Saturday, May 20, 2006

Direct entry midwives and hospitals

Although the terms are occasionally used interchangeably, there are really two different kinds of midwives, certified nurse midwives (CNMs) and direct entry midwives. On this board, we have generally been discussing direct entry midwifery.

There is a lot of talk about doctors being unsupportive of midwifery, but that is not really true. The number of CNMs in the US is growing rapidly. They are incorporated into physician practices large and small, and they have hospital privileges (as long as they have physician back up). So doctors are actually quite supportive of midwivery.

On the other hand, there are women who would like to assist in childbirth, who do not have the education and training of CNMs. Some of them simply call themselves lay midwives. Others get certification from degree granting programs run by direct entry midwives. Most doctors (myself included) will not work with them and they cannot get hospital privileges. This gives rise to several important questions.

1. Are direct entry midwives forced to be committed to homebirth no matter what the data is, because they are out of a job otherwise?

2. Do direct entry midwives misinterpret the hostility of doctors? There is a lot of talk that the doctors' hostility reflects a preference for intervention, or a failure to understand the way that birth should be. However, isn't it more likely that doctors object to direct entry midwifery simply because they don't think that direct entry midwives are adequately trained?

3. Is it really possibly for a direct entry midwife to be adequately trained since she is exposed to very few birth complications? If she does not train in a hospital, she cannot ever observe management of the most common emergencies during labor and delivery?

4. Wouldn't it make a lot more sense for all midwives to become certified nurse midwives?

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65 Old Comments:

1. Are direct entry midwives forced to be committed to homebirth no matter what the data is, because they are out of a job otherwise?

We are not "forced", we choose our venue of practice. Every woman (and the few men) who investigate the various pathways to midwifery decide on the type of midwife they want to be and with that must decide if being limited to a particular venue is going to be a large factor to their future. Even CNMs in some states due to politics must decide if being limited to hospitals is worth it to them.

2. Do direct entry midwives misinterpret the hostility of doctors? There is a lot of talk that the doctors' hostility reflects a preference for intervention, or a failure to understand the way that birth should be. However, isn't it more likely that doctors object to direct entry midwifery simply because they don't think that direct entry midwives are adequately trained?

I can't speak for everyone, but doctors I know usually have no idea there was any such training other than CNM programs and are always impressed with me when I can share my training history. I have never been received by OBs or CNMs with a transfer of care case in a hostile manner. If I am transferring care of my client it is because intervention is warranted.

3. Is it really possibly for a direct entry midwife to be adequately trained since she is exposed to very few birth complications? If she does not train in a hospital, she cannot ever observe management of the most common emergencies during labor and delivery?

Yes it is possible to be adequately trained.

4. Wouldn't it make a lot more sense for all midwives to become certified nurse midwives?

No. It's a matter of preference. By the way do you know there are also ACNM "certified midwives" who are not nurses?

By Anonymous Anonymous, at 4:02 PM  

Most doctors (myself included) will not work with them...

What does it mean that you won't work with them? (or you wouldn't since you are apparently out of practice)

By Anonymous Anonymous, at 4:09 PM  

I guess it depends on where you live and where midwives are growing in population- in this state midwives are actually loosing jobs the midwifery # are going down here. Doctors are truly against the midwives where I live and if they do practice they are extremely limited in what they are allowed to do.
the other pattern I see on lists with midwives is that they are hired to do prenatal care but not births... or gyn care-- I would say that every CNM I know is frustrated with the way doctors treat them and I do think that they are being mistreated. - do I think that they are against yes for the most part yes- in just this state no- look at CNMs in Oregon- or Washington, Missouri, Virginia, Florida , New York-- the laws governing CNMs in each state is different- just like with LMs and where it is bad for CNMs it is worse for LMs. In New Mexico that state is an exception and there are probably other exceptions.
in places where the laws don't govern roughly the hospitals and HMOs play games no hospital privileges, not allowed to admit patients even if you have limited privileges-- How about no payment unless a doctor signs off ( this policy is probably illegal- because many times the doctor doesn't provide any care for the client at all- yet if you don't have a doc sign off on your work- in an independent practice state you are not paid!!)
also look at the legislature and senate in your state- if republican probably you have a very strong medical lobby and laws that would benefit midwives never get passed-- what about the national attempt to not allow midwives to be paid medicaid!!!!!! perhaps you have had some kindly feelings for midwives but how politically involved and aware are you?

By Anonymous Anonymous, at 4:26 PM  

Anonymous 4:09:

"What does it mean that you won't work with them?"

It means that I would not agree to be back-up for a direct entry midwife. If am backing up someone, I need to have complete confidence in their training, since I will have to solve any problems they can't manage or any problems that they create.

By Blogger Amy Tuteur, MD, at 5:33 PM  

Amy, your questions further lead me to believe that you really are not well acquainted with the ways midwives practice. I would be much more willing to consider your arguments against home birth if I felt you were well acquainted with midwifery, the various types of midwives, and the various reasons why women, such as myself, prefer the care of a midwife.

If you would like to understand different kinds of midwives, we have a good explanation at the Nebraska Friends of Midwives website, www.nemidwives.org. You can also read about our political struggles there and find evidence that plenty of doctors are indeed hostile to midwives and to women who choose homebirth.

My midwife at my second birth was a Certified Nurse Midwife and she cared for me in a hospital setting. My midwife at my third (home) birth was a Certified Professional Midwife. (Direct-entry and lay midwives are not the same thing, by the way.)

Why would a direct-entry midwife want to practice in a hospital? I don't understand question #1. If a particular woman wanted to become a hospital based midwife, she could become a CNM. Or, maybe if she wanted to work in a hospital, she could become an obstetrician. Women who are direct entry midwives, in my experience, for the most part are very intelligent women. They don't choose to become midwives because they aren't smart enough for medical school, they become midwives because they believe in normal birth and the Midwives Model of Care.

By Blogger Mama Liberty, at 5:33 PM  

Danielle:

"your questions further lead me to believe that you really are not well acquainted with the ways midwives practice."

Isn't it true that direct entry midwives have less classroom experience, less direct experience delivering babies, no observation or participation in managing serious complications in the hospital setting, and a vanishingly small amount of exposure to managing complications at home?

It is difficult for me to imagine any advantages in having less basic knowledge and less experience. I'm not aware of benefits of direct entry midwifery over certified nurse midwifery.

I am not speaking about the direct entry midwives personally, just the particular training that they have. I don't think that even realize how little experience they have and how much knowledge they lack. Why would someone opt for a midwife with less training when she could have a midwife with more training?

Direct entry midwives are angry that they do not get the respect of certified nurse midwives, but are they really entitled to it? (I don't mean that they shouldn't be treated respectfully as persons, just that others do not hold their level of experience and training in the same esteem as they hold it themselves.)

By Blogger Amy Tuteur, MD, at 5:45 PM  

1. Are direct entry midwives forced to be committed to homebirth no matter what the data is, because they are out of a job otherwise?
can only answer for myself- I did not intend to be a midwife- my college studies were anthro and English - through my own experiences and births here I am ( most direct entry midwives are midwives because of a passion to serve)

2. Do direct entry midwives misinterpret the hostility of doctors? There is a lot of talk that the doctors' hostility reflects a preference for intervention, or a failure to understand the way that birth should be. However, isn't it more likely that doctors object to direct entry midwifery simply because they don't think that direct entry midwives are adequately trained?
I think one on one it is more a question of rude behavior and being use to a social environment where women for the most part look up to them and don't question- a couple examples- not OB- but could apply- friend working in telemetry and doc leaves written orders- no one on shift can decipher his writing- friend calls him up all the other freak out and are mad at her because she is calling him on it- he is such a busy man don't bother him- well friend says to doc I can't read it- who's it for- I can't read it- doc has to come back in and he can't read it- now these nurses and others have been putting up with his writing for years and just deciphering as best they can...this guy was good natured and should have been approached long ago.
other example- DH had a severe (10 cm ) hemorrhagic stroke- and is finally in the rehab hospital - he was in the regular hospital long enough to have surgery stitches taken out- well in going into the rehab they set an appointment to leave the rehab hospital and see the neurosurgeon at his office 1 week later- he is not well enough to ambulate and ride in a car- doc does stint at hospital right next door several day a week- drives past his patients in rehab- and has them come to him--- I call the office and say no we want to postpone and I get read the riot act- how dare I impose on the doc ... I say when dh is well enough to come we will be in- if doc is worried he can stop by- oh doc makes it a policy to not do that!! do we want any continuing care from him yes, should he be more reasonable- I think so. Much of the time I think docs are treated like spoiled children-- and so can't always blame them because they have a revered status--
on the other hand I also think it is just a territory issue- studies on folks even in department stores show that after a certain amount of time in a department employees become territorial and are rude and unpleasant to customers because they mess up the stuff or move it-- Docs are just as unpleasant to doulas and family members- we are just a more organized group and complain more loudly, also if it is a transport they are thinking like ok what have you done to mess this up already- a doctor in town who did not have privileges had some pretty rough treatment from a transfer she had- that is the client with the 20 week c secton- not a tubal pregnancy by the way-- bigger hospitals are better-
the same behavior is also what makes them poor care providers in my estimation- they don't listen to their clients- them often miss or dismiss complaints- they maybe excellent technicians - like maybe they would be who you would want to get to have a c-section asap because they are ready and willing- and they don't even care what the history is-
on the other hand good back up docs tend to be good care providers as well- don't know why that works out but it does- they are kinder listen better and respect women they work for- now some of the old ones are a bit fatherly or but well intended- personally I also have seen but do not like the ladies' man doc who will try to be charming and work with you and maybe fool around on the side as well... no thank you ; )

3. Is it really possibly for a direct entry midwife to be adequately trained since she is exposed to very few birth complications? If she does not train in a hospital, she cannot ever observe management of the most common emergencies during labor and delivery?
Yes, will we be as skilled as you - probably not atleast in some areas-
4. Wouldn't it make a lot more sense for all midwives to become certified nurse midwives?
no --- first off cost effectiveness- if I am charging nothing to 600$ for care how much will my costs go up? and in which state- some states I would need 8 years of schooling to be a CNM- only the funded poor could afford me in hospital- the medium no insurance folks are SOL
I have worked with CNMs who attend home births and first of all if they haven't worked as a lay/ direct entry midwife before they became a CNM- they do not have the skills for doing home birth- hospital training does not teach you how to be the labor sitter- stuff like how and when to do something beyond heart tones, maternal vitals-- there is no one to hand off to at home it is you and your assistant- and you would be better off sharing judgment if 2 midwives attend the birth together than the solo person who calls the shots and phones in the orders- you are on call 24/7 and you had better go and see that client either in office of at her house do not be tempted by the ease of phone management...
Now here is another point and that is overtraining in an area CNMs don't really just do low risk hospital births- they manage all sorts of complications- within the safety net of the hospital- some Direct entry midwives have had similar training- in some high risk stuff - either through humanitarian efforts in other countries or that they have come from another country they are trained beyond the scope of normal midwifery and think that it is part of what they can do- it is something that they have done and can be a bit cavalier about some problems that they have seen alot of or procedures they have pulled off successfully that do not belong in a metropolitan homebirth setting- things like using a vacuum extractor- or managing a primary herpes outbreak- (consulted with a CNM on one case and she was like it's ok we deliver um all the time just use the RX, my preference transfer of care-- this baby when labor comes needs to be born in a hospital, KWIM?) infact I know that some of the home birth stats reflect just such over trained providers--- just my 2 cents

By Anonymous Anonymous, at 5:53 PM  

Oh I forgot to add that no matter who is attending home births even doctors the transfer system needs to be better-
one of the CNMs I worked with we had a transfer of care because of a seeping but not hemorrhaging retained placenta- we had IV in place and had did everything we could safely do to get the placenta out at home- ambulance comes and we get the gal finally into it- but the nearest hospital with OB is on diversion so they say and it is just before we get into our cars to follow- we will take her to the heart hospital- we say no they can't deal with this- and the guys look at us like we are crazy and that of course a doctor can do anything-- and we said no we have done what they can do she needs an ob and a surgery -- we all reluctantly get into our cars gearing up for a problem- and they converse on the radio and get the go ahead to go to another hospital with an OB -- luckily like I said this was non-emergent- and we caught the mistake before it happened-

By Anonymous Anonymous, at 6:30 PM  

"Isn't it true that direct entry midwives have less classroom experience, less direct experience delivering babies..."

Less classroom experience, perhaps... but in many cases, MORE direct experience. I chose my midwife and backup midwife based on their direct experience. One of my midwives had 500 births under her belt and the other one had years of experience helping women in Mexico. I don't remember her number any more.

I think that classroom experience can be overrated. Learning doesn't have to happen in the classroom. Some of the most accomplished people in human history didn't have college degrees... Thomas Jefferson and Albert Einstein come immediately to mind. Many education reformers are heralding a call back to more hands on learning. I will choose my midwives in the future based on their direct experience. It will not matter to me whether they are CNM, CPM, direct-entry, etc. I will choose based on their experience and their birth philosophy. In the past I have put many "what-if" questions to my midwives to find out how they would handle different situations.

"...no observation or participation in managing serious complications in the hospital setting..."

I don't understand why you want them to have experience in a hospital setting. If I need to be in a hospital, I expect to be under the care of an obstetrician, not a midwife. It would be nice, however, if there were cooperation so that should I need to transfer there would be appropriate communication. For example, in cooperative systems, if there is a transfer, the physician accepts the midwife's assesment and valuable time isn't wasted. If I hit the hospital doors and I and my midwife suspects that my uterus is/has ruptured then I want the obstetrician and the staff ready to do a c/s.

"and a vanishingly small amount of exposure to managing complications at home?"

Ding, ding, ding, ding! We have a winner! Yes, they have a vanishingly small amount of exposure to (major) complications at home, because they rarely happen! That is the beauty of normal birth. A midwife is the student of NORMAL birth. She studies normal birth and consequently anything outside of normal stands out. The obstetrician studies pathological birth and wouldn't know normal if it hit him/her between the eyes! If I met an obstetrician who had observed 50 normal births, start to finish, without interfering (no vaginal exams, nuthin') I would seriously consider hiring that OB as my birth attendant.

Its amazing how damn complicated my first two OB attended pregnancies and births were (though I had a CNM and OB for my second) and how very normal my third midwife attended pregnancy and birth was!

By Blogger Mama Liberty, at 6:35 PM  

Ding, ding, ding, ding! We have a winner! Yes, they have a vanishingly small amount of exposure to (major) complications at home, because they rarely happen! That is the beauty of normal birth.

Exactly, Danielle. Exactly. I recognize the limits of generalizing from one's own experience, but I have talked to so many women who describe their homebirths as a completely different kind of undertaking. For a variety of reasons, more problems arise in hospitals than at home.

While searching for something else I came across this paper from the Wisconsin section of ACOG. Can anybody tell me what CPMs have to know about pharmacology, and how important pharmacology is to the practice of midwifery?

By Blogger Jamie, at 8:54 PM  

we need to know about the drugs we use-
pitocin, and methergin-- indications, counter indications , proper dosing
rh immune globin
vitamin K
and this section if you are allowed
IV fluids
antibiotics - dosing, indications and counter
and something for allergic reactions
suture materials- mainly the lidocane
oxygen
-------------
now I think that you have probably studied how to use these and these common things are generally included in most midwifery programs- I can't think of any that don't include them- but not all states allow LMs to use them- I think that there are questions pertaining to their use on the NARM exam

By Anonymous Anonymous, at 9:28 PM  

I think it must be hard for a person who has only seen/participated in hospital births to imagine how homebirth can be safe. Perhaps if you think back to how many frightening emergent complications happen to unmedicated, (ie not induced, no pain med,etc) women with good prenatal care, it might make more sense.
For the most part, situations which need OB care develop prenatally or slowly, with plenty of time to transport.

While it's true that we (I'm a licenced midwife) can't observe and train for every birth complication, we don't need to. We need to be able to handle certain common problems and be able to identify when to transfer care.

However, whether it seems true to hospital based care providers or not, homebirth has been proven in at least one well designed and documented study to be as safe as safe as hospital birth for many women.

It might be worth asking why this is true and why it feels like it can't be true to people who work in a higher risk environment.

By Anonymous jen, at 9:38 PM  

I have known two women who have chosen to give themselves prenatal care and have not had a birth attendant other than their husbands. Is this a "movement"? Is it supported by the lay midwifery community? Are there any restrictions that lay midwives use in deciding not to provide care "at the last minute"?

By Blogger Elizabeth, at 10:22 PM  

Mama Liberty:

"Ding, ding, ding, ding! We have a winner! Yes, they have a vanishingly small amount of exposure to (major) complications at home, because they rarely happen! That is the beauty of normal birth."

I smiled when I read this part because you have a very clever way of putting things!

Unfortunately, though, this is not a winner for direct entry midwives, it is probably the single most serious problem. Here's why:

You don't need any special training for a normal delivery. Anyone can do it. Basically you just have to make sure that the baby does not fall on the floor. However, if there is a complication, you need to be well trained and experienced. A perfectly normal delivery can turn into a life threatening situation in seconds. That's why any birth attendant is there in the first place, to deal with complications.

I found the article about ancient midwives to be intriguing for this very reason. Childbirth is inherently dangerous for both mother and baby and has been so for millions of years. Over those millions of years, women who had attendants at birth had a survival advantage. It was such a large advantage that the entire world came to be populated with people who all used birth attendants.

Birth is still inherently dangerous for both mother and baby. Modern obstetrics exists for the sole purpose of minimizing those risks. Prenatal testing, ultrasounds and monitoring will identify a large proportion of high risk patients before labor begins, but they won't identify them all. That's where the expertise of the birth assistant becomes important.

If you don't have experience managing labor and delivery complications and you have never even watched anyone do it, you are going to be at a tremendous disadvantage when it happens. That, to me, is a completely unacceptable risk.

By Blogger Amy Tuteur, MD, at 10:23 PM  

Jen:

"homebirth has been proven in at least one well designed and documented study to be as safe as safe as hospital birth for many women."

No, Jen, that's simply not true and if you are telling your patients that, you are not giving them accurate information. I have yet to read a single study done in the US, UK or Australia, that shows homebirth to be as safe as hospital birth. There is always an excess of preventable deaths in the homebirth group. If you read the actual papers, not simply the abstracts, you will see that this is the case.

By Blogger Amy Tuteur, MD, at 10:26 PM  

" said...
I have known two women who have chosen to give themselves prenatal care and have not had a birth attendant other than their husbands. Is this a "movement"? Is it supported by the lay midwifery community? Are there any restrictions that lay midwives use in deciding not to provide care "at the last minute"?"

I do know that there are midwives who will support this- and I think that they are crazy-- and they are getting midwives into trouble- if you are thinking that you don't need help or prenatal care don't call a midwife- midwives are not flying squads- and for the most part we want to avoid or detect early or screen out potential problems- and make sure that they are handled in a safe place. there are about 3 older studies about groups that don't seek out care and the Pang study that includes people who also don't seek out care but do have intentional home births. -- there are 3 ways that this goes - fine, or reasonable people who get scared and transfer probably at about 5-6 cm and women who have problems-- my biggest concern are the women who have problems- and I have gotten the calls- and before I had a clear mind about it I have done some prenatal care for some of these families- while I support the right of every woman to birth how ever she wants with what ever amount or care or not- they do not need to involve me in their decisions. If you call me in labor or with problems I will call an ambulance or tell you to call one- I WILL NOT COME..

I have been around the people in the UC movement that support women in all sorts of health conditions- including pre eclamptic, hypertensive, type 1 diabetics or type 2 on insulin before pregnancy, pregnant with twins, breeches of all types, transverse babies, how about a woman carrying twins who is also a vbac x 2. the promoters push an absolute belief in god or your ability with intuition to divine exactly what to do in every situation.

By Anonymous Anonymous, at 11:25 PM  

Where to put this here is a link to a doula's web site she is also in nursing school

http://millinersdream.blogspot.com/

at some point in the past she wrote about being invited to speak at the school to the students who are in the ob part of their education but the amount of time spent in school on this subject is very short, very short- and these will be the new grads who you are relying on in the hospital to have some judgment and call you.
-------------------------------------------
when you look at midwives' educations you are comparing to someone who is doing a focused course of study to someone doing a general course of study- in many states a CNM is called an advanced practice nurse and can do care for everyone including men and children and do the RX for them as well- midwives really do not need that wide of scope in education- unless the earth turns upside down we are never going to be able to rx for anyone let alone do general care for a household-- midwives in other countries are direct entry midwives in a similar way- with relatively short programs-

By Anonymous Anonymous, at 11:55 PM  

It means that I would not agree to be back-up for a direct entry midwife.

It's a flat no without any further evaluation of her education and experience? That's a very sad and generalized prejudice.

By Anonymous Anonymous, at 1:46 AM  

I said:

"I would not agree to be back-up for a direct entry midwife. If am backing up someone, I need to have complete confidence in their training, since I will have to solve any problems they can't manage or any problems that they create."

Anonymous 1:46 commenting about my decision not to back up direct entry midwives said:

"It's a flat no without any further evaluation of her education and experience? That's a very sad and generalized prejudice."

Anonymous 11:25 (who may even been the same person as the above Anonymous) said in regard to unattended childbirth:

"I do know that there are midwives who will support this- and I think that they are crazy-- ...there are 3 ways that this goes - fine, or reasonable people who get scared and transfer probably at about 5-6 cm and women who have problems-- my biggest concern are the women who have problems- and I have gotten the calls ... while I support the right of every woman to birth how ever she wants with what ever amount or care or not- they do not need to involve me in their decisions. If you call me in labor or with problems I will call an ambulance or tell you to call one- I WILL NOT COME.."

So here's my question:

What's the difference between my refusal to provide back up for direct entry midwives because I don't think they have the appropriate level of judgment and experience and a direct entry midwife's decision not to back up women who plan an unattended childbirth because they don't think they have the appropriate level of judgment and experience?

By Blogger Amy Tuteur, MD, at 7:40 AM  

"You don't need any special training for a normal delivery. Anyone can do it. Basically you just have to make sure that the baby does not fall on the floor. However, if there is a complication, you need to be well trained and experienced. A perfectly normal delivery can turn into a life threatening situation in seconds. That's why any birth attendant is there in the first place, to deal with complications."

OK, you have presented exactly the conflict with OB care and midwifery right here. OBs see problems where none exist because they have never or rarely observed normal birth start to finish, without interfering. OBs regularly use aggressive interventions when they are not scientifically called for. We have discussed some of them here. Therefore, they cause complications which never would have occured at home. The question is, on balance, does the hospital create more problems than it solves?

Yes, I will admit that there are certain catastrophic situations where had a baby & mother been in the hospital they MIGHT have been saved. But those kinds of situations are rare. And many of us having analyzed our current system and asked ourselves some real hard questions have come to the conclusion that we and our babies have more of a chance of being harmed in the hospital than having a rare fatal complication at home, under the care of a competent midwife.

Back to the CNM, DEM debate... midwifery is midwifery. Nurse midwives are nurses and midwives. DEMS are just midwives, specialists in birth, period. Many CNMs don't even have any training in home birth any more. DEMs are trained for and can handle most complications when they occur. The way they practice prevents many complications you might be used to seeing in a hospital. There are certain complications DEMs and OBs would handle differently. That is another reason why women will specifically choose the care of a midwife over an OB. (Shoulder dystocia is one example I brought up in another thread.)

Danielle

By Blogger Mama Liberty, at 9:47 AM  

you have that right-
but lets carry this out a bit further- if you work in hospital- you are there for all comers-
how about women who get no prenatal care?
this includes the women who choose to do UC births.
how essential do you feel prenatal care is?
good tool in prevention don't you think?
I would say that any midwife approaching a doc to do some back-up is going to be more reasonable and is clearly not the midwife who is just going to "pray" at births. she is also involved in providing prenatal care- and wants a safety net for her clients and some access to further/continuing care for her clients- many back up docs teach things or share studies and information that they think would be useful to midwives -( just think about the very old study of midwives with better stats than docs )
it is all is possible- what do you think about patient care tecs doing first assists? these people haven't even been taught anatomy,maybe focused anatomy and they learn the old way( many may not have finished high school) - on the job training, same with nurses they get how many hours in the study of obstetrics 8 hrs of instruction? a short rotation in a couple hospitals( nurses I know who did not even do 1 blood draw before they hit the floor) think about them getting an IV in timely.
in any case I am fairly sure that the tecs do not read any studies or do much more than work in the job every day. Many docs and institutions are sticking their necks out for help like this-

By Anonymous Anonymous, at 10:00 AM  

What's the difference between my refusal to provide back up for direct entry midwives because I don't think they have the appropriate level of judgment and experience and a direct entry midwife's decision not to back up women who plan an unattended childbirth because they don't think they have the appropriate level of judgment and experience?

I am "Anonymous 1:46", the same one who thinks a woman attempting an unattended birth with pitocin and methergine for self-administration is dangerous, and not "Anonymous 11:25". I would think the difference between you backing up a direct-entry midwife is easy to see: You and the midwife develop a professional relationship, a joint set of protocols, and among other things you know her; she is not just any random midwife off the street showing up at the hospital with a transfer of care requesting you because she got your name off the dust jacket on your book. Your state must be rife with unqualified midwives to put you at such odds with anyone less than a CNM credential. I rather suspect you don't have many occasions to run into them with your oft repeated fact that most births at home only require someone be around to keep the baby from hitting the floor.

I will attend an unassisted birth if the family commits to prenatal care, labs, and meets the criteria for home birth. I will have my supplies, equipment, and assistants with me. They can have an unhindered birth but I will not back up an unattended birth.

By Anonymous Anonymous, at 10:04 AM  

training in the normal includes how to recognize when something isn't normal- and often a few steps into investigating what to do next- nitrates on a urine strip = what ; ) yes we know- and how to send in a UA and how to read a lab report - now why we may not run a UA some docs will not read a lab that they did not order I kid you not- is this reasonable is it timely care?

By Anonymous Anonymous, at 10:25 AM  

Do you not have anything better to do with your time? You obviously know very little about the various types of midwives and the training that they all go through. Yes, there are midwives that should not be practicing midwifery but there are far more obstetricians that should not be practicing obstetrics. Why? This is because the midwifery model of care is very different. Most women want to be midwives because they want to support women in their search for a wonderful, beautiful and loving pregnancy, labor and birth. Obstetrics as a profession does not have this same model of care. Obstetricians are traiend to intervene at any moment because something could go wrong (yet birth goes right 98% of the time, particularly if left on its own with little to no interventions). Yes, I do believe obstetricians can be necessary and life-saving, but I think if they are used for a perfectly normal pregnancy then, because of their training, they are likely to do more harm than good because they are trained to intervene, not stand by and wait for the birth unfold on its own. Maybe you should be supporting safe homebirth instead of attacking it when, overall, more studies indicate that it is equally safe (and often times safer) than a hospital birth when dealing with low-risk pregnancies.

And, just for the record, my midwife for my son's birth (an amazing, perfect birth - an experience that I would not have had at a hospital) is a Certified Nurse-Midwife. However, she does not practice in hospitals. She attends homebirths and births in her birth center and only ten percent of her clients require any kind of obstetrician/hospital care during pregnancy, labor or birth which is significantly lower than hospital births (even with low-risk pregnancies). Midwives provide care that very few obstetricians would even consider. Did you notice that some countries with more midwives than obstetricians have a lower maternal and infant death rate than countries like the U.S.? This is because they understand that low-risk births (regardless of where they take place) are better attended by an experienced midwife (regardless of her certification) than an obstetrician because midwives provide all aspects of care - physical, emotional, spiritual and intellectual - that all mothers should have.

I'm not saying that all midwives are perfect. I have met midwives that would be better changing some things about the way they practice. However, as a whole, midwives are better suited for low-risk pregnancies and births as they are generally in the profession because they trust birth rather than expecting it to go all wrong.

If we want to lower our maternal-infant death rates, the alarming cesarean rate (approaching 30% in this country, whereas midwife attended births are roughly 5-10%), and risky interventions (EFM, IV, pain relief, episiotomy, pitocin, forceps, etc.) in this country then we need to support midwives - regardless of their "certifications" - and offer future midwives more options for complete training and recognize these options so more midwives who are truly a necessity to the future of childbirth will be supported in their practice.

By Anonymous Anonymous, at 12:29 PM  

Mama Liberty:

"OBs see problems where none exist because they have never or rarely observed normal birth start to finish, without interfering."

With all due respect, you have absolutely no idea what I or other obstetricians have observed. This is just part of the homebirth fantasy that only DEMs have seen natural childbirth.

First of all, I trained in a very large, very liberal city. We had quite a few patients who wanted and got natural childbirth; that's right, no interventions of any kind. Nothing, not so much as an IV.

Second, not everyone is American. Many people from other cultures approach childbirth from very different perspectives. I happened to have worked in a neighborhood health center among an ethnic group who saw little need for pain relief in childbirth. During the two years I practiced there, very few of my patients every requested an epidural.

Third, I myself have had natural childbirth twice, not for any philosophical reasons, just because I didn't feel I needed an epidural or anything else.

It is really important that you understand this. It is a complete MYTH that the average obstetrician has never seen natural childbirth. It is a story that homebirth advocates tell themselves to explain why doctors are opposed to homebirth. "Well, they've never actually seen a homebirth. They have no idea how wonderfully and smoothly it goes." No, no, no. Homebirth advocates appear to have no idea of the depth and breadth of the average obstetrician's experience. How would they? They've never worked with one.

By Blogger Amy Tuteur, MD, at 1:39 PM  

"what do you think about patient care tecs doing first assists?"

Every surgeon (including an obsetrician) is capable of doing an operation start to finish without any assistant. The tech is just there to hold things out of the way and sponge away the blood so you can see. They do not participate in the actual surgery.

By Blogger Amy Tuteur, MD, at 1:43 PM  

"You obviously know very little about the various types of midwives and the training that they all go through. Yes, there are midwives that should not be practicing midwifery but there are far more obstetricians that should not be practicing obstetrics."

Really? How on earth do you have any way of knowing any of this? This is your OPINION, and it has no basis in fact.

By Blogger Amy Tuteur, MD, at 1:46 PM  

one side of the work is done by the tec and is also left to close...
someone lifts while someone snips--

By Anonymous Anonymous, at 2:04 PM  

"With all due respect, you have absolutely no idea what I or other obstetricians have observed. This is just part of the homebirth fantasy that only DEMs have seen natural childbirth."

Oh, Amy, please let us be honest here. How many obstetricians have observed, let's say 50 births, from the time active labor begins until the placenta delivers without EFM, multiple vaginal exams, woman assumes position of her choice, no assistance in delivery of placenta, etc.? Perhaps you define "natural childbirth" as simply a birth with no epidural, (which is a fair definition), but I'm asking about experience obstetricians have in observing natural, NORMAL labor in which interventions are not more than periodically listening to fetal heart tones.

"First of all, I trained in a very large, very liberal city. We had quite a few patients who wanted and got natural childbirth; that's right, no interventions of any kind. Nothing, not so much as an IV."

Good for you! This is very rare today, however.

"Second, not everyone is American. Many people from other cultures approach childbirth from very different perspectives."

Scratching my head here. Many of us on this list have been asking you to consider the experiences of other countries in which midwives and homebirth are normal and outcomes are good. I feel like you dismiss those systems as irrelevant to the American system.

"I happened to have worked in a neighborhood health center among an ethnic group who saw little need for pain relief in childbirth. During the two years I practiced there, very few of my patients every requested an epidural."

Again, good for you! But I think your experience is unusual.

"Third, I myself have had natural childbirth twice, not for any philosophical reasons, just because I didn't feel I needed an epidural or anything else."

This is so true. Most women don't need epidurals. The pain of childbirth can be managed and has been managed well by women since the dawn of humanity. Most OBs in my experience will not tell women that, however.

"Homebirth advocates appear to have no idea of the depth and breadth of the average obstetrician's experience. How would they? They've never worked with one."

Amy, I could say the same thing about obstetricians... they have no idea of the depth and breadth of the average midwife's experience. I have experienced care from OBs, care from a CNM, and care from a DEM. The experiences were COMPLETELY different. I would have more respect for your arguments if I felt like you had made an attempt to step outside of your box and understand a way of doing things that is completely different than yours.

Danielle

By Blogger Mama Liberty, at 2:18 PM  

Here is something interesting for you, Amy. This is a family physician's home birth story in which there was an unforseen circumstance. Perhaps this might give you a taste for the fact that midwives CAN handle the unexpected.

http://www.twofloridadocs.com/its_toes.php

Danielle

By Blogger Mama Liberty, at 2:25 PM  

even in the BMJ study it is clear that midwives knew what to do- some unforseen problems can have very bad outcomes regardless of the setting home or hospital- so detecting that there is something wrong in pregnancy or labor wasn't the problem- the midwife detected a problem and transfered in early labor- a hospital procedure = a cord prolapse and the baby died in the hospital- if this patient started out at home as a hospital patient and came in during labor the very same thing would have happened- midwifery care was not causal nor was it in the vasa previa case- when the problem was detected the woman was transfered- vasa previa discovered in a hospital in a similar way may not have resulted in a live baby

By Anonymous Anonymous, at 3:04 PM  

"when the problem was detected the woman was transfered"

Actually, the vasa previa perfectly illustrates what can go wrong at homebirth. The vasa previa was discovered when the baby began bleeding to death. Had this occurred in a hospital, it is very possible that the baby could have been saved.

However, you are ignoring the main point. There was NO WAY to save either of those two babies at home. The hospital may not be able to save every baby in these settings, but homebirth midwives can save NONE.

By Blogger Amy Tuteur, MD, at 3:36 PM  

Amy, when did you stop practicing? I think the hospital climate has changed. There was a discussion on my blog last fall about natural childbirth in NYC hospitals now vs. 20 years ago -- it seems to be harder to go natural in a hospital these days for a variety of reasons.

By Blogger Jamie, at 3:38 PM  

No one is arguing that these babies should have been born at home. We are saying that even in the hospital, some babies die. Undiagnosed vasa previa appears to have a mortality rate around 60%. Diagnosis is unlikely with routine ultrasound screening.

In the prolapse case, the midwife made an appropriate call to transfer the laboring woman, but the hospital attendant's choice to rupture the membranes resulted in prolapse. Intrapartum deaths happen in the best hospitals, sometimes as a result of commonplace interventions like AROM.

By Blogger Jamie, at 3:48 PM  

Danielle:

"Amy, I could say the same thing about obstetricians... they have no idea of the depth and breadth of the average midwife's experience."

No, you couldn't not say the same thing about obstetricians. There is a very big difference. Obstetricians have to deal with the transfers from midwives of all kinds. They have a very solid basis on which to make comparisons.

Let's think about this for a moment. Obstetricians are responsible for knowing 100% of what it is possible to know about the management of labor and delivery (not everyone meets that expectation, but that is the expectation). CNMs are responsible for knowing abour 40% of what it is possible to know, and DEMs are responsible for knowing about 5% of what it is possible to know.

It's pretty obvious that virtually any complication is outside the competency zone of the DEM. The CNMs have a substantially larger zone of competence, plus they tend to have better judgment because they have broader and more varied experience.

I don't think you are going to get many people to believe that this doesn't matter or that knowing 5% of what can be known is really enough. I don't even understand why you are arguing the point.

For example, if a baby needs resucitation, there is probably not a homebirth midwife in the country who could intubate. How many babies will need this skill? Very few, but those who do will die if they are born at home.

In order to make a judgment about whether someone is competent to attend a homebirth, you need to KNOW the chance of various complications arising, and what you MUST know how to do to manage them. It is grossly oversimplistic to assert that most births go beautifully.

By Blogger Amy Tuteur, MD, at 3:50 PM  

I haven't seen anyone address the conflict of interest issue.

Can DEMs really evaluate the issue dispassionately when their entire source of income depends on insisting that homebirth is safe?

By Blogger Amy Tuteur, MD, at 3:53 PM  

Obstetricians are responsible for knowing 100% of what it is possible to know about the management of labor and delivery (not everyone meets that expectation, but that is the expectation). CNMs are responsible for knowing abour 40% of what it is possible to know, and DEMs are responsible for knowing about 5% of what it is possible to know.

As fond of numbers as you are, where did you scrape these up?

By Anonymous Anonymous, at 3:58 PM  

"It's pretty obvious that virtually any complication is outside the competency zone of the DEM."

OK, pounding my head against the wall. Obvious? Based on what???

By Blogger Mama Liberty, at 5:24 PM  

Mama Liberty:

"Obvious? Based on what???"

Based on the fact that DEMs have much less classroom background, much less clinical training, and much less experience in the management of complications than either CNMs or obstetricians.

Imagine a teacher's aide who declared that her aide training and classroom experience made her equivalent to any teacher and asserted that she would call for help if things did not go well. If everything went well, and no one complained, would that make her a teacher? Would you want her to be your child's teacher?

Imagine if a large number of teacher's aides created their own school and certificate program. Would that make them teachers, then?

Suppose that they argued that learning historically took place in the home under the tutelage of parents. Would that mean that teaching qualifications are not particularly relevant?

Should you care about the difference between an aide and a teacher if your child has no preexisting learning disabilities?

How is this situation different from women who have a fraction of the training of other health professionals (and a fraction of the training needed to practice safely)? They got together and declared themselves midwives. Does that really make them competent to practice midwifery?

By Blogger Amy Tuteur, MD, at 5:47 PM  

this is simply not true- I have known of midwives at home births who have either 1 delivered a baby quickly with a prolapse or pushed the head off the cord- enough that they made it to be sectioned and saved-

and the stats vasa previa are not good--

By Anonymous Anonymous, at 6:30 PM  

so as a DEM and having worked with CNMs I would disagree- I have been the one reading the studies and analyzing them for the CNMs-- or bringing in info to put together a protocol-- I would say at birth and in several things pregnancy related we were equals as far as education goes- in well woman care , and direct use of microscopes to evaluate wet mounts and doing lots of paps they have more experience but I haven't seen all the programs so don't know the content) . I really know very little about dx pneumonia or what antibiotic to prescribe for an adult ear infection- but I don't think that I need to know that- the CNMs I know would not and do not carry ET kits and do not use an electric suction unit at home- there is such a thing as vagal response- something you don't want to be eliciting either. If anything I have wanted to transfer sooner than they would-- bp up a bit oh just get her on her left side it will be ok- do this all the time in the hospital... Can rx the abx they use so don't have to convince a doc to write for them at home- they just do it. also write RX for sleep meds so mom sleeps in prodromal labor and wakes up active...
but on the other hand if you have good back up you could provide all this if your clients would find it acceptable.

By Anonymous Anonymous, at 6:52 PM  

Amy wrote"
Imagine a teacher's aide who declared that her aide training and classroom experience made her equivalent to any teacher and asserted that she would call for help if things did not go well. If everything went well, and no one complained, would that make her a teacher? Would you want her to be your child's teacher?"

now on to epistemology - we really are making the rounds the truth is I home school.
as far as obstetrics go - midwives existed first- usurped by MEN who weren't students for the most part- that invented a complete system to oppose your existence -- even when they were killing women senselessly because they had a good con... how do I feel about it

By Anonymous Anonymous, at 7:01 PM  

They got together and declared themselves midwives.

Sounds like something doctors did a while back...

By Anonymous Anonymous, at 7:31 PM  

"You obviously know very little about the various types of midwives and the training that they all go through. Yes, there are midwives that should not be practicing midwifery but there are far more obstetricians that should not be practicing obstetrics."

Really? How on earth do you have any way of knowing any of this? This is your OPINION, and it has no basis in fact.


The midwifery model of care is to care for all aspects of pregnancy, labor and birth - physically, emotionally, spiritually and intellectually. Obstetricians are generally trained to intervene when something goes wrong and because of this many have little patience and intervene too often. There is a small percentage of midwives who do not follow the midwifery model of care. However, there is a much larger percentage of obstetricians that intervene when no interventions are warranted or asked for (i.e., inducing because a woman is a week past her estimated due date regardless of the fact that the baby and mother are doing just fine) and, because of these unnecessary and unwarranted interventions, the risk to mother and baby significantly increases. These are people that should not be practicing obstetrics.

It should be that low-risk pregnancies are cared for by midwives and obstetricians get involved only when a problem arises. Obstetricians are not taught to handle a normal pregnancy, labor and birth. They are taught to handle complications (and, unfortunately, create many of those complications from the gross overuse of interventions).

Were you aware that countries where most low-risk pregnancies and births are handled by midwives at home or in birth centers, and the high-risk ones by obstetricians in hospitals, they have a much lower rate of cesareans, interventions, maternal-infant deaths, complications, etc.? This is because the midwives and obstetricians work together for the benefit of mother and child. Too bad the midwives and obstetricians in this country can't all work together for the benefit of all families.

By Anonymous Anonymous, at 8:09 PM  

"You obviously know very little about the various types of midwives and the training that they all go through. Yes, there are midwives that should not be practicing midwifery but there are far more obstetricians that should not be practicing obstetrics."

Really? How on earth do you have any way of knowing any of this? This is your OPINION, and it has no basis in fact.


The midwifery model of care is to care for all aspects of pregnancy, labor and birth - physically, emotionally, spiritually and intellectually. Obstetricians are generally trained to intervene when something goes wrong and because of this many have little patience and intervene too often. There is a small percentage of midwives who do not follow the midwifery model of care. However, there is a much larger percentage of obstetricians that intervene when no interventions are warranted or asked for (i.e., inducing because a woman is a week past her estimated due date regardless of the fact that the baby and mother are doing just fine) and, because of these unnecessary and unwarranted interventions, the risk to mother and baby significantly increases. These are people that should not be practicing obstetrics.

It should be that low-risk pregnancies are cared for by midwives and obstetricians get involved only when a problem arises. Obstetricians are not taught to handle a normal pregnancy, labor and birth. They are taught to handle complications (and, unfortunately, create many of those complications from the gross overuse of interventions).

Were you aware that countries where most low-risk pregnancies and births are handled by midwives at home or in birth centers, and the high-risk ones by obstetricians in hospitals, they have a much lower rate of cesareans, interventions, maternal-infant deaths, complications, etc.? This is because the midwives and obstetricians work together for the benefit of mother and child. Too bad the midwives and obstetricians in this country can't all work together for the benefit of all families.

By Anonymous Anonymous, at 8:10 PM  

"Were you aware that countries where most low-risk pregnancies and births are handled by midwives at home or in birth centers, and the high-risk ones by obstetricians in hospitals, they have a much lower rate of cesareans, interventions, maternal-infant deaths, complications, etc.?"

Were you aware that those countries have a much lower proportion of high risk patients than the US and that is the reason for their lower complication rates and death rates?

By Blogger Amy Tuteur, MD, at 9:19 PM  

Amy, I have asked this of you a couple of times and I'm going to ask it one more time:

As a childbearing woman, why should I accept your analysis that home births are dangerous and midwives are inadequately trained and dismiss the opposite conclusion of the World Health Organization and the American Public Health Association? Both of those organizations believe women should have access to midwives (including direct entry midwives) and home births. Both organizations believe it is a safe and reasonable choice.

By Blogger Mama Liberty, at 9:21 PM  

Mama Liberty:

"As a childbearing woman, why should I accept your analysis that home births are dangerous and midwives are inadequately trained and dismiss the opposite conclusion of the World Health Organization and the American Public Health Association? Both of those organizations believe women should have access to midwives (including direct entry midwives) and home births. Both organizations believe it is a safe and reasonable choice."

As I said before, you don't have to accept my analysis. You can read the papers and analyze them yourself. Several of your compatriots on this board have done that already, and have been surprised by what they found. They may not have changed their minds, but they were shaken up to discover that what they had been told in the past is not true.

Obstetricians and midwives are not the only people in the world. Take the papers and any evidence you can marshal to a statistician who has no vested interest in either side. Ask him or her to analyze it. The truth is the truth. Others can confirm it for you.

As to why you shouldn't take the word of the WHO or APHA, there are two reasons. First, if I could compile a list of respected organizations that oppose homebirth, would that change YOUR opinion. Probably not. You are invoking the WHO and APHA because they currently agree with you. If they changed their stance tomorrow, you would drop them.

Second, you don't have to get your analysis of the evidence second hand; you are truly capable of looking at and analyzing the evidence yourself.

By Blogger Amy Tuteur, MD, at 9:36 PM  

"Were you aware that those countries have a much lower proportion of high risk patients than the US and that is the reason for their lower complication rates and death rates?"

There is a high proportion of high risk patients in the Netherlands.

Danielle

By Blogger Mama Liberty, at 9:36 PM  

I would love to see statements opposing homebirth from organizations focused on public health and epidemiology. I've been looking for them and I can't find them.

Our discussions of the research stalled for a while there. I got busy with some family responsibilities, for one thing. But I also asked you for some documentation supporting your contentions that researchers did their work sloppily or dishonestly, since I've had trouble finding any substantiation online.

I have read the papers and worked through the calculations and listened carefully to your objections, but I'm not persuaded that the authors, peer reviewers, and editors are all overlooking or trying to hide dead babies. After careful reading of the papers under discussion, I have found that the authors' conclusions make sense to me. In some cases, we agree about those conclusions: breeches and twins are safer in the hospital; it's important to respond promptly to fetal distress; some babies need immediate specialized care. But I have not seen a convincing rebuttal of the studies' central findings: homebirth is a safe choice for low-risk women and their term vertex babies.

By Blogger Jamie, at 9:52 PM  

"Second, you don't have to get your analysis of the evidence second hand; you are truly capable of looking at and analyzing the evidence yourself.

Amy, I have analyzed the evidence myself. I have also considered the analysis of others because I am not in the medical research or statistics field. A wise person seeks counsel and knows what one's own abilities are.

I have spent alot of time (too much) on your blog and have spent some time thinking today about why I care so much about what some anonymous retired obstetrician thinks. I care because your opinions hold so much weight in our society that they are able to take my options away from me. The care I have received from obstetricians has been humiliating, invasive, demeaning and harmful. Women and babies deserve better. I know there are good doctors out there, but on the whole I believe those in the field of obstetrics need to do alot better.

By Blogger Mama Liberty, at 9:54 PM  

Mama Liberty:

People in obstetrics can and should do a lot better. People in all branches of medicine can and should do a lot better. My other blog Treat Me With Respect is basically a continous rant on just that topic and I agree with you 100%. Unfortunately, though, it just means that some doctors are jerks; it does not make homebirth any safer than the evidence shows it to be.

By Blogger Amy Tuteur, MD, at 10:09 PM  

"it does not make homebirth any safer than the evidence shows it to be."

(This will be my last post for awhile. I'll be back certainly, but its time to turn my attention to other things.)

Well, homebirth IS safer for me and my babies. I am an individual, not a statistic. I have had very demeaning experiences in the hospital and my feelings about childbirth are complex. Childbirth for me is more than a physical experience... it is emotional; it is part of my sexuality & it is part of my spirituality. I don't feel safe in hospitals and I know my body will not function properly where I feel a lack of privacy, a lack of respect and a general sense of loss of control. Many mammals can stop their own labors when they feel they are in danger. I believe this is true to a certain extent for humans as well. (Think about hormonal interactions and the effect on labor.)

The bottom line is that the homebirth and attendant decision should belong to the mother. It shouldn't be an obstetrician's decision and it shouldn't be a midwife's decision. It is the parents who are ultimately responsible for the lives of their children.

By Blogger Mama Liberty, at 10:51 PM  

"Were you aware that countries where most low-risk pregnancies and births are handled by midwives at home or in birth centers, and the high-risk ones by obstetricians in hospitals, they have a much lower rate of cesareans, interventions, maternal-infant deaths, complications, etc.?"

Were you aware that those countries have a much lower proportion of high risk patients than the US and that is the reason for their lower complication rates and death rates?


Okay, so let's take the high-risk pregnancies out of the equation. If you compare those low-risk pregnancies and subsequent births to this country's low-risk pregnancies and subsequent births, they are still significantly lower even though almost all births here are in hospitals yet a huge chunk of births in those countries are at home.

By Anonymous Anonymous, at 10:57 PM  

My other blog Treat Me With Respect ...

Some constructive criticism: your margins are horrible for viewing on Firefox and Safari so that the text on the left is pretty much on the edge of the window making it very hard to read. Maybe a better template?

By Anonymous Anonymous, at 11:06 PM  

"If you compare those low-risk pregnancies and subsequent births to this country's low-risk pregnancies and subsequent births, they are still significantly lower even though almost all births here are in hospitals yet a huge chunk of births in those countries are at home."

No, you're wrong about that. The neonatal mortality rates for low risk white women are comparable to almost any country in the world.

By Blogger Amy Tuteur, MD, at 11:31 PM  

I can't reist this.

Mama liberty said:
I think that classroom experience can be overrated. Learning doesn't have to happen in the classroom. Some of the most accomplished people in human history didn't have college degrees... Thomas Jefferson and Albert Einstein come immediately to mind.

So what?

This is plain old idiotic.

But hey, we can all play! Look how much fun this is:

We are justified in reducing the use of chemo to treat cancer, because (insert person here) didn't need it and was cured.

College will not increase your likelihood of getting a good job and/or a good salary, because (insert person here) didn't go to college and did well anyway.

Paying attention in school is unrelated to your future ability to do great work, because Einstein was bad at math.

The funny thing is that you don't even stay in the same genre. It would be ridiculous if you said "midwives don't need to be trained because XXX was not trained and is a good midwife".

But you don't even say that!

Let me try again:

"midwives are the best way to deliver babies because Edison, who was trained and educated, was wrong about the utility of DC power"

By Blogger sailorman, at 9:30 AM  

so lets see- maybe there are less complications in places that maintained midwifery care though out because of the scientific knowledge that was integrated into an already good existing system. Instead of trying to invent the wheel all over again- as in American obstetrics- and you may be right about risk factors-- the recent English/American study came out that middle aged middle income
Americans are less healthy and have more illnesses that English poor- even though we have 2x the access to medical care- they are planning the follow up studies as we speak to figure out why-- and they already looked at some confounders like maybe we just have more dx but that was not the case the drs in the study confirmed the disease states in the Americans and the lack of in the English.
As for births our stats have always been poor -- how did we compare in WWII ? were we top then?

By Anonymous Anonymous, at 10:16 AM  

"If you compare those low-risk pregnancies and subsequent births to this country's low-risk pregnancies and subsequent births, they are still significantly lower even though almost all births here are in hospitals yet a huge chunk of births in those countries are at home."

No, you're wrong about that. The neonatal mortality rates for low risk white women are comparable to almost any country in the world.


Why did I even bother saying that? You read the studies and numbers that benefit your beliefs.

Try reading something that's unbiased without disregarding it for once...

By Anonymous Anonymous, at 1:25 PM  

"Why did I even bother saying that? You read the studies and numbers that benefit your beliefs."

You haven't shown me any studies and numbers that I can read to support that claim. Until you do, it is simply your opinion. Furthermore, it is not consistent with the facts.

By Blogger Amy Tuteur, MD, at 4:56 PM  

Jamie,
"But I have not seen a convincing rebuttal of the studies' central findings: homebirth is a safe choice for low-risk women and their term vertex babies."

That's because that is NOT the issue being debated. "Safe" is a value judgment. "Safer," on the other hand, is a testable statement.

Homebirth can be "safe" and still be less safe than hospital birth. If you can't process that because of all the argiung going on, try thinking about travel:

Both auto and airplane travel are considered "safe". However, they are not equally safe. The fact that the government considered them both to be "safe" has NOTHING TO DO with whether they are EQUALLY safe.

By Blogger sailorman, at 12:40 PM  

Sailorman, I hear you. I'll rephrase. I have not seen a convincing rebuttal of the studies' central findings: for low-risk women and their term vertex babies, homebirth is as safe as hospital birth.

By Blogger Jamie, at 1:32 PM  

Hmm. You haven't?

After all the explaining?

Well, that's you I suppose. Bit I think it leads to an obvious followup:

What would it take to convince you? How far to I have to go in dissecting a study to get you to discount it?

If you could be excruciatingly clear about that, it would be very helpful.

By Blogger sailorman, at 1:49 PM  

Sailorman, I'm responding up here.

By Blogger Jamie, at 12:11 AM  

here here! Lay midwives in the u.S. in my 23 yrs experience as a hospital labor/del. registered nurse here, have sent us the worst disasters from mismanaged home birthing attempts. They are conveniently not accountable, being held to a very low standard due their basic"survivor birthing" training.Do most of their consumers know that if something goes wrong, there will mostlikely be no recourse and no one to sue if baby is damaged and needs life long care?? OH, yeah, they are waiting to get the mom in hospital first, so they can blame them for whatever happens. Which happens. Even if it is obvious to everyone the laymidwife screwed up royally, she gets off scot-free!! And her business Definitely relies on demonizing hospital births and romatisizing(SP?) home ones. Transferring to hospital is usually delayed if things start to go awry(if its recognized, one had been pushing until a family memeber noted it "looked like a buttocks coming out", then came to hospital with numerous complications to ensue)due to the feeling of failure and the parents can also refuse as they have invested emotional energy into it and want to save face at that point.It's all a recipe for disaster. I cannot suffer these pseudo-practioners- using people for their personal gain and cause in my presence and their manipulating ways. In case of wartime or other disasters, it would be great to have these people when no one else or facilities are up and running, just likeas a trained nurse I could do a birth if I had to , and have done in emergency, but otherwise, why would we want to go backward? Why not insist and choose professionals/birthing centers that will support your natural childbirth urges but in a SAFE environment? Why settle for the most primitive care when advanced care exists? Would you go to an herbalist for a newly diagnosed early treatable cancer as your first resort? Hardly. most would go for the evidence based life saving treatment and choose complimentary holistic therapies as desired. First, do everything to save your life, or your infant's life, then go for the niceties. Enough for now.

By Anonymous Anonymous, at 10:42 AM