Thursday, May 18, 2006

When does natural = bad?

In the article about homebirth philosophy that I referenced in a previous post (O'Connor BB, J Med Philos. 1993 Apr;18(2):147-74.) the author describes the homebirth movement in the United States as:
"an alternative health belief system that promotes a model of pregnancy and childbirth contradictory to the conventional biomedical model... [This belief system] assigns primacy and goodness to the Natural ..."
Is this important part of the homebirth belief system really true? What does it mean for something to be "natural"? Why should natural always be considered good? Under what circumstances is natural bad?

I ask these questions because there is absolutely no doubt that high maternal mortality and very high neonatal mortality is clearly a "natural" part of pregnancy and childbirth. Since death is a natural part of human reproduction, why should "natural" automatically be viewed as better than medical interventions?

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43 Old Comments:

are you serious- just being silly now

By Anonymous Anonymous, at 8:55 AM  

In terms of childbirth, I always define "natural" as "unmedicated" (I believe most other women do the same) - and by this definition, the only time "natural" equals "bad" would be when the mother wants to be medicated.

Good grief, Amy. A lot of what you say makes sense, if one bothers to weed out the mean-spiritedness with which you say it, but saying that women who support natural childbirth also therefore support all things natural, mosquitoes and eclampsia and being mauled by lions and all, is blatant and obvious misrepresentation.

I wouldn't call embracing all things natural just because they occur naturally, an "important part" of the homebirth movement. I don't know of anyone who thinks that this is the case.

If there is someone who truly thinks that death is better than medical intervention, I would think that they are lost indeed. Perhaps there are some lost souls out there, but I can't attribute this logic to homebirthers as a group.

By Blogger jenn, at 9:20 AM  

lets see- sex can be one of the riskiest things you can do- think of Africa-, not to mention HPV- so the safest- but still not without risk is artificial insemination - so lets all agree to never have sex again because natural is so dangerous. not to mention abusive relationships that can also be a danger...

By Anonymous Anonymous, at 9:24 AM  

"If there is someone who truly thinks that death is better than medical intervention, I would think that they are lost indeed."

this is ethics and judgment and quality of life issues- how do you feel about having a newborn baby having open heart surgery without medications- and baby doesn't survive but lives 29 days- not a neonatal mortality - and this baby has been "saved" where as the same baby dies sooner because he/she is born at home- neonatal mortality. some extremely preterm babies also suffer greatly before they die- many parents (very often nurses and others in the medical field opt to stay home) rather than expose the child to amount of fruitless efforts that bring about more suffering for an infant.
baby born with one of the chromosomal abnormalities incompatible with life parents are aware but still want to have the baby at home,

By Anonymous Anonymous, at 9:36 AM  

Jenn:

"saying that women who support natural childbirth also therefore support all things natural, mosquitoes and eclampsia and being mauled by lions and all, is blatant and obvious misrepresentation."

You are right, of course. I am just trying to get people to think about whether they really believe that "natural" is best or whether they just say it without appreciating what it actually means.

I am also thinking here of the various "alternative" health movements and the $40 billion dollar and growing supplement business. I personally believe that American business is unscrupulously taking advantage of consumers. There is not a single supplement that works or a vitamin that cures any disease besides vitamin deficiency, yet people are buying them because they are "natural".

"Natural" cures for cancer or other disease are just a means of stealing money from ill people; trading on the belief of many Americans that natural is better. Over the years, many patients, friends and relatives have asked me about "natural" medicines. I always tell them the same thing: Natural does not = good. Tobacco is natural. Heroin is natural. Cocaine is natural. They are not good. I can practically see the wheels turning in their minds. Of course, they knew about tobacco, heroin and cocaine all along. They just never realized how that knowledge could help them see past the claim that natural = good.

I believe that many homebirth advocates honestly are unaware of the true mortality rates of "natural" childbirth. If they were aware, "natural" might take on an entirely different value.

By Blogger Amy Tuteur, MD, at 9:43 AM  

Those are excellent points Anonymous. I would say that the homebirth community does view death much differently. (Not that any of us WANT to experience a death, lest anyone twist my words.)
I wouldn't say that an "excess" (Amy'word) of death is part of birth, but death does happen. Every homebirth mother and father I know have to take responsibility for this fact.

Perhaps if the medical community didn't give parents a false sense of security, there would be fewer malpractice suits.

By Blogger Mama Liberty, at 9:45 AM  

"I believe that many homebirth advocates honestly are unaware of the true mortality rates of "natural" childbirth."

Would you please drop the premise that homebirth parents are a bunch of ill-informed yahoos? What we are talking about is a completely different set of beliefs. You do not have the truth market cornered.

By Blogger Mama Liberty, at 9:50 AM  

I believe that many homebirth advocates honestly are unaware of the true mortality rates of "natural" childbirth.

Let us be clear about this: the mortality rates are a reflection of place of birth and not whether the birth was natural or medicated. Saying the phrase natural childbirth to mean homebirth is not entirely accurate.

I think I understand what you are getting at (you are using "natural" as meaning "out of hospital" I think) , but I want to clarify your position.

To me this is an important distinction. I personally believe that natural - meaning unmedicated - is usually best, but I take issue with homebirth being the best option.

Amy, do you think that birth, when left to progress on its own, usually goes well, or usually leads to complications?

By Blogger jenn, at 10:24 AM  

That answer depends on how you define "goes well" vs. "complication", of course.

And it also depends (a lot) on whether you're including all births, or just talking about vertex singletons with no apparent risk factors born to apparently healthy mothers.

If the answer to the first is "it goes well unless severe intervention is needed" and you're only looking at the lowest risk infants, than almost all of those births will go well.

OTOH if you consider any need for help beyond a few stitches and some pressure to be "complications" and you're looking at ALL infants and mothers, many many more will not "go well".

What are you trying to ask?

By Blogger sailorman, at 10:40 AM  

"Amy, do you think that birth, when left to progress on its own, usually goes well, or usually leads to complications?"

Most of the time it goes well, fortunately. That's the part I like. That's why I went into OB in the first place.

However, a surpisingly large proportion of births do not go well (or wouldn't without medical intervetion):

premature births
some postdates births
breech sometimes
twins sometimes
pre-eclampsia and eclampsia
cord accidents
placenta previa and vasa previa
postpartum hemorrhage
postpartum infection
CPD
intra-uterine growth retardation
prolonged labor, fistula formation
fetal distress
shoulder dystocia
meconium aspiration
congenital anomalies
pre-existing medical conditions

This is just an abbreviated list. It is pretty clear that a large amount of maternal and neonatal "wastage" is a natural part of pregnancy and childbirth.

By Blogger Amy Tuteur, MD, at 10:55 AM  

Amy, I think you're assuming that homebirth advocates are opposed to all intervention, no matter the cost. I'll echo some others in saying that I don't know any parents who would willingly choose a dead baby rather than submit to any intervention in birth.

I also don't know any obstetricians who walk into an LDR room rubbing their hands with glee - "What harm can I cause today with unnecessary technology?" But there's always risk. There's risk if you do nothing, and there's risk if you intervene.

It's not intervention I'm opposed to - it's routine intervention. One size does not fit all.

I'm sure you'll agree that most women and babies survive the birth process, regardless of birth location. Most even come through without major complications. I trust the normal. I trust Occam's Razor, that the simplest answer is usually the best. I'm prepared for the worst, but I don't expect death and destruction to be a frequent occurrence.

I must thank you for this discussion, because it's made me think about statistics and probability in childbirth. I realized that a key difference between the medical and midwifery models of care is that in medicine, data have primacy. In midwifery, individual women have primacy.

I don't want to be treated as a walking bundle of statistics - I'm a person with highly individual needs, entirely different from every one of the billions of women who have given birth before me. I expect that my clients (I'm a doula, by the way) will be individuals too.

Again, it doesn't mean that we shouldn't be prepared for complications - but it's a matter of attitude: do you work from the premise that disaster lurks around every corner, or do you work from the premise that it's very likely to work out just fine?

When you drive to work in the morning, do you call a fully staffed ambulance to follow you, just in case of a car accident?

By Blogger Anne, at 11:17 AM  

Anne:

"I realized that a key difference between the medical and midwifery models of care is that in medicine, data have primacy. In midwifery, individual women have primacy."

Give me a break! That sounds great but it means nothing.

Statistics are information that patients and providers use to plan. They are the accumulated experience of millions of women.

Midwives use them all the time. A woman's blood pressure goes up at the end of pregnancy and the midwife uses statistics to predict the chance that the woman will develop full blown pre-eclampsia. She doesn't gaze at the woman and think: This woman is an individual. She is unlike any other woman in the world. How can I possibly tell what will happen? I'll just have to wait and see.

The difference between doctors and homebirth midwives is not that doctors use statistics and midwives don't; the difference is that doctors know A LOT more statistics and therefore, can make better, safer decisions.

By Blogger Amy Tuteur, MD, at 11:49 AM  

For those who commented about infants being kept alive in the NICU and then dying after being in severe pain, I just want to add one thing further. If I were to go into labor at 23 weeks, I still have a CHOICE as to whether or not I want that baby to be resuscitated. I can opt to hold her until she dies if I do not want to put her through further pain with questionable outcome.

I just wanted to make that clear. And just in case that is unique to Pennsylvania, it is PA that I've researched this in.

I've also spent time researching that and asking around at my hospital as to knowledge of that very concept. I have run into OB residents who did not know that, and therefore I've spoken up about it. However, the reason I looked into it is because it is MY duty to know that I have that choice for my baby. Nobody would force me into keeping a 23 week preemie alive against my will for my child. I have informed myself about my rights on this issue (at least in my state) so that this will not happen.

By Blogger NeoNurseChic, at 12:00 PM  

Anne:

I wrote a new--and not agressive--blog post based on this.

You might want to read it, and I'd be ineterested as to your comments.

By Blogger sailorman, at 12:04 PM  

I'd like a better grasp of how you see this issue, Amy. You state that a surprisingly large proportion of births do not go well and then list a bunch of complications. What percentage of births would you guess are complicated?

This isn't a scientific question; I'm just trying to seek out your stance.

the difference is that doctors know A LOT more statistics and therefore, can make better, safer decisions.

I'm not completely sure that the "therefore" is a guarantee. The trend I see is that some developments were implemented in obstetrics to address some situations, and now are being widely used without regard to their necessity. I think routine induction for postdates, even where there is no sign of medical need, is a good example.

By Blogger jenn, at 12:12 PM  

Don't forget, though, that many mothers asked to be induced because of postdates. While anecdotal, I have at least 2 friends who were induced for postdates because they wanted to be...and I've seen many more.

Induction for postdates is not simply because of MD decision alone. And no, the people I know were not connived into being induced by some doctor scare tactic. They did it because it was their choice.

Just thought I'd throw that out there. :)

By Blogger NeoNurseChic, at 12:17 PM  

"I realized that a key difference between the medical and midwifery models of care is that in medicine, data have primacy. In midwifery, individual women have primacy."

Thanks for that Anne, how true.

I think one thing missing from the viewpoint of those working within the medical model, is that intervention always introduces both risk and benifit with it's use. It's the Judicious use of the intervention that carries more benifits than risks. The routine use may bring more risk than benifit.

Those working within the medical model are much quicker with the intervention. The midwifery model is more wholistic, and the client is a partner in the decision making process.

To the question is natural always better?
I also define natural to mean unmedicated, with minimal interventions. I believe natural is always better, unless the woman doesen't want to go natural. Then it's not.

Epidurals are a great example. Besides their own set of risks, (drop in B/P, debilitating headaches, incomplete coverage, nerve damage, malpractice) Epidurals require a laundry list of other interventions to create a safe application. IV, CFM, being the basic ones.
Constant Monitoring has been shown to have no effect on outcome, except to raise the rate of cesarean, when compaired with intermittant monitoring.
Cesarean carries much higher rates of risks.
Dextrose in your IV has been shown to lower your threshold for pain and cause hypoglycemic babies. There is some debate as to if the fluid in the IV itself overloads the body. Epidurals cause maternal fevers, which bring with it all the resultant testing of the newborn, all carrying their own set of risks. Separation of the newborn to facilatate all this testing has big implications on breastfeeding initiation and duration, effecting the child throughout their entire lives.
And of course there are the physiological differences in the birth process between being bed-ridden with an epidural, as compaired to being upright and moving. (labor dystocia, etc)

There are a ton of things that changes risk with one of our most common interventions. You simply can't talk about interventions individually, because they all go together. You can't have one without requiring another. This is the classic domino effect.

In this light, natural is better. Except, if the mother wants to assume all the excess risk that goes along with getting one.

By Anonymous Anonymous, at 12:30 PM  

neonursechic:

That is a good point! I know several women who have been induced because they have family arriving or are tired of being pregnant, etc.

But, I might add, being induced carries risks, and I'm not assured that most women understand what the risks are. The doctors do, and I would assume they have an obligation to explain to women what the risks are. And in the absence of medical need, why encourage a risky procedure on a healthy pregnancy? This is the kind of practice I find objectionable, especially if the doctors are fully informed of risks and are familiar with statistics and studies. They generally appear to support the routine induction of women for postdates alone.

By Blogger jenn, at 12:30 PM  

Amy wrote:

"The difference between doctors and homebirth midwives is not that doctors use statistics and midwives don't;"

I didn't say that doctors use statistics and midwives don't. I said that midwives look at the person first and then the statistics, not the other way around.

Both approaches have their benefits and drawbacks, by the way. Some women much prefer to see a practitioner who uses the medical model.

"the difference is that doctors know A LOT more statistics and therefore, can make better, safer decisions."

Not sure I agree with this. Are there secret statistics that only doctors have access to?

By Blogger Anne, at 12:31 PM  

Jenn:

"I'd like a better grasp of how you see this issue, Amy. You state that a surprisingly large proportion of births do not go well and then list a bunch of complications. What percentage of births would you guess are complicated?"

I'll try to find some good statistics for you, but I think that looking at homebirth midwives themselves will give you a good idea of what is going on.

Take the BMJ study for example. There were 7228 midwife patients included in the study. Of these, only 5418 were cleared for homebirth by the time labor began. So 1810 women (fully 25%!) were transferred by the midwives themselves before labor began.

Then 655 women were transferred by their midwives after labor began. So, out of the original group, the midwives transferred 2465 women, fully 34% of their own patients, to the hospital, because they felt that the situation had become too complicated for them to handle.

That gives you a good idea of what we are dealing with. In the lowest of the low risk populations, 34% of women developed problems that were too serious for homebirth midwives to handle.

That's a pretty astounding figure when you think about it. That means over a third of all women who were considered low risk at the start of pregnancy developed a significant complication of pregnancy or childbirth. Even I'm surprised by how high the proportion is!

By Blogger Amy Tuteur, MD, at 12:53 PM  

Anne:

"Are there secret statistics that only doctors have access to?"

No, of course, not. It's just that doctors read and know the statistics and homebirth midwives clearly do not.

By Blogger Amy Tuteur, MD, at 12:54 PM  

"Take the BMJ study for example. There were 7228 midwife patients included in the study. Of these, only 5418 were cleared for homebirth by the time labor began. So 1810 women (fully 25%!) were transferred by the midwives themselves before labor began."

But this is exactly what you want, isn't it? Almost all women start their pregnancys low risk. It's when complications develop that they should be transfered to a specialist. What exactly are you argueing for here? This is exactly how it is supposed to happen!

By Anonymous Anonymous, at 12:57 PM  

Amy:

I'll try to find some good statistics for you, but I think that looking at homebirth midwives themselves will give you a good idea of what is going on.

I think I'm being misunderstood. I'm not looking for studies - I can try to find those if I'm interested in them. What I want to know is what YOU think, what your guess is, based on your experience and your views. Do you think that 70% of ALL births are uncomplicated? I'm not looking for home vs. hospital here - I'm trying to figure out how safe or unsafe you believe childbirth really is, regardless of place.

Maybe I should frame my question differently. If all births were out of hospital, what do you believe the rate of complication would be? What percentage would go smoothly? And what percentage would have one the complications you listed?

By Blogger jenn, at 1:00 PM  

not all were midwife decisions- some transfers were for pain relief or parents who decided to let insurance pay - depending on state they practice in some midwives would have to transfer care for things like IV abx to treat GBS- something that can and is done at home in some states but not everywhere is it legal . so not all the transfers were change in risk status-

By Anonymous Anonymous, at 1:21 PM  

" I have run into OB residents who did not know that, and therefore I've spoken up about it. "

thank you for making improvements in your area- informing care providers of parent's choices is helpful and useful-
but the statistics show that the area of increase in infant mortality has to do with perinatal conditions that survive beyond the neonatal period-
semantically and statistically there are less neonatal deaths but infant mortality not really.
I know parents who have made stay at home decisions - their care provider did not agree to just allowing them to hold the baby... how about a c-secton done for a 20 week pregnancy.....

By Anonymous Anonymous, at 1:33 PM  

Jenn:

"Maybe I should frame my question differently. If all births were out of hospital, what do you believe the rate of complication would be? What percentage would go smoothly? And what percentage would have one the complications you listed?"

What difference does it make what I might guess? The important information IS the statistics because that is what really happens.

By Blogger Amy Tuteur, MD, at 4:19 PM  

Amy wrote:
"It's just that doctors read and know the statistics and homebirth midwives clearly do not."

I'm not sure that's so clear. I haven't seen any proof for your assertion that midwives don't read studies. And please don't use me as a case in point - I'm not a midwife.

By Blogger Anne, at 6:20 PM  

I didn't read all the posts so i'm sorry if this is repetitive. There are other ways to think about birth then what you have given, Amy. Medical interventions = bad and natural=good is a very simplisitic dichotomy.

How about, natural is best when there is a well-trained, experienced care giver who doesn't intervene unless medically necessary? Now where we might disagree is what is a medically necessary intervention. And instead of arguing about every possible intervention I will just say that I believe that about 75% (some say more, but to be cautious) of women go into labor low-risk and most can stay that way.

By Anonymous Adriane, at 10:10 PM  

quoting ANne "I realized that a key difference between the medical and midwifery models of care is that in medicine, data have primacy. In midwifery, individual women have primacy. "

WOW! I can't believe someone who supposedly support the midwifery model of care just said this!

This is ABSOLUTELY NOT true! wow... And because it's not true, its exactly why they don't use routine interventions, it's exactly why they encourage the use of doulas, unlike most maternity care providers in our country. And I think this is exactly why midwives and OBs who support the Mother-Friendly model individualize their care as much as possible. Not throw away the evidence so they can individualize their care. good grief!

Have you ever heard of the Childbirth Connection (formerly the Maternity Center Association) or Lamaze? or The Coalition for Imporving Matenity Services? Henci Goer? All of these organizations (and the one individual who is a maternity care researcher) support the midwifery/Mother-Friendly maternity model of care and ALL use the research to support their stance.

By Anonymous Adriane, at 10:17 PM  

Actually the research on homebirth shows that when homebirths are planned and attended by an expeirenced, trained birth attendent they have equal outcomes as those in hospitals. Now if you are to include unplanned homebirths, as some research does, you will find worse outcomes, obviously.

By Anonymous Anonymous, at 10:29 PM  

Anonymous:

"Actually the research on homebirth shows that when homebirths are planned and attended by an expeirenced, trained birth attendent they have equal outcomes as those in hospitals."

No, the research does not show that! The Farm Study, the Fullerton and Murphy Study, and the Johnson and Daviss study all show an excess of neonatal deaths in the homebirth group. I know what the authors conclude in each study (that homebirth is safe), but that is not what the results of the study showed. If you read the actual papers, you will see that.

This is one of the things that we have been arguing about on this site. Almost all homebirth advocates believe that there is research that shows homebirth to be as safe as hospital birth. There is no such research.

By Blogger Amy Tuteur, MD, at 7:09 AM  

Adriane wrote:
"WOW! I can't believe someone who supposedly support the midwifery model of care just said this! [....] And I think this is exactly why midwives and OBs who support the Mother-Friendly model individualize their care as much as possible. Not throw away the evidence so they can individualize their care. good grief!"

Oh, I absolutely was not saying that midwives (and others who support the midwifery model) don't use statistics. Clearly I didn't explain myself very well!

I was trying to say that midwives look at the person first and then the statistics, and make a decision based on the individual, the probabilities, and often their gut instinct - all in combination.

On the other hand, doctors are usually dealing with greater numbers of patients, and therefore don't have the luxury of spending hours and hours getting to know each one. To balance that, they look first at the statistics about "most women" or "the average woman," then evaluate the individual based on that.

Just two different models, and both have their strengths and weaknesses.

When I had a normal, healthy pregnancy and normal, healthy baby, I went to someone who specialized in that area of care - a midwife. If I'd had placenta previa, or quadruplets, or a baby with a rare kidney malformation, you bet I would have gone to an obstetrician.

By Blogger Anne, at 11:32 AM  

Amy said:
What difference does it make what I might guess? The important information IS the statistics because that is what really happens.

And Anne said:
midwives look at the person first and then the statistics, and make a decision based on the individual, the probabilities, and often their gut instinct - all in combination. On the other hand, doctors ...look first at the statistics about "most women" or "the average woman," then evaluate the individual based on that. Just two different models, and both have their strengths and weaknesses. etc

Thanks, Anne. I was working towards that very point, about the different models of care.

Whether a practitioner views birth as a normal, healthy process that sometimes needs intervention, or sees normal birth as a retroactive diagnosis, makes a HUGE difference in how they will treat laboring women, what standards of care they implement, and in which places they think birth is safe.

That's why our guesses matter. If we think birth is more likely to be complicated, we will treat all births as pathologic; but if we think of the process of birth as a healthy event, then we will (hopefully) approach birth with the outlook that it will proceed normally, without complications, unless there is evidence to the contrary.

By Blogger jenn, at 12:54 PM  

Jenn:

"That's why our guesses matter."

But, Jenn, our guess are our prejudices and whether a guess is right or wrong is irrelevant. Doctors and midwives should be treating women based on what is likely to happen, not what they guess might happen.

Personally, I think this is where homebirth midwives get themselves into trouble. Their approach to childbirth is based on their personal feelings about how dangerous childbirth is. However, they are very, very far off the mark. Since childbirth is much more dangerous than they imagine it to be, they are hampered in their ability to recognize problems when they are right in front of them.

This is where the stereotype of homebirth midwifery comes from: the homebirth midwife blathering on about the miracle of birth while the baby is dying right in front of her. I feel pretty confident that this is not a stereotype that you would want to confirm. However, by suggesting that guessing is as important as knowing the facts, or that it is your "attitude" toward the data, rather than the data itself that is important, you are confirming the stereotype.

By Blogger Amy Tuteur, MD, at 1:34 PM  

But, Jenn, our guess are our prejudices and whether a guess is right or wrong is irrelevant.

Cripes! Do you deliberately miss my point? I said nothing about right or wrong guesses - I was saying that attitudes reflect the kind of care a practitioner gives, and that that's why it matters. Our outlook will affect someone else directly, will influence their experience, and it may have an impact on the type of care they receive, how much intervention or not we are willing to use, and therefore it (meaning what we believe) has the potential to influence statistics.

Doctors and midwives should be treating women based on what is likely to happen, not what they guess might happen.

Will you answer my question about what is likely to happen? How common are complications of any kind? Are they the exception or the standard?

Since childbirth is much more dangerous than [midwives] imagine it to be, they are hampered in their ability to recognize problems when they are right in front of them.

I don't know which midwives you're referring to - I imagine you mean the unqualified sort that shouldn't be in practice. Midwives are trained to handle normal births and to immediately recognize when childbirth deviates from normal. At that point they should transfer care to an obstetrician. Saying that midwives can't recognize when complications are beginning because their feeeelings get in the way is entirely unwarranted.

All I was trying to say is that your perception about birth will influence what you do in your practice, whether statistics bear you out or not. That is perfectly reasonable and does not deserve the personal attack you gave.

By Blogger jenn, at 1:57 PM  

Jenn:

"All I was trying to say is that your perception about birth will influence what you do in your practice, whether statistics bear you out or not. That is perfectly reasonable and does not deserve the personal attack you gave."

I apologize. I'm sorry you took it as a personal attack because I certainly didn't mean it that way. I think I know where you are trying to go with this (correct me if I am wrong) and I don't agree.

I think you are trying to suggest that since doctors think there will be a higher number of complications, they treat everyone as if she were a potential complication. In contrast, midwives, who think that there will be a very low number of complications, treat every woman differently.

My personal philosophy is that in low risk patients, there is unlikely to be a complication. I am surprised that studies show such a high rate of complications in low risk populations because that was definitely not my experience. However, I always viewed every labor as having the potential to go wrong very quickly. Some of the greatest tragedies I witnessed in my career were low risk situations that went terribly wrong with no advance warning. Even some of the hospital staff took a while to figure out what was going on because they simply weren't expecting it.

In particular I recall actually having an argument with the nurses in the hallway, because I had called for a stat C-section on patient and they disagreed with my judgment. The fetal tracing looked like nothing I had ever seen before and I had a very bad feeling about it. The nurses argued that since it didn't look like anything particularly ominous, and since the patient was low risk, we should let her continue to labor.

I remember shouting at them that they had better get us all in the operating room right away and they could report me later if I was wrong. I made the initial abdominal incision and blood spurted out from everywhere. The uterus had ruptured and the baby was in the abdominal cavity with around 3 quarts of blood.

When we talked about it afterward, the nurses were really shook up. There had been such a low risk that something bad would happen, that it had been difficult to imagine that it was happening. If we had waited until the situation had become crystal clear, the baby definitely would have died and the mother may have died, too.

Attitude may be important as you say, but it is not as clear cut as it first appears.

By Blogger Amy Tuteur, MD, at 4:31 PM  

Thank you, Amy! Thank you for addressing my almost completely off-thread-topic question.

I'm not lying in wait to attack you with this line of questioning; I was merely curious about where you stand.

I can extrapolate from your response that you suspect I would argue that "if most births are normal then homebirth should be a safe option for most women" - but I'm not prepared to say that. I'm honestly undecided about most of what this debate has brought to light.

Thanks for this forum. I've learned a lot.

By Blogger jenn, at 5:04 PM  

"My personal philosophy is that in low risk patients, there is unlikely to be a complication. I am surprised that studies show such a high rate of complications in low risk populations because that was definitely not my experience. However, I always viewed every labor as having the potential to go wrong very quickly. Some of the greatest tragedies I witnessed in my career were low risk situations that went terribly wrong with no advance warning. Even some of the hospital staff took a while to figure out what was going on because they simply weren't expecting it."

I am enjoying getting to know you even through this heated debate-- but again I could say my own experiences and where does that get us? Maybe some agreements on best practices, in our biased opinions i don't know-
But what I will say is that the majority of routine practice has a lot to do with preparing for an event and I am always surprised at how freaked-out the staff is when ever something happens-- maybe its post-traumatic stress disorder or something?
any how routine things like IVs and NPO and limiting movement, not allowing tubs or showers, constant monitors , do you have the telemetry ones yet or is it easier to get women to lay down with the wired ones-- I have always felt that monitors were the new restraints-

By Anonymous Anonymous, at 2:27 AM  

Yes, the research does show that homebirth is safe. Your summary of the Johnson homebirth study was a gross misrepresentation. Looking at the study in detail here is what we find:

Johnson KC, Daviss BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330(7505):1416.

-- 103 women made an initial visit and never returned

-- 436 (6%) had social reasons (chose hospital birth, moved, changed midwife, cost, other) for not having a home birth

-- 469 were referred for medical reasons (6.5%), including pregnancy complications (205), miscarried (171), preterm labor (58), antepartum fetal death at 20 wks or more (19), twins (16)

-- Of the women continuing care with the midwife, 667 (11%) intended care in a birth center at labor onset, and 163 (2.5%) intended a hospital birth.

-- Of the 5418 women still planning a home birth at labor onset, 655 (12%) were transferred to hospital during labor or afterwards. Almost all (83%) of these transfers were before the birth, and in half of these cases, the reason was poor progress, desire for pain relief, or exhaustion. The cesarean rate among these 5418 women was less than 4%, so the vast majority of the transfers in labor resulted in vaginal births.

So you see, when you look at the details, a very different picture emerges: Less than 7% of the original population were transferred out of midwifery care in pregnancy, of which only half had pregnancy complications of some kind, and nearly 90% of women intending home birth at the onset of labor gave birth and recovered at home.

Below is a list of studies that support homebirth for certain populations of women.. In addition to these, there is the infamous Pang 2002 study, concluding that home birth was dangerous. This was a poor study and you can read why here: http://www.lamaze.org/institute/flawed/intro.asp
Ackermann-Liebrich U et al. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ 1996;313(7068):1276-7.

Bastian H, Keirse MJ, and Lancaster PA. Perinatal death associated with planned home birth in Australia: population based study. BMJ 1998;317(7155):348-8.

Duran AM. The safety of home birth: the Farm study. Am J Public Health 1992;82(3):450-453.

Gulbransen G, Hilton J, McKay L, et al. Home birth in New Zealand 1973-93: incidence and mortality. N Z Med J 1997;110(1040):87-9.

Janssen PA, Lee SK, Ryan EM, et al. Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ 2002;166(3):315-23.

Johnson KC, Daviss BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330(7505):1416.

Olsen O. Meta-analysis of the safety of home birth. Birth 1997;24(1):4-13.

Weigers TA et al. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in The Netherlands. BMJ 1996;313(7068):1309-13.

Woodcock HC et al. A matched cohort study of planned home and hospital births in Western Australia 1981-1987. Midwifery 1994;10(3):125-35.

By Anonymous Anonymous, at 9:18 PM  

When I became pregnant for the first time (a little over two years ago), I didn't know much about childbirth or the different options involved. I'm a scientist (PhD), so the first thing I did was set out to get myself educated. I wanted to know why each procedure was done, what evidence there was for it's effectiveness and what possible side effect there were. I have to say I was shocked by the lack of really good studies in this field. You would think that since birth is so important more people would have done proper studies on every aspect of it. Sadly this really doesn't seem to be the case. So many procedures are standard that appear to actually interfere with the normal hormonal flow of labour. I'm a biologist and I believe in general biological processes work. If they didn't our speices wouldn't have survived. Of course, there are problems and when there is a problem then it is wonderful that we have treatments. However, labour and birth in general are not problems. They require no treatment. Drugs given in labour disrupt the process. That is why there is often a decrease in the strength and or frequency of contraction after their administration. This often leads to the need to agument the labour with synthetic oxytocin to a degree that is higher than the biological levels would normally be. This leads to more pain. Honestly, after tons of reading (not internet....Pubmed) I decided that I did not want any drugs in labour. If there was a problem with my baby then I would have to discuss with my midwife (in UK midwives attend all normal births) how serious the problem was and either try to change positions or something natural to help or call and have them prep a operating table for a c-section. I honestly think that increasing the strength of contractions artifically when the baby is in distress is a bad idea. This would only serve to cause more distress, I would not risk that. I think the problem is that most women do not have access to the medical research that I have. They are not told by their doctors that pain medication can have these effects. If I didn't know this then, yes, I would have wanted pain relief. Labour is hard, it hurts. I'm not a martyr. If I didn't truly believe that those drugs do more harm than good I would have taken them.

That being said this is an individual choice. I was lucky I was in a good comfortable supportative place for my labour. Because I this I didn't have fear. Even when the pain was almost overbearing I had confidence in my body and in my care givers. If I didn't have that, then maybe I would have needed drugs to get through.

Oh and by the way herion is not natural. It is a totally synthetic drug. It was made by the Bayer company in the 1920's or 30's to alliviate morphine addiction. Oops.

By Blogger Dawn, at 8:54 AM  

"So you see, when you look at the details, a very different picture emerges:"

Right. So look at the details about neonatal deaths. There were 14 neonatal deaths out of 5418 women in the homebirth group. That's a rate of 2.6/1000. The rate for low risk white women at term in the hospital is probably less than 1/1000. There were excess deaths in the homebirth group.

That's only one of the problems with this study.

As for your other studies, ALL of them show poorer outcomes for homebirth:

Bastain actually shows an excess of deaths in the homebirth group.

The Farm study has a neonatal death rate of 10/1000, an extraordinary high level of neonatal death.

Olsen is not a study.

Ackermann-Liebrich study has less than 500 women in each group and attempts to compare the home birth group to a hospital group which contained high risk patients.

Wiegers study showed a homebirth death rate of 3.5/1000 and compared to a hospital rate of 2.9/1000. They hid this in a "perinatal index" that included over 20 different factors like episiotomy, etc. Only the "perinatal index" of the two groups was equivalent, not the death rate. In addition the hospital group was a higher risk group.

Gulbransen had a MATERNAL death rate of 10/100,000, much higher than expected in a low risk population.

Woodcock shows that neonatal mortality at homebirths was 25% higher than at hospital births.

Janssen and Ryan had a neonatal death rate of 3/1000 in the homebirth group and a neonatal death rate of 1/1000 in the hospital group.

It's amazing what you find out when you read the actual studies.

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

Dawn;

"However, labour and birth in general are not problems."

Really?

What are the maternal and neonatal mortality figures prior to the advent of obstetrics?

What are the current maternal and neonatal deaths rates in places that don't have access to modern obsetrics?

Why is it that all studies of homebirth show an excess of deaths over comparable low risk hospital groups?

What percentage of women have pregnancy complications such as pre-eclampsia, gestational diabetes, breech, twins, etc.?

What percentage of patients do DEMs transfer to doctor care before labor begins? What percentage are transferred during labor?

By the way, heroin is derived from the poppy. If you'd prefer the more "natural" term opium or even poppy itself, feel free to use it. It doesn't change the fact that this "natural" substance has been responsible for more destroyed lives that virtually anything that has been synthesized.

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

Herion is a synthetic opioid. It is not derived from the poppy, but made to mimic the chemical structure. Opium is natural, heroin is not. I do drug research. Of course naturally occuring substances can be harmful. Nature has created some of the most toxic substances known to man. I don't think you should have 'natural' interventions in labour either.

I will comment on the other when I get a few free minutes.

By Blogger Dawn, at 10:53 AM