Tuesday, May 30, 2006

Should doctors provide back up for homebirth?

Homebirth midwives cannot and should not practice without obstetrician back up. However, many obstetricians, myself included, refuse to back up homebirths.

Most of the time a homebirth will go well and no assistance of any kind is needed. However, it is virtually guaranteed that there will be some serious problems (10% or more of homebirths). So when an obstetrician backs up a homebirth midwife, he or she is agreeing to handle only serious problems. Furthermore the problems are often compounded by the fact that there is a delay between discovery of the problem and transfer of the patient, turning some of these problems into life threatening situations. In addition, the obstetrician has no prior relationship with the patient and enters a situation that the patient had been determined to avoid.

Given the fact that backing up a homebirth represents everything an obstetrician wants to avoid (a serious complication, a delay in properly managing it, and a patient who considers the doctor a stranger), doesn't it make sense for the doctor to refuse to back up a homebirth?

17 Old Comments:

I'm glad I do not practice anywhere near your alternate world because encountering you or one of your colleagues on a transfer sounds like a nightmare waiting to happen.

I don't have a back-up because my state considers its CNMs and DEMs to be independant practitioners. CNMs and DEMs alike use the hospital system as our back-up plan for home to hospital transfers. We have working relationships with the hospitals and their staff.

I don't understand your objection to meeting a "stranger" in labor. What do you do when a random woman walks in or is bussed off the street without a midwife and she's in labor and didn't plan on your hospital?

By Anonymous Anonymous, at 11:39 PM  

You didn't address the question. Why should a doctor willingly take on that responsibility?

By Blogger Amy Tuteur, MD, at 12:43 AM  

is it nice for continuity of care yes- does it help in emergencies no- because with rare exceptions doctors don't practice by themselves anymore and one doctor who has agreed to be back up does not mean he will even be on call when you need help.
just like the studies about hospitals- night time complications have worse results double the neurologic and death rate of day time-- probably because there is staff on hand in the day- I know of one case woman transfered at 4/5 cm because mom did not feel right- got into hospital and nurse got her into a room and ruptured membranes- cord prolapsed but it was day time and they just shoved the scheduled C-section out of the way and did the section asap from decision to incision was less than 5 minutes luckily for them- in this hospital at night it is probably more like 45 minutes.

By Anonymous Anonymous, at 12:51 AM  

I think the stranger aspect of it is on the part of the woman not trusting and being less than cooperative with the doctor, not the doctor being uncomfortable delivering for a stranger.

Anyway, there is a solution to the lack of trust/stranger issue.

And that is that the doctor have a closer professional relationship with the midwife. Two of the prenatal visits can involve the doctor. The ultrasound would be a good time, and one during the third trimester. Both of these would be 'getting to know you' and discussing of the risks and what a transfer would involve should it prove necessary. Considering she has a 1 in 10 chance of needing the doctor, is such a set up that far fetched? Also, the hospital of a doctor that would be this kind of backup should have its EMTs prepared for this kind of emergency.

I think a better doctor/midwife relationship can result in more trust from the midwife, with her being more capable of knowing the limitations of a homebirth, as well as the benefits. Also, the doctor would be more able to access the history through the midwife as colleague than the midwife as doula, which is what she would become in the hospital where she does not have such privileges. I think such a back-up would probably result in better results than just admitting through the emergency room or general office staff.

BTW, CNMs are independant practitioners, but tend to deliver in the hospital and do have doctor backup in case they come across something they can't handle, just like OBs may refer a known high risk situation to a perinatologist.

Some OBs may be cut out for this particular job, and others might not.

By Anonymous Amka, at 1:09 AM  

Absolutely NOT. IMO doctors should keep completely out of homebirths. Should a complication arise then the woman should transfer in, and then doctors can be involved, but until then, keep your hands and noses out.

Of course this is coming from the viewpoint of a country where midwives are autonomous practitioners and do not need a doctor to back them up at birth. Interestingly given the choice between doctor and midwife caring for them, it seems more than 80% of women CHOOSE a midwife....and I suspect many of the other 20% choose an OB because of medical or obstetric complications.

By Anonymous Anonymous, at 9:26 AM  

Well, what country are you from?

By Anonymous Amka, at 10:02 AM  

well I've been round long enough that we have done midwifery that way-- even before routine ultrasound. In some places it is still that way but as I said before harder to deal with a group-- and you do find the most amazing reactions from medical staff---- from accepting and great to wanting to punish the mom for wanting a home birth in the first place- and they drag everything out admitting, calling the docs...docs who won't come in until the midwife has left ( small places with only 1-2 providers) so whether or not a mom/baby get timely and good transfer care depends on attitudes at the hospital, and attitudes rightly or wrongly are usually not good --exceptions to this- Amish or Mennonites usually do not get treated as badly- I think that the cultural differences are obvious and accepted better

By Anonymous Anonymous, at 10:21 AM  

well I've been round long enough that we have done midwifery that way-- even before routine ultrasound. In some places it is still that way but as I said before harder to deal with a group-- and you do find the most amazing reactions from medical staff---- from accepting and great to wanting to punish the mom for wanting a home birth in the first place- and they drag everything out admitting, calling the docs...docs who won't come in until the midwife has left ( small places with only 1-2 providers) so whether or not a mom/baby get timely and good transfer care depends on attitudes at the hospital, and attitudes rightly or wrongly are usually not good --exceptions to this- Amish or Mennonites usually do not get treated as badly- I think that the cultural differences are obvious and accepted better - other details like midwifery being illegal, moms may actually get a limited amount of care from a doc- but now lets see- self-paying clients need to pay ahead of time, so by visit #2 a self-paying client will have had to put out $500-$1000 at a time.

By Anonymous Anonymous, at 10:28 AM  

Popping back in for a quick read and thought I'd contribute why OUR doctors back up our practice: because we do not bring them disasters, and we do generate them revenue. Believe me they like the income generated from colpo and endometrial biopsy referrals, A&P repairs, tubals, planned repeat c/sections, etc etc...

By Anonymous maribeth, CNM, at 12:18 PM  

Maribeth! We miss you.

By Blogger Jamie, at 12:20 PM  

Why should a doctor willingly take on that responsibility?

Uh... what is the issue? If a doctor is willing to provide coverage for a midwife in an out-of-hospital practice, I am unclear on your objection.

I would think it preferable to have a "stranger" show up with a midwife I know and a chart to provide a background of care, report of events leading to the reason for hospitalization, and proceed with the doctor on deck. In fact this is how we do it in my area, both CNMs and DEMs because there is no back-up doctor thanks to insurance underwriters who make the rules on behalf of sympathetic doctors who can't be trusted to set their own practice parameters with midwives.

So does it make sense for a doctor to refuse back-up to a midwife? No it doesn't make sense but it's not necessary as I've outlined above.

Now answer my question: What is the difference between a random woman off the street presenting in labor without any documented prenatal care to a midwife presenting along with her client and providing you everything you need to proceed?

By Anonymous Anonymous, at 4:01 PM  

"Now answer my question: What is the difference between a random woman off the street presenting in labor without any documented prenatal care to a midwife presenting along with her client and providing you everything you need to proceed?"

The difference is that most private obstetricians don't have to take care of women who walk in off the street. That is the job of hospital employed physicians or interns and residents. So when a private obstetrician agrees to back up a midwife, he or she is taking on an additional responsibility. The question is why should a doctor agree to take on this additional responsibility.

By Blogger Amy Tuteur, MD, at 6:54 PM  

The question is why should a doctor agree to take on this additional responsibility.

I think you will have to recruit some of your colleagues to participate on this blog in order to have that question answered (where are they anyway?). I don't think you'll find any DEMs or CNMs to say physicians "should" provide back up unless they care to do so. The community hospitals satisfy the need for back up from AP to IP to PP to newborn care when we or the family do not have a set consultant.

By Anonymous Anonymous, at 7:04 PM  

I think I have answered this question before- continuity of care, respect for the patients they care for and the choices they make, to help provide some safe options rather than women who would seek no care-- some interaction and possible quality control via discussion and information exchange between midwife and doc-- women/babies who may not have access to things not allowed for midwives to provide like - GBS coverage- some docs weigh the risk of not treating to treating and think that it is better to offer some care-- also a doc who is inclined to assist are also going to get no emergent transfers of care- and also word of mouth advertising that says that this person is willing to work with and do things in a midwife friendly way...
as far as discussing numbers- it just isn't fair to say abstracted and shocking things to readers-- things like some studies show that 40% or more of cord prolapses are likely caused by procedures done in the hospitals- and that up to 50% of those babys will die or have neurologic problems... if you have your baby at night in the hospital and an emergent situation happens then you have a 50% higher chance of having a baby with injury or neuro problem-, even though natural labor occurs more at night- and this is probably part of what accounts for the improved planned c-section stats at least now-- but we will see after we have this huge drive for c-sections on demand- after the dust clears we will see if there are any docs still around.

By Anonymous Anonymous, at 7:14 PM  

a typo above should say non-emergent not no

By Anonymous Anonymous, at 7:15 PM  

Amy, have you read The Myth of Vicarious Liability? It can be found at http://www.midwife.org/display.cfm?id=495

I think it will help clear up why some physicians are willing to back-up OOH birth midwives.

By Anonymous maribeth, CNM, at 9:35 PM  

I don't feel that doctors should have to back up midwives and am glad that they don't have to in order for midwives to practice. It would be nice if more wanted to back up midwives though.

I do feel however, that if I were to show up at the hospital after having complications during a planned homebirth that I should be treated with respect and that a doctor should have to treat me. I would hope that they wouldn't chose to walk out the door just because I was planning a homebirth.

By Anonymous Anonymous, at 10:20 PM