Tuesday, May 30, 2006

Isn't a high rate of interventions a small price to pay for a live baby?

One thing that has become quite clear from reading the homebirth papers is that no one, not midwives and not doctors, can predict a certain subset of serious emergencies. Our diagnostic tests and skills often cannot predict which women will have an abruption or which babies will have significant meconium aspiration, for example.

Most parents feel that the death of a baby in childbirth is an intolerable and unacceptable outcome. They are willing to do virtually anything in order to insure the health of their baby. Doctors feel the same way and have been constantly trying to lower the neonatal death rate to zero. At the beginning of the 20th century, there were a series of medical breakthroughs that began to substantially reduce neonatal mortality. These included anesthesia, blood banking, antibiotics and the entire field of neonatalogy. Each new medical advance lowered the neonatal death rate further, but as we get closer to zero, there is going to be less and less return on the addition of new technology.

Doctors and parents do not want to give up at this point and say that we have achieved the lowest neonatal deaths rates possible. They don't want a single baby to die unnecessarily. In response, the use of technology has crept ever upwards and the threshhold for acting on information has dropped lower and lower. In a very real way, the rising C-section rate reflects this. There is no more fetal distress now than there was in the past. Now, however, borderline cases are being examined more closely, and many women who never would have had C-sections for fetal distress in the past are having them now.

We have some tools for assessing fetal distress in labor including electronic fetal monitoring and fetal scalp sampling for checking the pH of the baby's blood to determine if it lacks oxygen. Unfortunately, though, these tools are not very specific. They are accurate in that they pick up all cases of fetal distress, but they include many more cases in which fetal distress is not really present. In the future we may have a tool similar to the oxygen saturation monitors (clipped over the end of a finger) that adults and children use when under anesthesia or during a hospitalization for serious illness. Oxygen saturation monitors can tell us in real time whether a person is getting enough oxygen and can show us in real time if different maneuvers improve the level of oxygen in a patient's blood stream. Until we have such a tool for babies in the uterus, we will have to make do with the indirect tests that we have now.

A similar situation applies to breech babies. Most can be delivered vaginally without a problem. However, there is no way to accurately predict which ones will have trapped heads and die or sustain serious damage as a result. In response, we offer C-section to all women with breech babies.

There is no doubt that c-sections for breech have saved lives and this is reflected in the dropping neonatal death rates. It is much more difficult to assess the effect of the rising C-section rate because we are only talking about the occasionally baby. The result may be a drop of a fraction of a percentage point, and it may get lost in the vast number of deliveries each year.

Like most obstetricians, I am inclined to think that a high rate of interventions is a small price to pay for a healthy baby. I think that most parents do, too.

37 Old Comments:

OK, Amy. You have finally succeeded in pushing me off the deep end with this one. I'll go ya' one better...

What if because of advances in neonatal technology, we find that all babies can be removed from their mother's womb at 34 weeks and incubated in the NICU for an additional 4 weeks with a 0% neonatal death rate?

Many of those babies will be more susceptible to severe respiratory illness during the next year of life, some of those babies dying. Many babies have breastfeeding difficulties and some of them develop attachment disorders because of the maternal separation during their early life. Many are even orphans because the increase in antibiotic resistant organisms leads to higher rates of maternal mortality. There is also a declining birth rate because of increased rates of hysterectomy.

But its all good because there is a 0% neonatal mortality rate, right?

By Blogger Mama Liberty, at 5:06 PM  

Mama Liberty, it's easy to be cavalier about the neonatal death rate when all your babies survived. It's not a joke to the women whose have lost precious, wanted, and loved children.

By Blogger Amy Tuteur, MD, at 6:01 PM  

Danielle and I were (as usual!) thinking along similar lines, Amy. Though you rejected the perinatal outcomes index in Wiegers et al., you are using some sort of perinatal outcomes index to make decisions about birth choices. Otherwise, if the most important outcome measure were live babies, it would make sense to section everybody at 37-38 weeks. You'd have some increase in neonatal morbidity and a larger increase in maternal morbidity/mortality. Your costs would skyrocket and the effects on future pregnancies would be suboptimal as well. But if the most important outcome measure is live babies here and now, why not?

I'm sure you know I think this is ridiculous, but Feldman and Freiman got published in the NEJM advocating this very idea. (Or so I hear -- I don't have access to the piece so I'm relying on secondhand info about its content.)

In my community, the C-section rate approaches 45%. Forty-five percent -- that's madness. You've estimated that a C-section rate around 10% is appropriate, which would mean that a third of the women who plan a hospital birth in my community walk out of the hospital having undergone unnecessary abdominal surgery.

As I look at the set of risks, both short- and long-term, that accompany hospital birth here where I live, and look at the outcomes for home vs. hospital birth in the studies we've discussed, I have no doubt in my mind that I am doing something helpful for women in my area when I tell them about my wonderful homebirth midwife.

By Blogger Jamie, at 6:08 PM  

Jamie:

"Though you rejected the perinatal outcomes index in Wiegers et al., you are using some sort of perinatal outcomes index to make decisions about birth choices."

No, what I said about the perinatal index was that it buried neonatal deaths in with episiotomies as if they were in any way equivalent. Here we are looking at neonatal death because I and most other people believe it to be the MOST important factor in the decision making process.

You are free to use other parameters to make your decision. You are perfectly free to say that some neonatal deaths are acceptable in order to prevent an overuse of technology. However, it is important to understand that your position is a minority view.

I have been pounding away at one specific point. The scientific evidence shows that the neonatal death rate at homebirths is higher than at hospital births. What people want to do with that information is up to them.

I do think that people are getting a little desensitized by the term "neonatal deaths". These are not just statistics, they are real babies and they represent real and tragic losses to the parents who loved them. It's easy to say that "some neonatal deaths" are acceptable. It's much harder to find the death of your own child acceptable just to prevent the over use of technology.

Furthermore, I am not attempting to justify very high C-section rates. I think there are a lot of absolutely unnecessary C-sections that are not justified by any medical indications and they should be stopped.

By Blogger Amy Tuteur, MD, at 8:23 PM  

I'm concerned that our medical culture and the majority of people in the U.S. have come to over-value technology and this attitude has lead to the feeling that a high rate of interventions is a small price to pay. We need to think not just about unecessary or ineffective interventions, but about maternal morbidity and mortality caused by interventions. It is too easy to think about the baby first. The woman (and mother) must be as whole and supported and healthy as possible to ultimately benefit this new child. My mother died when I was 28 from ovarian cancer. I promise you my mother was as precious, wanted, and loved as I was when I was a newborn. This disease is typically diagnosed in late stages because the morbidity and mortality associated with the diagnosis is "too high." As a nurse, she asked me, "is a high rate of invasive diagnositics a high price to pay for fewer deaths from ovarian cancer?"
This topic line is moving away from the debate on homebirth, but I think an acceptance of overuse of interventions in favor of live babies is a false argument. Wherever women are birthing, let the evidence inform and support best practice for the baby AND the parents.

By Anonymous Anonymous, at 10:17 PM  

"This disease is typically diagnosed in late stages because the morbidity and mortality associated with the diagnosis is "too high." "

Screening for ovarian cancer has been tried in other countries, particularly in Scandanavia. It was abandoned because the complications from false positive tests were unacceptable. There were many unnecessary major abdominal surgeries that found no cancer, and one surgery resulted in death.

Screening for ovarian cancer is not done routinely because more women are hurt by the screening than are saved by it.

By Blogger Amy Tuteur, MD, at 10:41 PM  

Doctors feel the same way and have been constantly trying to lower the neonatal death rate to zero.

It's very romantic and noble, but impossible. Sounds like a recipe for abortions, test tubes, and premium babies.

By Anonymous Anonymous, at 11:24 PM  

"It's very romantic and noble, but impossible. Sounds like a recipe for abortions, test tubes, and premium babies."

Give me a break. What's your solution? Just let some babies die so other women can have a better "experience"?

By Blogger Amy Tuteur, MD, at 12:38 AM  

"Give me a break. What's your solution? Just let some babies die so other women can have a better "experience"? "

Come on. Do you actually truly believe that women who have homebirths choose to do so for the "experience"? I thought you at least had a better understanding of their reasonings, even though you may not agree and may think their decisions are based on false information. A statement such as that is hurtful in my opinion. I can assure you that when I chose a homebirth it wasn't for an "experience." There was much more that went into my choice, even though you may not agree with my reasoning. That is a very judgmental statement you made.

By Anonymous Anonymous, at 1:28 AM  

Oh, and by the way, the statement above is from me, and I am not the original "anonymous" on this thread, that was my first post here.

By Anonymous Anonymous, at 1:29 AM  

My solution is more technology :)

Seriously, though... why are people so afraid of technology? In my opinion, more sophisticated technology will lead not only to better outcomes but _less invasive_ procedures.

A fine example of this is laparoscopy. This requires more complicated technology than a laparotomy, but the results are much, much better.

Here is an example of cheap, but more advanced technology making birthing better in the hospital:

My first three births involved two uncomfortable straps pulled tight with velcro in order to keep the monitors in the right place. In adjusting the monitors took a lot of fiddling with the straps. Couldn't move too easily because of the straps.

Last pregnancy, the monitors were held on my tummy by a wide, ace bandage tube top. It was so comfortable on my huge tummy I wanted to take one home after a non-stress test I had. I could move around easily, was allowed to walk around and be on a birthing ball during EFM and adjusting the monitors was much easier for the nurses. The next advance here would be to make them wireless. I bet they exist, but probably expensive.

Certain electronics are getting smaller. Ultrasound is getting more sensitive and more mobile. Power supply technologies are also improving. Knowledge is giving us advantages previously undreamed of.

Technology is not the problem. Human judgement causing inappropriate use or refusal of that technology can be a problem, though.

By Anonymous Amka, at 1:34 AM  

anonymous regarding not choosing for the experience:

If you honestly chose a homebirth because you thought it would be safer, I fear you chose such a course based on unfounded information.

Homebirth is not safer than hospital birth.

It is more pleasant, it is more empowering, but it is not safer.

I wanted a homebirth. I opted against it. I do not regret my decision, even though I had four normal, successful deliveries that would have been fine.

By Anonymous Amka, at 1:38 AM  

"Come on. Do you actually truly believe that women who have homebirths choose to do so for the "experience"?"

No, but I am trying to get them to think a little more carefully about what they say. I thought the original remark was sarcastic and an attempt to dodge the medical and moral implications of what we are discussing.

By Blogger Amy Tuteur, MD, at 7:47 AM  

Amka:

"My solution is more technology :)

Seriously, though... why are people so afraid of technology? In my opinion, more sophisticated technology will lead not only to better outcomes but _less invasive_ procedures."

I agree. First of all, direct entry midwives are extremely dependent on technology already. They use technology to determine which women are in high risk groups so they can transfer them to obstetricians. They bring technology with them to the home and depend upon it in the event of complications. And, of course, they resort to technology when things go wrong by transferring the mother or baby to the hospital.

It's more than a bit hypocritical for homebirth advocates to protest against technology when they are so dependent on it, but simply use it less than doctors. It's ironic that so many homebirth advocacy websites and publications are paeans to the virtues of giving birth without technology, when the only way you will be permitted to do so is if are screened by all sorts of technological tests first.

The second reason why more or better technology is likely to be the answer is that the problem with homebirth is that you can't predict which low risk women will experience serious complications. If technology were to permit midwives and doctors to determine in advance which women will have complications during labor and delivery, those women could be transferred to obstetrician care before labor. Then, theoretically, the neonatal death rate at homebirth would be zero.

By Blogger Amy Tuteur, MD, at 8:00 AM  

My first birth almost resulted in a c-section thanks to over zealous doctors who couldnt bear waiting the 12 hours it took me to dilate. Thankfully the hospital was busy with real emergencies and their dire predictions of me being the 8th c-section that night didnt come to pass because they had other things to occupy them.

Thankfully - because had I had one c-section the chances are high I would have had another for my next baby who was a whole pound larger...

Not to mention that in between those two I had a stillbirth (iatrogenic IMO) thanks to a conscientious doctor pressuring me to have an IUD (when I didnt want any contraceptive) - result: perforated uterus, systemic sceptaceamia which nearly killed me, stillborn son at 24 weeks, massive PPH as placenta adhered via IUD, aspiration under GA and spent 10 days in ICU fighting for my life.

Hence I would have been obligated to have c-sections - and THAT would have interefered with my plans to have a large family....

IMO interventions in birth have gone to far - its all very well to save the babies that need it, but we dont have to cause harm to mothers who dont need it in order to make a point...

By Anonymous Anonymous, at 9:34 AM  

Amy, who is going to pay for all of your technology in a single payer system?

I think you misunderstand how the home birth community feels about technology. I think most feel thankful for advances in technology and the judicial use thereof, but it shouldn't be universally applied to all laboring women because there is a point where there is more harm than good. Furthermore, childbirth is a human event and treating women as simply a physical vessel from which to extract a baby is dehumanizing and misogynistic.

By Blogger Mama Liberty, at 10:05 AM  

mama liberty -

In my case, the ace bandage tube tops were an innovation, were better, but were actually cheaper than the previous velcro straps.

Laporoscopy is cheaper.

Clearly, this isn't true for all technologies and some take a lot of R&D before they become cheaper.

But technology doesn't treat women badly. People do.

This isn't technology vs humanity.

In all cases, what determines how much dignity the woman maintains is how the provider treats her. It all comes down to the human interaction.

Whether birthing at home or having a C-section, honesty, compassion, and gentle handling are the most important tools a provider has.

By Anonymous Amka, at 10:40 AM  

Amka:

"Whether birthing at home or having a C-section, honesty, compassion, and gentle handling are the most important tools a provider has."

Absolutely, positively. I agree 100%.

By Blogger Amy Tuteur, MD, at 11:06 AM  

Amka, I think you are missing my point. I don't have any problem with technological advances in treating disease. But childbirth isn't a disease. A natural childbirth will always be cheaper that a complicated childbirth that requires technological intervention.

By Blogger Mama Liberty, at 11:44 AM  

"Many of those babies will be more susceptible to severe respiratory illness during the next year of life, some of those babies dying. Many babies have breastfeeding difficulties and some of them develop attachment disorders because of the maternal separation during their early life. Many are even orphans because the increase in antibiotic resistant organisms leads to higher rates of maternal mortality. There is also a declining birth rate because of increased rates of hysterectomy.

But its all good because there is a 0% neonatal mortality rate, right?"

Mama, this is perhaps a telling statement. Why?

Because you imply that these things would NOT be acceptable to acheive a 0% death rate.

and that means you equate

-severe respiratory illness
-breastfeeding difficulties
-attachment disorders

as equal to DYING. As in "better to die than to have that."

To quote you again, "You have finally succeeded in pushing me off the deep end with this one."

That is seriously fucked up.

By Blogger sailorman, at 12:45 PM  

mama liberty,

I often hear that phrase, "pregnancy and childbirth is not a disease", as if this proves something. It doesn't. It is an emotional phrase meant to inspire an emotional response.

The fact of the matter is that pregnancy and childbirth are the most dangerous intended bodily processes a woman will experience.

Unecessary interventions are only uneccessary on hindsight. When following proper guidelines, we cannot know before if the intervention was needed or not until there is an outcome.

The breathing difficulties come from being born too early, something often impossible to prevent.

I am still of the opinion that breastfeeding difficulties are more a matter of maternal motivation and education than baby being unable to.

I've not heard of attachment disorders being attributed to hospital experience. If there is significant maternal seperation, it is because either the baby is seriously ill or the mother has chosen to have the nursery take care of baby. In one case, technology is saving the babies life. In the other case, technology doesn't have a thing to do with the problem.

I've never heard of a maternal death being associated with contracting an antibiotic resistant infection. Even so, I'd take the extremely low chance of contracting an antibiotic resistant infection in this day and age over contracting an infection when there were none of those unnatural antibiotics.

By Anonymous Amka, at 2:17 PM  

I've never heard of a maternal death being associated with contracting an antibiotic resistant infection.

One story here

Another here

And here

Not a death, but terrible loss here

By Anonymous Anonymous, at 2:56 PM  

amka,

"Even so, I'd take the extremely low chance of contracting an antibiotic resistant infection in this day and age over contracting an infection when there were none of those unnatural antibiotics"

What is this extremely low chance? I'm wondering what source you are talking about that describes the chance of contracting an antibiotic resistant infection as "extremely low?"

By Anonymous Anonymous, at 3:02 PM  

"One story here

Another here

And here

Not a death, but terrible loss here"

First of all, this just proves my point that when a woman agrees to have a C-section she is taking the risk of complications onto her self so that the baby will have less risk of dying.

You will also find cases of women dying of anesthetic complications during C-section and other surgical complications as well.

Second, "flesh eating bacteria" are found in the enviroment. They are not hospital acquired. Anyone can get them from any kind of breach of the skin.

By Blogger Amy Tuteur, MD, at 3:55 PM  

"They are not hospital acquired."

So even if the bacteria is in the environment, are you saying that somebody can't acquire it in the hospital?

By Anonymous Anonymous, at 4:02 PM  

Give me a break. What's your solution? Just let some babies die so other women can have a better "experience"?

When backed into a corner you will always throw the "experience" argument back into the mix and it is growing rather tiresome especially given the fact you have no idea where most of the people come from who post here. You know nothing of my experience.

I restate that a neonatal death rate of zero is impossible to achieve without compromising on other levels. Some babies die and that is the way it is. Look at the lamentation of your good friend Neonatal Doc who is left with emotional aftermath of your quest for Zero.

By Anonymous Anonymous, at 4:09 PM  

It's very interesting to note the conclusion of the following study:

Outcomes of planned home births with certified professional midwives: large prospective study in North America


The study evaluated the outcomes of 5418 women who planned to deliver at home when their labor began.

It reads as follows:
"Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States."

So, if planned homebirths for low risk women were actually proven to have a HIGHER risk of neonatal mortality, your logic would most certainly apply.

It seems logical, though, that with no statistical guarantee that a woman has a higher probability of having a live baby in the hospital, paying the price of a higher intervention rate seems pointless, if not too steep.

And that's not even mentioning the higher neonatal mortality rates ASSOCIATED with certian interventions (such as pitocin, cesearean birth and forceps use).

And that the US, with it's low rate of homebirth, has a SIGNIFICANTLY higher neonatal mortality rate than that of countries where homebirth is the norm.

It has to be said that necessary medical interventions in birth are most definitely a boon for high risk women. If your baby is breech or you're carrying twins or you have preeclampsia, the game changes completely. And I would tell most women in such situations that any the price of those interventions is most likely worth it.

But, when it comes to low risk women, the scare tactic of "You don't want your baby to DIE, do you?!?" is hardly a logical argument and all too often a cowardly way to get out of an actual discussion of the comparative benefits and risks of homebirth vs. hospital birth.

By Blogger Heather, at 4:35 PM  

First of all, this just proves my point that when a woman agrees to have a C-section she is taking the risk of complications onto her self so that the baby will have less risk of dying.

Second, "flesh eating bacteria" are found in the enviroment. They are not hospital acquired. Anyone can get them from any kind of breach of the skin.


You will also find newborns dying of necrotizing fasciitis. They can be infected from circumcisions or fetal scalp electrode monitoring.

But this:

Second, "flesh eating bacteria" are found in the enviroment. They are not hospital acquired.

is not completely true. Since the bacteria are found in the environment, that would include the hospital, correct? And it can be transferred in the hospital by health care workers who fail to wash their hands.

Anyone can get them from any kind of breach of the skin.

This seems to contradict your original post. Shouldn't we be trying to curb the high rate of interventions, especially when serious complications can occur because of them?

By Anonymous Anonymous, at 5:30 PM  

Sailorman,

"That is seriously fucked up."

How analytical of you!

My post was about shifting risk. Maybe you could get close to a 0% neonatal mortality rate, but payment will be due somewhere else. If I have a baby who lives for 28 days, yet dies later that year of RSV, am I to feel better? If I have one child born by c-section and my third is is an unexplained stillbirth or dies because of placental problems, am I to feel better?

Danielle

By Blogger Mama Liberty, at 6:12 PM  

Risk doesn't shift in exactly that way, Danielle.

You aren't going to get more deaths later on in infancy or more still borns simply because we've reduced neonatal mortality to zero in low risk populations.

And that is the specific debate we are talking about on this blog, because no one at all is arguing for homebirthing a premature infant. Of course we want all of those babies saved too.

By Anonymous Amka, at 6:28 PM  

You aren't going to get more deaths later on in infancy or more still borns simply because we've reduced neonatal mortality to zero in low risk populations.

The opening post to this thread wasn't referring to a 0% death rate among low risk populations. She was referring achieving a 0% neonatal mortality rate period.

By Anonymous Anonymous, at 6:32 PM  

"The opening post to this thread wasn't referring to a 0% death rate among low risk populations. She was referring achieving a 0% neonatal mortality rate period."

That's right. The problem with your analysis is that there is no reason to believe that any of the babies saved will die in infancy or at any time before old age.

From 1900 to 1990 the neonatal mortality rate dropped over 90%, and not only did the neonatality rate NOT go up in response, it went down. Almost all of the babies who were saved have lived long and healthy lives.

People keep talking about preventing neonatal death only to have the baby die later. I don't know where that is coming from (except in the case of extreme prematurity). There is no reason to believe that these babies could expect anything other than a long and healthy life.

By Blogger Amy Tuteur, MD, at 6:59 PM  

"From 1900 to 1990 the neonatal mortality rate dropped over 90%, and not only did the neonatality rate NOT go up in response, it went down."

So why is it that you call me out on the fact that correlation doesn't equal causation and yet you try to slip that by in your arguments?

By Blogger Mama Liberty, at 7:56 PM  

Danielle:

"So why is it that you call me out on the fact that correlation doesn't equal causation and yet you try to slip that by in your arguments?"

Danielle, I was NOT saying that a drop in neonatal mortality was correlated with or caused the drop in infant mortality. I wouldn't say that because one did not cause the other.

Several people have insisted that a drop in neonatal mortality automatically insures a rise in infant mortality because the babies survive birth and then die after 28 days of age. I quoted those statistics to show that those people are wrong.

By Blogger Amy Tuteur, MD, at 10:35 PM  

sailor man you glossed over
" higher rates of maternal mortality"
more DEAD mommies because that is so less f-up right! that is a real cost not to mention morbidity-- and children who have severe respiratory illnesses if they survive infancy can have life threatening episodes and lets see we are still looking at what is safe in oxygen exposure...

By Anonymous Anonymous, at 10:41 PM  

Amy again it is not since the 20th century that Obstetrics did any of this-- the improvements were fist and foremost things that had to do with over all health- clean water, clean and less crowded living conditions, better wages( you have a rise in worker unions) better working conditions, less disease( water borne illnesses were rampant before they figured out that sewage that was often dumped right into drinking sources some places could not figure out how to change that because they would be down stream from other contamination - filtration and water treatment with chlorine came into being - amazing accomplishments SCIENCE and wide spread EDUCATION of this information did- in this time period even before antibiotics which don't come into play until around 1945 .... and then again in the 1960s when abortion became legal you see another drop in maternal mortality-
Some of the biggest drops in maternal and neonatal mortality from 1900 through the 1930's beyond living conditions were- in home births done by very experienced midwives who where then "trained" by some specific programs- those numbers would not be realized by physicians and hospitals until well after the invention of antibiotics and what did training really consist of back then for midwives-- how to wash your hands, to be sure you had clean clothes, how to make sterile packs how to sterilize instruments- to prevent neonatal tetanus - midwives did not do instrumental, surgical nor drugged births so were not dealing with that as a aspect- they also learned how to take blood pressure and look for other signs of pre-eclampsia in women also how to put eye drops into infant eyes to prevent blindness.
as for more modern day inventions - yes there have been steady improvements in anesthesia that have improved infant mortality an many other things in recent years-- but when I have made statements about a tradeoff of neonatal mortality for infant mortality that has been very recently--
DIRECT QUOTE from John's Hopkins Bloomberg School of Public Health-- "the only cause of post-neonatal deaths that has been increasing are those due to perinatal conditions - RDS, birth trauma, complications of LBW, intrauterine hypoxia/birth asphyxia may be due to the increased survival of infants suffering from these conditions in the neonatal period, who then go on to die in the post-natal period"

By Anonymous Anonymous, at 6:38 AM  

"Amy again it is not since the 20th century that Obstetrics did any of this"

That's another myth of homebirth advocacy and it's also not true.

I have an assignment for you. Find out what the leading causes of maternal and neonatal death were in 1900. Then you can tell everyone else and we can see whether improved sanitation and public health were truly responsible for the dramatic improvements.

I'll give you a hint. Eclampsia with seizures and hemorrhage were among the most important cause of neonatal and maternal death. I'd like to see anyone argue that improved sanitation affected either of those.

There are so many myths and lies that go into homebirth advocacy, and this is one of the biggest.

By the way, the germ theory of disease, antisepsis and public health were all discovered and implemented by DOCTORS. Obstetricians are happy to share the credit for dramatically improved neonatal and maternal mortality with other doctors including anesthesiologists and especially neonatalogists. I don't believe that anyone attributes ANY of the improvements in mortality to midwives.

By Blogger Amy Tuteur, MD, at 6:54 AM