Tuesday, May 16, 2006

Midwives and research

I have remarked repeatedly on the fact that midwives do not understand research and therefore persist in beliefs and practices which have no scientific foundation. Furthermore, they get incredibly angry when others point this out to them. Evidentally obstetricians are not the only people who find it troubling that midwives have so much difficulty understanding and using scientific research.

Midwifery professionals recognize "there remains a considerable amount of clinical activity which relies only on historical ritual rather than on rational scientific evidence." They see this (appropriately) as a serious problem. The following paper explores the reasons: "One widely accepted reason for midwives' non-use of empirical findings is simply that a large proportion of the workforce does not have the knowledge and training in the necessary skills to enable them to assess the value of published articles" and suggests ways to remedy this deficiency.

Bridging the gap between research and practice: an assessment of the value of a study day in developing critical research reading skills in midwives.

Hicks C. , Midwifery. 1994 Mar;10(1):18-25.

Despite increasing professional pressure on midwives to make their clinical practice research based, there remains a considerable amount of clinical activity which relies only on historical ritual rather than on rational scientific evidence. This apparent failure to integrate research into practice has generated a lot of debate regarding its cause. One widely accepted reason for midwives' non-use of empirical findings is simply that a large proportion of the workforce does not have the knowledge and training in the necessary skills to enable them to assess the value of published articles. Clearly the cost in time and human resources involved in providing a thorough training for the entire midwifery workforce in research skills would probably be unnecessary for the majority of midwives who simply want to be able to translate published research into their clinical practice. Consequently, a more pragmatic approach might be to assess the value of brief training days in developing midwives' competencies in reading research articles critically as a precursor to facilitating the integration of theory and practice. If the value of such courses could be demonstrated, then it is conceivable that study days of this type might be made more widely available for all midwifery personnel. This study investigated the effectiveness of one such study day in (a) modifying the participating midwives' evaluations of a published research article in accord with those of expert judges and (b) influencing the longer term use by the participants of published research. The day provided a brief introduction to basic research techniques both in theory and in practice, as well as a set of structured guidelines for evaluating research articles.

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39 Old Comments:

Why do OBSTETRICIANS persist in "beliefs and practices which have no scientific foundation"?

For example EFM and induction of labor for postdates? I don't think there is much of a scientific foundation to justify a 30% c-section rate, either. Off-label use of Cytotec anyone?

By Blogger Mama Liberty, at 8:03 PM  

Mama Liberty, are you trying to be helpful and illustrate my assertion that midwives get incredibly angry when you point out to them that they do not understand scientific research?

Why is it so hard to comment on the matter under discussion? Why do homebirth advocates reflexively sneer "well, I bet you do it, too" as if that were actually a defense.

I'll probably get pilloried for this, but here goes:

Homebirth advocates make themselves look very foolish when they respond to a scientific paper with insults, with sarcasm, with conspiracies theories, with anything other than a rational critique of the information presented. It is the intellectual equivalent of the schoolyard taunt: "I'm rubber, you're glue. Everything you say bounces off me and sticks to you." If you thought that worked poorly in the schoolyard, observe how poorly it works here.

Please, don't make yourself look foolish.

By Blogger Amy Tuteur, MD, at 8:19 PM  

I am not a midwife. I was simply pointing out that obstetricians aren't in the position to call midwives out on their lack of evidence based practice, (which IS relevant to this discussion). That fact is what initially led me to investigate seeking my care from a midwife instead of an obstetrician.

By Blogger Mama Liberty, at 8:29 PM  

a while back there were a couple of studies that showed that prenatal care was worthless imagine managed care getting ahold of those.
from the bit you published this is an opinion piece, does the article have examples of what rituals? There are rituals in prenatal care and birth that many practitioners are guilty of for instance- glucose as part of the urine dip sticks-
limiting weight gain thinking that it will change infant size
doing cervical checks near due date as a predictive tool
adhering strictly to the info extrapolated in Freedman's curve-( even he said it has been miss used)
valsalva pushing once a woman hits 10 cm

By Anonymous Anonymous, at 9:56 PM  

So, where can we learn?

By Anonymous Anonymous, at 10:09 PM  

I think it's worth noting that the Hicks article Dr. Amy quotes is over 10 years old. Most providers who do know how to review articles or research, regard anything older than five years, with skepticism.

American midwives have professionalized to a great degree since the writing of Hicks' article.

By Anonymous Anonymous, at 11:13 PM  

in reading over the multiple on this blog, there are things that I just don't think we are going to be able to communicate effectively about birth.
I have been practicing for over 20 years - and can and do read studies, and sift through them as well.

Basic things like knowing why unmedicated birth is important to women and babies.
what informed choice means
that the people you care for deserve absolute respect - and that is shown in how you listen, how you discuss -
studies are limited by observers and the questions they are paid to ask( funding funding funding) --- it seems like every year there is some new component in breast-milk that is newly discovered - imagine when expert advice pushed formula as equal maybe even preferential to breastmilk- you know us babies of the 50's and early 60's were getting karo and canned milk--- yum --- or how many years were we told that - hydrogenated vegetable oil was preferable to butter-- this is all just to say that it is fine and well to say evidence is the top guide to practice- but who's evidence and during what time period?

By Anonymous Anonymous, at 11:19 PM  

Maribeth, if you see this, would you send me an email? It's selkiejamie at yahoo dot com. Thanks!

This is an issue for any provider of clinical services. It's an issue in my own discipline; it's an issue for doctors. The skill set a person needs to provide good clinical care doesn't necessarily overlap with the skill set needed to run a one-way ANOVA.

I would rather be the patient of a healthcare provider with strong clinical skills and average statistical skills than the reverse any day of the week, provided that he or she is committed to ongoing CE participation.

I have a friend who's an MD MPH, and one of his areas of research is doctors' reluctance to adopt evidence-based practice. He has plenty of material to work with. What standards of statistical proficiency do you suggest for clinical providers in general, and midwives in particular?

By Blogger Jamie, at 11:52 PM  

have you done an analysis of variance Jamie?

By Anonymous Anonymous, at 12:05 AM  

Anonymous:

"So, where can we learn?"

It seems to me that there are some important steps to take even before learning about statistics.

The first step is to make a commitment to evidence based decision making. Once you've made that commitment, you are always going to be asking yourself: Is there evidence for doing things this way? If I disagree with someone, which side does the evidence support?

The second thing is to read and learn what others in the field have to say. I doubt there is a doctor in existence who did not learn a great deal from the nurses he or she worked with. Midwives can and must learn from doctors to provide effective care.

Therefore, when midwives disagree with doctors, they must be able to understand what the doctors are saying and why. That requires an attempt to analyze the arguments of doctors in a scientific way. Conspiracy theories and insults are NEVER a substitute for an analysis. If you see a conspiracy theory in a book, textbook, website, etc. in place of a scientific explanation, you will KNOW that the author of the conspiracy theory has conceded the point on scientific grounds and has nothing else to say.

Third, resolve to learn more about areas of controvery. Take postdates, for example. Is postdates really a risk factor? To hear some midwives tell it, postdates is just another phony designation created by doctors to rob women of their birth experience. Well, that's a conspiracy theory, so we know right away that it is not true.

Pick up an OB textbook (they are much easier to read than scientific literature) and look up postdates. Now you can see that doctors have found that the risk of neonatal death goes up dramatically after 42 weeks of pregnancy. Does it go up enough for you to consider your postdates patients at risk? That's a judgment call, but now you have some information with which to make the judgment.

The research on the safety of homebirth is filled with instances in which midwives tried to deliver twins, breech, premature and postdates at home and the babies died. I doubt that the midwives involved were even aware that these conditions are true risk factors, not something made up by doctors. Had they looked into it (as opposed to accepting a conspiracy theory from other midwives) some, at least, would have exhibited greater caution.

Fourth, there are publications for people who don't have the time and inclination to read every single article. These publications summarize the results of recent studies. If a particular study catches your eye, you can look it up to learn more. Regardless, you will be aware of all the latest health information, although you might not agree with it.

In summary, the most important thing is something that everyone can do even if they have no special training: be open to the ideas of others and question what you are told, especially if someone can't provide evidence to back up their point of view.

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

Jamie:

"I would rather be the patient of a healthcare provider with strong clinical skills and average statistical skills than the reverse any day of the week, provided that he or she is committed to ongoing CE participation."

So let's see.

We have now progressed from:

there is research to show that homebirth is safe to-

well, actually, the research shows homebirth isn't safe, but the research is just not true to-

well, midwives actually can't explain why the research that shows homebirth to be unsafe is flawed, but they know it is anyway to-

just because midwives can't offer scientific evidence doesn't mean that midwives don't read, understand and use scientific research to-

never mind, it isn't important anyway!

So, first you've conceded virtually every point about the scientific studies sailorman or I ever made, and now you've announced "who cares, it was never important anyway, so I'm perfectly free to continue ignoring it".

Here's a novel idea: why not LEARN something from this? Why not vow to review information on the areas of contention? What is more important, the safety of patients, or the vanity of homebirth midwives?

By Blogger Amy Tuteur, MD, at 7:11 AM  

Can you post a full text link?

By Blogger sailorman, at 8:58 AM  

No, Amy, that's not what I'm saying at all. Surely you can see that's not what I am saying.

A commitment to evidence-based practice doesn't require a practitioner to re-do the statistical calculations in the papers she reads. In more than ten years as an allied health professional I've never once done that with the professional literature. If you think that makes me an inadequate care provider, you're welcome to your opinion but I strongly disagree with it.

In a midwife I am looking for someone who is reading the current professional literature, who is committed to ongoing continuing education, who has a clear understanding of the risks and benefits of various interventions, who has an open mind about the fact that clinical practices change. I am also looking for someone with excellent clinical skills.

Of course evidence-based practice matters. I continue to disagree that you have a better handle on evidence-based practice than the WHO, the APHA, the Cochrane reviewers, and the ACNM. I'll respond more specifically later to the rest of your comment. My baby is wearying of this polemic-disguised-as-conversation. He's not the only one.

(Oh, and anonymous, I've never done an analysis of variance.)

By Blogger Jamie, at 9:03 AM  

"Take postdates, for example. Is postdates really a risk factor?"

I think this is a good example to discuss within the framework of your contention that obstetricians practice evidence-based medicine and midwives don't. Obstetricians employ a variety of interventive measures which have not been scientifically proven to improve outcomes at all. What exactly would YOU have midwives do differently? How do they manage postdates? What should they do differently? Keep in mind, your recommendations must be based on sound scientific evidence.

By Blogger Mama Liberty, at 9:29 AM  

evidence based practice to a degree- how does it measure up to what else is known-
lets see how many times was prozac tested and found short or = to placebo ; ) eventually they got the answers they wanted ----- not by changing the formula of prozac.

By Anonymous Anonymous, at 9:50 AM  

I find this whole conversation astounding.

Amy, what is your interpretation of the evidence for episiotomys?

Here is the link to your chapter on episiotomys in your book, for those who would like to review what you've already written:
http://www.askdramy.com/Chap21.html

I think this area is an excellent example of what you are trying to point out with your original post. How a practitioner reads the evidence is important in their clinical practices.

I am not a midwife. But I would like to see some of the midwives here, as well as you Dr. Amy, share your personal episiotomy rates, along with your tear rate.

Does the evidence support these episiotomy rates?

By Anonymous Anonymous, at 10:25 AM  

Mama Liberty:

"Obstetricians employ a variety of interventive measures which have not been scientifically proven to improve outcomes at all."

There is absolutely no doubt that obstetrical interventions dramatically reduce maternal and neonatal mortality.

So the real question then becomes, do obsetricians go overboard? Of course they do; they would be the first people to tell you that. Most of the C-sections I have performed for fetal distress were probably not necessary. That's because there does not yet exist a test that can tell us with 100% accuracy, which babies are suffering from life threatening fetal distress, and exclude with 100% accuracy those babies who are showing fetal distress but are not currently being damaged by it.

The same thing applies to postdates pregnancies. Does inducing women at 42 weeks save babies? There is copious data to indicated that it does. Is every pregnancy that goes over 42 weeks guaranteed to yield a dead baby. Of course not. However, since we can't know in advance which are the ones who will die, we recommend inducing everyone at 42 weeks.

I'm not sure what argument you are trying to make here. Even if obstetricians were to violate their own principles and practice without evidence, does that mean it is acceptable to practice without evidence? I don't. Remember that old saying: "Two wrongs don't make a right."

What purpose, exactly, is being served by resorting to saying "I can do it if they do it too". It's not the patients' interests, for sure; it's the midwives' vanity.

By Blogger Amy Tuteur, MD, at 10:45 AM  

http://www.askdramy.com/Chap21.html

WOW. Astounding. Please tell us you wrote this years ago and plan to change it, Amy.

By Anonymous maribeth, CNM, at 10:50 AM  

Anonymous and Maribeth:

"Amy, what is your interpretation of the evidence for episiotomys?"

Prepare to be astounded further. I did write that years ago and I changed my practice when I saw the new evidence.

By Blogger Amy Tuteur, MD, at 10:56 AM  

And Amy, What would you say your episiotomy rate was before, and after you changed your practice?

What rate do you believe is supported by the evidence?

By Anonymous Anonymous, at 11:02 AM  

Great news! You should probably change your website too.

By Anonymous maribeth, CNM, at 11:11 AM  

maribeth, here's a hypothetical for you:

A large study, well-run, with good data, comes out today showing that episiotomies give a significant benefit over tearing.

What do you do? Do you change your practice?

Have you done similar things in the past? Can you identify a time, or a method, in which you have changed your practice in response to new scientific evidence?

How about another interesting hypothetical:

Let's say you read a new series of reports, well performed, showing that home birth has a distinctly increased risk of fetal death (small, but distinct) compared to hospital birth.

What would you do? How would you advise your clients differently?

And a final hypothetical, taken from another thread:

You read a study which shows that the survival rate for infants requiring resus is increased by 35% with the presence of a pediatrician at the birth. Do you immediately make your best efforts to find a pediatrician who will attend, so you can offer that option to your clients with a clear explanation of the risks?

The strange thing here is that I get the sense you wouldn't change you mind, or your practice, anyway. SO I'm thinking the whole "show me more data" request is moot for you--it's just a smoke screen you use to obscure the fact that you believe what you believe, dammit, and that's that.

Or am I wrong? Can you explain?

By Blogger sailorman, at 11:31 AM  

"The same thing applies to postdates pregnancies. Does inducing women at 42 weeks save babies? There is copious data to indicated that it does. Is every pregnancy that goes over 42 weeks guaranteed to yield a dead baby. Of course not. However, since we can't know in advance which are the ones who will die, we recommend inducing everyone at 42 weeks."

No, there is not "copious" data to show that inducing women saves babies. There is data to indicate that postdates does increase risks to fetuses, but there is no clear data to support that current obstetric management of postdates contributes to better outcomes. By the way, what obstetrician waits until 42 weeks anymore? Most inductions now are done well before that time.

You didn't answer my questions, though. How do midwives manage postdates? What would you suggest that they do differently to bring their practices in line with science?

Danielle

By Blogger Mama Liberty, at 11:33 AM  

Danielle:

"You didn't answer my questions, though. How do midwives manage postdates? What would you suggest that they do differently to bring their practices in line with science?"

They should never deliver a postdates baby at home. The deaths of postdates babies in the homebirth studies are the result of the fact the midwives involved were unaware of the risks.

By Blogger Amy Tuteur, MD, at 11:42 AM  

"They should never deliver a postdates baby at home. The deaths of postdates babies in the homebirth studies are the result of the fact the midwives involved were unaware of the risks."

To the best of my knowledge, there are no studies that compare risks of home versus hospital birth in this situation. You are making an unsupported claim. You still haven't explained to me specifically how midwives manage postdates and what should be done differently (other than they shouldn't do it). What do obstetricians do specifically, that has been scientifically proven to lead to better outcomes, that midwives should be aware of?

By Blogger Mama Liberty, at 12:03 PM  

Danielle:

"To the best of my knowledge, there are no studies that compare risks of home versus hospital birth in this situation."

Here is the National Library of Medicine's review of the literature on the Management of Prolonged Pregnancy. The section of perinatal mortality discusses in detail the results from 7 separate papers including the paper by homebirth advocates Mehl-Madrona and Madrona (1997) which:

reviewed self-reported data from midwives in the western United States between 1970 and 1985. A total of 4,361 midwife-attended home births were compared with 4,107 family-practitioner-attended home births performed in California and Wisconsin during the same time period... Deliveries were matched by maternal age, insurance status, parity, and presence of risk factors. Midwives were significantly more likely to deliver postdate pregnancies, defined as gestational age greater than 42 weeks, than were family practitioners (midwives also were more likely to deliver breech and twin pregnancies). Mortality rates were significantly higher for midwives compared to family practitioners [I have the original paper; it shows a mortality rate of 14.1/1000 for midwives and 5/1000 for family practice doctors], a difference that was attributable entirely to more postdate, twin, and breech deliveries in the midwife group.

That should get you started. I can provide additional references if you need them.

By Blogger Amy Tuteur, MD, at 2:54 PM  

But you have discredited several other papers submitted in this conversation if they were based on self reporting, or if they were 'old' (1970s) Why should we even look at this one?

By Anonymous Anonymous, at 4:17 PM  

Amy,

Yes, please provide additional references which meet the critera you have set forth for good research.

Please, tell me how it is that home midwives should change their practice in managing postdates, based on scientific evidence. You can't say they shouldn't do it. Because they do. So what
specifically should they do differently?

Danielle

By Blogger Mama Liberty, at 5:23 PM  

Danielle:

"Yes, please provide additional references which meet the critera you have set forth for good research."

Certainly, right after you demonstrate that you read the ones I already gave you by explaining them to the rest of the group. I'm sure you're happy to share your newly accrued knowledge with everyone else so they can participate in the discussion, too.

By Blogger Amy Tuteur, MD, at 6:31 PM  

Hmmm now just out of curiosity, what does a midwife do when a baby is born that aspirated meconium due to being postdate? In the evil hospital world, we intubate and suck it out with a meconium aspirator. We also can place them on ECMO if all else fails. But we do intubate and use the mec aspirator, which is a lifesaver for those babies.

What do you do at home if a baby aspirates meconium, as this is a risk in postdates? Just curious on that one!

Carrie

By Blogger NeoNurseChic, at 3:24 AM  

I guess you should read the new guidelines - no suction unless shown not to be able to breath- mec or not.
we would suction/ delee before starting bagging efforts- actually we probably initiate resuscitation before it is started in hospital because we don't hand the baby off.
911 is called the info is that MAS cannot be prevented at birth- MAS happens before birth- an infant that cannot stabilize- retractions, lower O2 stats is given oxygen - low heart rate will get chest compressions as well-
although some midwives do carry scopes many do not because we do not get enough practice and could do more harm than good

By Anonymous Anonymous, at 5:49 AM  

Anonymous:

"info is that MAS cannot be prevented at birth- MAS happens before birth"

So, if meconium aspiration syndrome happens before birth, shouldn't you transfer any mother with meconium in the amniotic fluid to the hospital? The meconium means that MAS is a definite possibility. Shouldn't the baby be born in a hospital so the baby can be treated if necessary?

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

"Certainly, right after you demonstrate that you read the ones I already gave you by explaining them to the rest of the group. I'm sure you're happy to share your newly accrued knowledge with everyone else so they can participate in the discussion, too."

Amy, I have reviewed the literature on postdates up, down and sideways because this is an area of personal curiosity to me. I carry my babies for 42 weeks (plus a couple of days). When I had my first, I didn't know anything about postdates. So, I went along with everything and my 42 week son one an all expenses paid two week trip to the NICU due to MAS.

So, I learned everything I could about postdates and MAS. I'm very familiar with how obstetricians deal with postdates. Postdates are an increased risk, period. There is no evidence that anything obstetricians do improve outcomes.

I also familiarized myself with how midwives deal with postdates. You don't even know how midwives manage postdates. I decided that I and my baby would be better off at home. I made this decision particularly because of the postdates issue. I didn't have my second baby at home due to a completely unrelated condition, but I was able to have my third at home. I knew he would be "postdates". He was 42 weeks and one day. Easy labor. Easier than my pitocin/epidural labor. And much better outcome!!!

Amy, my son's stay in the NICU was very traumatic. It caused health and emotional difficulties that have been with him even to this day. No, I have no studies to back me up on this one. But, I am his mother! I know him. I am the person who cares most about the "birth outcomes" of my own children.

You have demonstrated through this debate that you don't really understand what you are arguing against. So, physicians much like yourself show up at legislative hearings, where women like me are there asking to have access to midwives. We are asking to have a healthcare system where midwives and physicians work together. Then, physicians like you say, "but babies will die!!!" Since in our society we accept a medical monopoly and the words that come out of the mouths of medical doctors may as well have come straight from the mouth of God, then no midwives it is!

Luckily, the evidence is mounting, despite your claims to the countrary. So, state by state the laws ARE changing. But, unfortunately I live in the midwest and this will be the last place to change. But it will change, Amy. I wish you would put your efforts toward developing a system where there is cooperation and understanding between midwives and the established obstetrical/hospital system. Perhaps you could study the Dutch model where they cooperate quite nicely. What works? What doesn't? Even if you still think home birth is more dangerous, surely some cooperation between midwives and physicians would at least make it safer. There is room for improvement.

Danielle

By Blogger Mama Liberty, at 8:50 AM  

"actually we probably initiate resuscitation before it is started in hospital because we don't hand the baby off."

Totally incorrect. The NICU team is present for any birth where meconium is detected in the amniotic fluid upon rupture of membranes - spontaneous or otherwise. When the baby is delivered, there is about a split second where the OB hands the baby to the NICU nurse. If that's what you mean by delayed compressions due to hand off, then I'm a bit baffled as to how you can do this more quickly. The OB returns focus immediately to the mother and the NICU team is instantly caring for the infant. The heart monitor is on in a matter of seconds.

And when we suction for thick meconium, it is via intubation because of retractions and respiratory distress. This meconium will never be effectively removed by small french suction catheters. It is done by intubating with at least a 3.0 ET tube where a meconium aspirator is placed on the end of the tube and connected to suction. The ETT tube is pulled back out of the infant's airway while the meconium suction removes the thick meconium. In cases of serious mec asp, special equipment designed to deal with this scenario must be used.

By Blogger NeoNurseChic, at 11:52 AM  

Thanks, neonursechic, for your description.

One of the baseline issues here is that many homebirth advocates have very little experience and have not seen complications and how they are appropriately managed.

This is what I mean when I say that homebirth advocates don't even know what they don't know. A homebirth midwife who thinks that she can manage MAS at home as well as it could be managed by NICU nurses and a neonatologist on the spot is deluding herself. It is only a matter of time before a baby in her care will pay with its life.

By Blogger Amy Tuteur, MD, at 4:36 PM  

So, if meconium aspiration syndrome happens before birth, shouldn't you transfer any mother with meconium in the amniotic fluid to the hospital? The meconium means that MAS is a definite possibility. Shouldn't the baby be born in a hospital so the baby can be treated if necessary?

Yes and yes.

By Anonymous MetroMidwife, at 4:50 PM  

forewaters are not always stained- or at times when membranes rupture and rightly so is at birth

the only difference here that I see- is that we don't cut the cord in a non-breathing baby- if the heart is still beating that is oxygenation/perfusion - one rural family practice doc I know did a 15 min until first breath resus with mec as thick as peanut butter - cord still attached the whole time - heart rate fine- he had eyes and hands on follow up for 10 years this kid was fine-
the MAS baby we had there was noting that could be suctioned out- but what was used was surfactant - My assistant who works in the hospital all the time would not say the within seconds is the case in where she works--

By Anonymous Anonymous, at 9:47 PM  

I know this is an anecdote, but I asked a relatively new nurse (been doing this for 2.5 years) tonight if she's seen a home birth baby in the NICU since working. Where we live, home birth is really very rare unless by absolute accident or a teenager trying to hide something. But home birth in the sense that it has been debated here is not a big thing in inner city Philadelphia....

That being said, the only home birth this girl saw in 2.5 years was a woman whose baby had, oddly enough, Mec Asp and came in extremely sick...almost went on ECMO but didn't have to be.

So odd that the one thing that came to mind was the Mec Asp this morning with respect to post dates and the only home birth the unit has seen in 2.5 years about is a mec asp.... Just found that interesting...

I know...I know...it's an anecdote!

In reality, home births just aren't seen very often in our unit. I never knew the half of what people were thinking out there until I started reading some of these posts and comments lately! Maybe back in centre county where I used to live it would be more common, but in Philly, it isn't seen very often at all...

Just thought I'd share!

By Blogger NeoNurseChic, at 12:48 AM  

even in the studies that were quoted comparing the hospital to home the babies in hospital with mec no ETT just suction , the home birth babies were the ones with ETT-

so with your story how was the baby brought in? ambulance, car transport?
was it an intentional home birth with a midwife- intentional home birth without a midwife? accidental home birth?

By Anonymous Anonymous, at 1:28 AM