38 PM  

Anonymous:

"Exactly what grief do I have?"

I mistakenly thought that you were the woman on Neonatal Doc whose baby died. I'm glad that you weren't.

By Blogger Amy Tuteur, MD, at 5:48 PM  

Anonymous 4:52:

"Inductions. Most women in the care of OBs are not allowed to go more than one week overdue (far less in some areas), even if there is no other medical cause for induction.

OBs admit that due dates are estimates, but by the end of pregnancy, it is an iron-clad date.

Length of labor. When a laboring woman enters the hospital, she is on the clock. If she doesn't deliver within an arbitrary amount of time (10-24 hours, especially if her water has (been) broken), her risk of c-section - even without any other medical reason - increases."

Why do you think this happens? Surely it is not because doctors want to make birth more complicated, so what do you think it might be?

By Blogger Amy Tuteur, MD, at 5:50 PM  

Anonymous 5:26:

"We have tons of data showing that as deliveries shifted from home to hospital, the neonatal and maternal mortality rates dropped by over 90%. Now you want to go back to homebirth. It's up to YOU to prove that homebirth is safe, since it was never safe in the past."

"OK, Amy, this is bad logic AND bad history."

You're changing the topic again.

We are discussing whether the burden of proof is on the homebirth advocates or the doctors. The issue is not whether one thing caused the other. (Although it is undoubtedly true that the switch to the hospital IS what improved the mortality rates.) The issue is that historically homebirth has been unsafe. If you want to assert that this has changed, then YOU must prove it, not me. And so far, no one has been able to provide proof.

By Blogger Amy Tuteur, MD, at 5:57 PM  

my deep and abiding respect for natural birth

Ok, I'm going to assume then that you were playing devil's advocate in other posts, because that sure hasn't shown through Amy. And yes, we all wish most OBs were as you described them, but how long have you been out of clinical OB? Because most are emphatically NOT. Most also feely admit to me that they would happily turn all the normal births over to midwives and only do high-risk and GYN.

What is the difference in reimbursement for an OB for a vaginal delivery compared to a c/section?

Anonymous, I'm the Maribeth in PA at a birth center practice :) And I think by your 'grief' Amy thought you were the homebirth mom with the damaged baby in NeoDocs original post, rather than the first poster (I thought that initally too).

By Anonymous maribeth, CNM, at 6:14 PM  

Wow.

Maribeth, it seems like you're suggesting OBs prefer complicated and surgical births because they make the OB more money.

If that's NOT what you're saying, what are you saying? Can you clearly state your point?

And if that IS what you're saying, can you defend it?

I mean, it shouldn't be so hard to find out whether a natural or assisted birth nets the OB more money. I think Dr. Amy will answer that soon.

Do you plan to find out whether C section rates change when OBs are salaried rather than per-service?

Do you plan to find out whether the C section rate changes, for example, when available reimbursement is known to be limited?

Do you plan to find out whether midwives advise their clients to stay away from hospitals in order to make more money, for comparison's sake?

Or are you just trying to insult OBs in general?

By Blogger sailorman, at 6:41 PM  

Quoting neonatal doc..

I knew that sooner or later I would write about home deliveries. I do it now because a commenter on a recent post of mine (CDMR) said that after she had a caesarean section she had her next two deliveries at home. In a nutshell, I hate home deliveries.

That would be me.
Happy healthy baby, trying to chew on the dog now.

By Anonymous Anonymous, at 7:21 PM  

"It doesn't work that way. When a drug company invents a new drug it doesn't put it on the market and say "if you think it isn't safe, the burden of proof is on you."

But Amy, you've said yourself that 'natural' childbirth is the default. Going to the hospital is like taking the pharma's drug.

Anyway, it's clearly a matter of perspective. We aren't going to come to any lasting resolution here.

I've looked at some of your other sites and blogs. Had any of us bothered to look first, it'd be clear we were wasting our time here. There are OBs and then there are OBs. And with your very silly statements on narcotics/drugs being perfectly safe, and that downright stupid commentary on episiotomys.... well, it's pretty clear you fall into the second category. If you can't accept the truly overwhelming amount of literature proving up, down and sideways that episiotomys are bad news.... nothing I or anyone else posting here is going to make any difference.

Thanks for stepping out of practice.

Thanks also to Maribeth, Navelgazer, metromidwife, Jami, and all the others for your well thought out and well documented posts. I've learned a lot, and I hope others have too.

I'm pretty much wandering off now.....

By Blogger Cherrie, at 8:47 PM  

I have birthed 4 children ,one at a hospital, three at home,two were waterbirths and the last was unassisted. As far as statistics I have read " The Five Standards of Safe Childbearing" and seeing those statistics years ago.They showed that the countries with the highest survival rate of mothers and babies were ones that had homebirths with trianed midwives who has access to modern hospitals in case of emergencies. Mostly the scandinavian countries.
Now I can give you my personal experiences. My first child was hospital born. I am a loud birther and apparently the hospital staff doesn't like that because they kept offering me pain medication. the medication immediately slowed my labor that before hand had been going along quite fast. After the epidural I lost my abilty to feel contractions and push with them,resulting in a vacuum extraction, a perineal tear and of course stitches. My child was then taken before I could see him ,scrubbed and swaddled then placed on something resembling a french fry warmer. I was told this was all standard procedure. Then the OB pushed on my belly to make my uterus contract which was extreemly painful. Now in retrospect I know that if I had been given my baby right away to nurse him the nursing would have stimulated the contractions.

My three homebirths were short, sweet uncomplicated labors. I had no need for medication as I could make whatever sounds I saw fit. I could walk about freely,stand, squat, drink tend my other children, go for a long walk in the park,relax in the tub,play video games....My last child was only 45 minute of labor. He was born in the tub.He nursed right away. No one had to catch him for me . I caught my own babies at home.No one had to tell me boys or girls, I saw for myself. No one had to watch my other children, they were present for the births.They all had midwifery care. They had no vit K shots, no eye drops,no pokes or tests. No perineal tears even with my 9 lb 2 oz baby Are they all healthy? You bet! Is homebirth safe? In my opinion,unless during prenatal care I found I was at risk for a particular thing,I'd prefer a homebirth to a hospital birth any day!

By Anonymous barefootmamax4, at 9:24 PM  

the shift from home to hospital actually increased maternal and infant mortality-- clear into the 1920's
.
the biggest shifts in maternal and infant mortality- in this country as in many parts of the world- clean water, food to eat and reduction of diseases that accompany that ( like typhoid, diptheria, typhus, cholera) - also the problems faced in many third world countries today- along with wars and poverty that have

By Anonymous Anonymous, at 9:49 PM  

In 1900 only 5% of births took place in the hospital; in 1950, over 90% of births took place in the hospital. Look what happened during those 50 years:

1900 neonatal mortality 100/1000
maternal mortality 850/100,000

1920 neonatal 72
maternal 780

1930 neonatal 60
maternal 600

1940 neonatal 38
maternal 300

1950 neonatal 30
maternal 80

So, as birth switched from being almost exclusively at home to almost exclusively at the hospital, the neonatal mortality rate dropped by 70% and the maternal mortality rate dropped over 90%.

By now, over 99% of births take place in the hospital and the neonatal mortality rate in in the range of 7/1000 and the maternal mortality rate is about 12/100,000.

"the biggest shifts in maternal and infant mortality- in this country as in many parts of the world- clean water, food to eat and reduction of diseases that accompany that (like typhoid, diptheria, typhus, cholera)"

No, the biggest drops in maternal and infant mortality came from antibiotics, blood transfusions, improved anesthesia, neonatal resucitation, the invention of the incubator, the discovery of surfactant and other medical discoveries.

Look up the main causes of maternal and neonatal deaths in 1900 and you will find that they had nothing to do with food or water or infectious diseases.

Deaths from the diseases you mentioned were not recorded as either maternal or neonatal deaths, so they could not have contributed to maternal or neonatal death rates.

By Blogger Amy Tuteur, MD, at 10:20 PM  

I keep meaning to mention this. Post hoc non est propter hoc, and correlation isn't causality (as you pointed out to me at Neonatal Doc's). ;-) Mortality stats for homebirth plummeted at the same time. Many lifesaving advances (oxytocics, neonatal resuscitation techniques) were portable.

By Blogger Jamie, at 10:51 PM  

THE WHITE HOUSE CONFERENCE ON CHILD HEALTH AND PROTECTION- TOPIC OBSTETRIC EDUCATION- Report of the subcommittee on ob teaching and education Fred Lyman Adair MD (chair) published 1932

this book is a must find and read- on the same pages where the "midwife problem" is discussed are statements and statistics that show midwifery to be a safer option- in New Jersey from the dept of health 1916-1921 " showing that maternal mortality rate per 1,000 live births among cases delivered by midwives had varied from 1 to 2.2 during the five years, while that for doctors in private and hospital practice had ranged from 6 to 8.7 ."
or from pages 196-198
in comparing states they make 2 points- 1 that figures on births attended by midwives frequently include births attended by persons who are not midwives (2) that of the women who serve as midwives only a small number are trained in midwifery.
" In the United States birth registration area in 1929, there were 13 states with maternal mortality rates higher than 80 per 10,000 live births. Mostly these are the southern states with a large Negro population. These states also have a large percentage of births attended by so-called midwives.While the ignorant and untrained colored 'mammy' undoubtedly contributes her share to this high rate, other factors contribute to high mortality rates from all causes among the Negro population and proportionately to maternal mortality are too well known for us to conclude that the high rates in the South are due per se as to the high incidence of so-called midwife deliveries. In fact, statistics from 3 states (table 5) show a considerably lower maternal mortality rate among Negro women attended by midwives than among those attended by physicians." 111/10,000 physician attended compared to 51/10,000 midwife attended; 140/10,000 physician attended- 55/10,000 midwife; 110/10000 physician attended- 49/10,000 midwife."
and yet they persisedt in thinking that midwives had more to learn from them and would eventually need to be replaced completely by physicians

By Anonymous Anonymous, at 11:01 PM  

an example-- from savannah Georgia 1920-1930
morbidity and mortality from tetanus neonatorum

rather than copying the entire chart- the decline from 33.4/100,000 mortality in 1920 down to 2.4/100,000 in 1929

info on the other diseases I will have to dig out-- but it is a clear contributor -- just as these diseases are in 3rd world countries today- tetanus is in the top three as a cause of infant mortality.-India, Tibet, Thailand....

By Anonymous Anonymous, at 11:32 PM  

Maribeth, it seems like you're suggesting OBs prefer complicated and surgical births because they make the OB more money

I have had OBs tell me that c/sections save them liability and gain them finances. I have. Same for hysterectomies.

I am not suggesting all OBs do c/sections for profit, but I think the concept exists. Do I have research to show it? No. But I'd love to see a study comparing surgical rates for salaried and fee-for-service docs, as you suggest.

I truthfully did not mean that as a direct correlation when I asked Amy (yet another post of mine unanswered by her). I was actually wondering what the $ difference was.

I do think, contrary to Amy's opinion, that most docs do prefer 'complicated and surgical births'.

By Anonymous maribeth, CNM, at 11:44 PM  

straight from the CDC
look yourself
http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm

-----------------------------------------

Control of infectious diseases has resulted from clean water and improved sanitation. Infections such as typhoid and cholera transmitted by contaminated water, a major cause of illness and death early in the 20th century, have been reduced dramatically by improved sanitation. In addition, the discovery of antimicrobial therapy has been critical to successful public health efforts to control infections such as tuberculosis and sexually transmitted diseases (STDs).

Since 1900, safer and healthier foods have resulted from decreases in microbial contamination and increases in nutritional content. Identifying essential micronutrients and establishing food-fortification programs have almost eliminated major nutritional deficiency diseases such as rickets, goiter, and pellagra in the United States.
( remember that rickets was a cause of infant and maternal mortality)

Healthier mothers and babies have resulted from better hygiene and nutrition, availability of antibiotics, greater access to health care, and technologic advances in maternal and neonatal medicine. Since 1900, infant mortality has decreased 90%, and maternal mortality has decreased 99%.

By Anonymous Anonymous, at 11:52 PM  

Jamie:

"Post hoc non est propter hoc, and correlation isn't causality"

True. In and of itself it would not be enough to show that the movement to hospital birth CAUSED the decrease in mortality. However, it is just one piece of information in a very substantial body of information that shows that the switch to hospital birth resulted in decreased mortality.

Keep in mind, the main causes of death in 1900 included eclampsic seizures, hemorrhage, prematurity and similar causes. None of these can be treated at home to this day.

"Mortality stats for homebirth plummeted at the same time."

That could have happened. However, I don't think that anyone has collected homebirth statistics from those years. Have you found some that we can look at?

By Blogger Amy Tuteur, MD, at 6:47 AM  

Anonymous:

"THE WHITE HOUSE CONFERENCE ON CHILD HEALTH AND PROTECTION- TOPIC OBSTETRIC EDUCATION- Report of the subcommittee on ob teaching and education Fred Lyman Adair MD (chair) published 1932"

We are not talking about what happened in 1932. If the best you can do is a reference from 1932, you've pretty much conceded the point.

By Blogger Amy Tuteur, MD, at 7:01 AM  

Anonymous:

"Healthier mothers and babies have resulted from better hygiene and nutrition, availability of antibiotics, greater access to health care, and technologic advances in maternal and neonatal medicine. Since 1900, infant mortality has decreased 90%, and maternal mortality has decreased 99%."

Infant mortality is not what we are talking about here. Infant mortality is deaths from 1 month of age to 1 year of age. We are talking about perinatal (at the time of birth) and neonatal (birth up to 1 month) mortality.

The above quote is using the term "maternal mortality" to mean death of mothers, not death of mothers in childbirth.

So in both instances, this information is not relevant to our discussion because it is not talking about birth (at home or anywhere else).

By Blogger Amy Tuteur, MD, at 7:06 AM  

One reason everyone seems to be forgetting when it comes to why hospitals develop certain policies regarding labor and delivery is lawsuits. I believe OBs are the #1 sued specialty in the US and have the highest insurance costs of any specialty (that used to be the case, anyway, but my youngest just turned 18, so it's been a while).

Here we have all these women who are claiming that OBs are responsible for this, that and the other thing, and that same attitude tends to culminate in a ripping great lawsuit. If women are being taught to go in with an antagonistic attitude towards docs, odds are they're going to blame the doc regardless of what the facts are should they not end up with the perfect Hallmark birth moment.

Doctors are damned if they do, damned if they don't in the US and it's because we live in a culture of blame and litigation.

By Anonymous Anonymous, at 8:07 AM  

Anonymous:

"One reason everyone seems to be forgetting when it comes to why hospitals develop certain policies regarding labor and delivery is lawsuits"

However, they are only vulnerable to lawsuits because there is scientific data to show one way of doing things might be better than another.

For example, the need for inductions in postdates pregnancies. It has been implied here that inductions for postdates are done to "complicate" natural childbirth. No, inductions for postdates are done because the perinatal death rate begins to rise dramatically after 42 weeks. It is not an arbitrary point. The perinatal death rate at 42 weeks is essentially the same as it is as 40 weeks (perhaps slightly higher). After that it rises sharply and that changes the risks.

In some ways, this comes back to the completely false notion that childbirth is inherently safe. It also calls into question the basic training and judgment of homebirth midwives. If you don't understand why postdates is dangerous, or if you don't understand what the Friedman curve means, you are going to make bad decisions.

By Blogger Amy Tuteur, MD, at 10:06 AM  

you know I am beginning to think you are not a doctor.
awareness of living conditions and disease states that were primary causes of morbidity and mortality should be in the realm of your understanding
In that time period the primary cause of morbidity and mortality were infectious diseases - and you know I forgot to mention TB -in any case they do and did have a huge effect on maternal and newborn populations.
You cannot just capture a topic like improvements in maternal and newborn health from when births started in the hospitals, because it isn't true hospital births were detrimental to maternal and newborn health- and if we were having this discussion back then- hospital births because of their mortality rates should have been outlawed! Even the CDC lists the improvements in maternal and child health- the CDC has the info you provide- improvements since 1900 but do not credit hospitals with that read carefully what they list as improvements. Realize that it did change maternal and newborn health status- subtract the change in death rates from those improvements. from an article on the CDC web site- "In 1900, the three leading causes of death were pneumonia, tuberculosis (TB), and diarrhea and enteritis, which (together with diphtheria) caused one third of all deaths"

so you show me when the hospital death rates started improving ------because in 32 they were not good-

the babies that died from tetanus are newborns they died from cord site infections- but the site of birth has little to nothing to do with it, and babies still die from cord site tetanus.
so subtract that improvement from the side of hospital improvements--
the problem like what they are looking at in Nepal- the fuel only fuel around to set on fire and cook with is manure and when mothers warm gee to apply to the cord stump- the gee which is not contaminated with tetanus becomes contaminated through heating--- and guess what they are finding that topical antiseptics are helping prevent tetanus--
----------------------------------------------------------------------------------------------------------------------------------
"The 19th century shift in population from country to city that accompanied industrialization and immigration led to overcrowding in poor housing served by inadequate or nonexistent public water supplies and waste-disposal systems. These conditions resulted in repeated outbreaks of cholera, dysentery, TB, typhoid fever, influenza, yellow fever, and malaria.

By 1900, however, the incidence of many of these diseases had begun to decline because of public health improvements, implementation of which continued into the 20th century. Local, state, and federal efforts to improve sanitation and hygiene reinforced the concept of collective "public health" action (e.g., to prevent infection by providing clean drinking water). By 1900, 40 of the 45 states had established health departments. The first county health departments were established in 1908 (6). From the 1930s through the 1950s, state and local health departments made substantial progress in disease prevention activities, including sewage disposal, water treatment, food safety, organized solid waste disposal, and public education about hygienic practices (e.g., foodhandling and handwashing). Chlorination and other treatments of drinking water began in the early 1900s and became widespread public health practices, further decreasing the incidence of waterborne diseases. The incidence of TB also declined as improvements in housing reduced crowding and TB-control programs were initiated. In 1900, 194 of every 100,000 U.S. residents died from TB; most were residents of urban areas. In 1940 (before the introduction of antibiotic therapy), TB remained a leading cause of death, but the crude death rate had decreased to 46 per 100,000 persons (7)."

By Anonymous Anonymous, at 10:34 AM  

I think there is a middle ground here. Homebirth is safe for low risk women, in part because of hospital back up. They are safe because midwives are far better trained than they were in 1900. They employ aseptic technique and many are now professionaly certified and undergo rigorous training.

Hospitals and OBs have contributed to a lower infant mortality rate (which ours by the way is dismal compared to the rest of the industrialized countries who have universalized healthcare and use midwives for a large percentage of births). But if one was to divide the infant mortality rate among low and high risk moms I would suggest that they have provided much more benefit to moms who are high risk. That is what OBs are best at.
But, as stated in previous posts, birth is safer for a lot of other reasons besides hospitals and OBs. And is is short sighted to believe other wise.

By Anonymous Anonymous, at 11:05 AM  

The perinatal death rate at 42 weeks is essentially the same as it is as 40 weeks

And yet most women are not allowed to go past 41 weeks. Babies are rushed out before they are ready, causing complications.

Anonymous, I don't think all the problems were talking about come down to docs. Docs are a symptoms of the problem, for sure. But it's the problem of institutionalized, medicalized, birth that is the real culprit. I agree that 10-15% of women NEED high-risk care. But when you treat the other 85-90% of normal, physiologic birth as either a disease, or a disaster waiting to happen, guess what -- disasters happen.

By Anonymous maribeth, CNM, at 11:11 AM  

The issue is that historically homebirth has been unsafe.

Actually, I think the real issue is that great advances have been made by doctors, when they are committed to the scientific method/evidence-based practice. Being a good physician means being teachable, being open to better, healthier, less pernicious ways of approaching science. It means being committed to the truth.

The problem, Amy, is that if someone were to present information that home birth is as safe as - or safer than - hospital birth, then I doubt you would accept it. I don't think you are open enough to the possibility, and that is probably because in your work you have seen a high number of complicated births. This has made an impression on you and you have concluded that birth itself is complicated and unsafe.

Those of us who believe that birth usually goes well, will never change your mind on this, no matter the source for our statistics.

By Anonymous Anonymous, at 12:12 PM  

Anonymous:

"In that time period the primary cause of morbidity and mortality were infectious diseases - and you know I forgot to mention TB -in any case they do and did have a huge effect on maternal and newborn populations."

No, you clearly do not understand the meaning of mortality statistics.

These diseases are NOT included the NEONATAL and MATERNAL mortality statistics. If a baby or mother died of diphtheria, it would be registered in the INFANT or the adult FEMALE mortality statistics. Since is was NEVER counted as part of neonatal or maternal mortality, wiping out diphtheria had no impact on the mortality rates that we are discussing here.

By Blogger Amy Tuteur, MD, at 12:18 PM  

in that part of the century I do believe it was included Amy- pregnant , laboring and postpartum women were dying due to those disease and their newborns were as well--
if not included in the stats they should have been and if they were not truly included then it means that the hospital birth death rates were greater than they are show-- talk about playing with numbers and statistics-- exclude people who catch diseases in the hospital-from being in a bed 3 feet away from a sick laboring/postpartum woman, nurses and doctors moving from one patient to the next but it isn't part of anyone's problem.

By Anonymous Anonymous, at 1:29 PM  

Anonymous:

"in that part of the century I do believe it was included"

No, it was not included. If you think differently look at the information from the Bureau of Statistics and it will explain.

By Blogger Amy Tuteur, MD, at 4:37 PM