Monday, May 15, 2006

Why don't homebirth midwives have pediatrician backup?

Every study of homebirth safety has shown that a significant number of the avoidable deaths were due to inability to resucitate a baby born with unanticipated respiratory distress or congenital anomalies. Why don't homebirth midwives use pediatrician backup? In discussions on this website, many homebirth advocates have emphasized the fact that homebirth midwives carry resucitation equipment. However, that is not particularly meaningful if they don't have extensive experience in using it, and the deaths in the studies attest to the fact that the midwives aren't successful in neonatal resucitation. Why not simply have a pediatrician there?

Labels:

32 Old Comments:

I think this is an easy to answer question. The pediatrician isn't going to show to a homebirth because of liability reasons. Their liability insurance is expensive and they are fearful that they won't be covered if something goes wrong.

By Anonymous Anonymous, at 9:21 AM  

a ped doesn't do the resus in the hospital most times anyway - it is a neonatal nurse or a tec

trouble with transports is you have to hand off to ambulance drivers- and when they are good they are very good and when they are bad they are horrid - I know from experience
would not take report,
did not have the equipment to resuscitate a newborn nor know how to use it
understand to not do compressions on a baby who has a heart rate of 80 or above and to do them with a lower heart rate
for not breathing they seem to know to use a bag and mask--
but for breathing they are confused
( after one bad transfer I wanted to pay for the entire department to take neonatal resuscitation with me!!!!!!)
we actually have ped's who will take calls- and neonatologists who will phone consult---have also had mistakes made with this system where they said we will call the ambulance - ended up 20 min later and we are seeing and hearing nothing so call back and they said woops should have called you-back to let you know you need to be calling them----
if you weren't having a birth at home but some other breathing emergency with your newborn after going home this same system you too can experience- first hand.

By Anonymous Anonymous, at 10:21 AM  

Again, Amy, I'm troubled by the generalizations. Many homebirth midwives DO have pediatrician back-up. We certainly do. And not, they're not coming to the home any more than the OB is. But... the review and approve our guidelines, are available 24/7 for consult, and will accept our baby transfers.

And again with the lack of experience! I guarantee you Amy, that I have more experience with neonatal resus than you (unless you were something other than an OB in a past life). Why? Your role was to hand the baby off to someone else. In hospital I was that someone else for 8 years.

I worked for awhile at a rural hospital in New Mexico. A woman, a trucker's girlfriend, walked in and dropped a 29 week baby in my hands. I did the resus independently for 25 minutes until someone else got there (so much for that hospital safety net). I only had an RT who was struggling to set up the neo vent the whole time. I have resus'd SO many babies in hospital -- a thousand? -- because of all the narcs (but no harm there eh?), because of all the mec. The incidence of mec OOH is much, much lower than in hospital.

Please be mindful of these generalizations, as I've been with lumping all OBs into the same vain.

By Anonymous maribeth, CNM, at 11:20 AM  

"maribeth, CNM said...

Again, Amy, I'm troubled by the generalizations.


They're not done to piss you off, or to trouble you.

We generalize because that is the only way we can make general decisions, or come to general conclusions. Statistical analyses, by definition, are "general", not "individual".

As part of that, individual experiences are really irrelevant.

You may be an extraordinarily experienced midwife. That does NOT mean that "midwives are experienced" any more than the reverse is true.

Many homebirth midwives DO have pediatrician back-up. We certainly do. And not, they're not coming to the home any more than the OB is.

I think (though am not sure) she was referring to onsite MD backup, not on-phone MD backup.

And again with the lack of experience! I guarantee you Amy, that I have more experience with neonatal resus than you (unless you were something other than an OB in a past life). Why? Your role was to hand the baby off to someone else. In hospital I was that someone else for 8 years....

maribeth, this isn't about you. There is no need for you to continually see this as a personal attack. You PERSONALLY may be an amazing, safe, experienced, midwife. Kudos to you! But that doesn't really answer the question of "are midwives in general skilled at resuscitating infants, as compared to pediatricians."

...Please be mindful of these generalizations, as I've been with lumping all OBs into the same vain.

Generalizations based on data are what this is all about, so nobody is going to stop doing them soon.

By Blogger sailorman, at 12:05 PM  

Amy has repeatedly taken offense to generalizations of physicians. Demanding likewise is only fair, sailorman.

I am not here worrying about my personal feelings! I am asking for Amy to stop and think for a minute, that midwives are better prepared than she imagines. She has no direct experience with homebirths, how would she know, if I didn't share my background, etc? It's informative, not personal.

Onsite physician support?? Where does that idea come from, what do you mean?

By Anonymous maribeth, CNM, at 1:32 PM  

" maribeth, CNM said...

Amy has repeatedly taken offense to generalizations of physicians. Demanding likewise is only fair, sailorman.


If you want to make a generalization based on data, i don't think anyone will protest. "Physicians are more likely to push women towards a C/S" is an accurate generalization.

The ones you have been making are more often in the "physicians are assholes" or "physicians hate midwives because they might make the MD less money", or "I know a lot of bad doctors" category. And the ones you make are usually NOT supported by a "...as shown in this study:___" link.

I am not here worrying about my personal feelings! I am asking for Amy to stop and think for a minute, that midwives are better prepared than she imagines.

I "imagine" based on what I see. I have looked at the data for many many studies which have been posted here--most of them put forth by the home birth crowd.

As a general rule, midwives are not doing so well. Are there exceptions? Sure! Maybe you're one of them. Maybe you are better than 90% of OBs at delivering babies.

But that has NO EFFECT on whtehr, as a general rule, it is as safe to go to a midwife vs. a hospital.

She has no direct experience with homebirths, how would she know, if I didn't share my background, etc?

That's what statistics and studies are for. Without having had breast cancer, I know my chances of survival (if I get it) will be higher with chemo and possibly surgery, than with no treatment. My "lack of experience" doesn't matter. Similarly, your personal background isn't really relevant to 'midwives in general'.

It's informative, not personal.

No, it's personal. When you start sentences with "I" and refer to "my" and "me" and "people who I have met", it's personal.

Of course, you can make your own general conclusions. Bit if you make those conclusions based on personal experience (rather than well-collected data) they're simply not reliable.

Onsite physician support?? Where does that idea come from, what do you mean?

I'll let Dr.A handle that one. I thought she was referrring to pediatricians actually attending home births to be available for emergent infant care. perhaps I'm wrong.

By Blogger sailorman, at 1:47 PM  

- I don't just carry the equipment, I know how to use it.

- My clients hire their pediatricians for back-up. We call them when it is necessary to receive their consultation. If it is not necessary to consult with them they will receive a detailed summary of the birth and newborn assessment, including metabolic screening results.

By Anonymous MetroMidwife, at 1:52 PM  

again peds may be who is on the phone for someone in hospital too. now at a trauma center you may have someone in house who can actually do something - neonatologist but I would say that most of the time it is nurses and tecs that do the bulk of the saving in the moments post delivery in hospital. Even the ob does not usually do anything for a baby-

By Anonymous Anonymous, at 2:53 PM  

Sailorman:

"I thought she was referring to pediatricians actually attending home births to be available for emergent infant care. perhaps I'm wrong."

You're right. I did mean pediatricians actually available at the home in case a resucitation might be needed.

By Blogger Amy Tuteur, MD, at 4:39 PM  

Metromidwife:

"I don't just carry the equipment, I know how to use it."

How many times have you used it over the last 10 years?

"My clients hire their pediatricians for back-up. We call them when it is necessary to receive their consultation."

Why don't you hire (and pay) them to be available for resucitation, since unsuccessful resucitation appears to be a major cause of homebirth death in every study we have seen?

By Blogger Amy Tuteur, MD, at 4:42 PM  

How many times have you used it over the last 10 years?

I have not been in practice 10 years. I have used my equipment "several" times and practice with it regularly with my birth team.

Why don't you hire (and pay) them to be available for resucitation, since unsuccessful resucitation appears to be a major cause of homebirth death in every study we have seen?

Interesting idea that I will pass on to my clients. I would like to know why you think having a pediatrician on call for resuscitation is smarter than having me do it since I am already on site and providing transport to hospital via ambulance if the resuscitation is prolonged? Are you suggesting I waste precious time waiting for a doctor to arrive and expertly assess the situation? Doing it your way I WILL have a dead baby.

By Anonymous MetroMidwife, at 6:09 PM  

Metromidwife:

"I would like to know why you think having a pediatrician on call for resuscitation is smarter than having me do it"

Well, I think that's rather obvious. They are far more knowledgeable, skilled and experienced. "Practicing" neonatal resucitation is not the same as doing it. If you've only done it several times in several years, then you are not experienced at all.

Neonatal resucitation is a highly specialized medical skill. Would you go to a surgeon who had only done several appendectomies in the last several years? Would you use an anesthesiologist who had only administered anesthesia several times in the last several years?

As Dr Crippen said in his blog, the most dangerous thing about homebirth midwives is that don't even know that they don't know. Homebirth midwives don't seem to realize that carrying resuciation equipment which you have used rarely is not the equivalent of being skilled in neonatal resucitation. The deaths of babies at homebirths are a sad testament to that fact.

Furthermore, I am talking about having a pediatrician on site, not on call, and I have clarified this once already.

By Blogger Amy Tuteur, MD, at 6:30 PM  

Metro:

Amy means to hire the ped MDs such that they arrive when you do (or in time to 'guarantee' their presence at the birth) and attend the birth as backup infant care.

By Blogger sailorman, at 6:37 PM  

It is a good point about resuscitation but I would rather hire a nurse if I were going to include anyone else - what are the percentages? from neonatal resuscitation books it is going to be 1% of babies who are going to need resuscitation greater than bag and mask-- summary of the new guidelines
are out at the NRP web site
in the last 25 years I have helped resuscitate probably 2 babies --- and have had to stabilize a couple as well - most recent piece of equipment a pulse oximeter --

By Anonymous Anonymous, at 6:47 PM  

What dead babies? They don't ever die in the hospital? I have been involved with homebirth for 12 plus years and have not seen a dead baby yet. Does that make homebirth invalid since my population is small? Why is homebirth guilty until proven innocent? Why is the medical system in this country the standard that we have to hold up to? Why is it all about the total population when homebirth midwives don't serve the total population? We serve the individual, who is low risk, is that so wrong? Yes, we transfer care when it is beyond our scope, so what? What is the problem with homebirth? I am trying to understand the argument, but it is getting lost on me the more this goes on.

By Anonymous Anonymous, at 6:49 PM  

"Practicing" neonatal resucitation is not the same as doing it. If you've only done it several times in several years, then you are not experienced at all.

I am not expert, I am experienced.

Furthermore, I am talking about having a pediatrician on site, not on call, and I have clarified this once already.

If I can't get an obstetrician to back me up on paper and to meet me at the hospital, what makes you think getting a pediatrician to attend the birth will be any easier? And now that I am not laughing and able to type again, how many pediatricians attend hospital births? None that I have ever seen, except the residents who weren't even smart enough to know that using a stethoscope is helpful in assessing heart tones and lung sounds on a neonate in respiratory distress.

By Anonymous MetroMidwife, at 7:16 PM  

"If I can't get an obstetrician to back me up on paper and to meet me at the hospital, what makes you think getting a pediatrician to attend the birth will be any easier? And now that I am not laughing and able to type again, how many pediatricians attend hospital births?"

I'm not sure what's supposed to be funny about this. Practicing without appropriate back up is not a joke. If you can't get appropriate back up to prevent infant death the answer is to stop practicing, not to practice without appropriate back up.

Moreover, there are pediatric nurse practitioners and neonatal nurses. Both would have considerably more experience than midwives. Let's fact it, the real reason why you don't have pediatric back up is that you don't think is is necessary. Fine, but you should be telling "clients" about the small but real risk that their baby might die at home because you did not think it necessary to hire experienced back up.

In every hospital where I ever worked there was always a neonatalogist in the hospital, and several NICU nurses no matter what time of day or night. If I wanted a neonatologist at a delivery, all I had to do was ask.

By Blogger Amy Tuteur, MD, at 8:06 PM  

no it really is that docs don't go places they only practice in their office and at hospitals-- sure you might get some decent humanitarian effort out of um if they join a 3rd world thing but most of the time no--
you don't even need a neonatal nurse- my one apprentice works as a tec and "catches" babies everyday- which means un-dried and from the hands of the ob into her hands on to the heating table...

By Anonymous Anonymous, at 9:45 PM  

I'm not sure what's supposed to be funny about this.

What is funny is that you live online and in your past, not in the real world and not in our lives with the families we serve.

Practicing without appropriate back up is not a joke. If you can't get appropriate back up to prevent infant death the answer is to stop practicing, not to practice without appropriate back up.

Good idea Amy. We'll all quit home birth as a protest for inadequate back up doctor support. That will really help to improve neonatal mortality.

Moreover, there are pediatric nurse practitioners and neonatal nurses. Both would have considerably more experience than midwives.

Right, but unfortunately they don't work in home birth or free standing birth centers based on their varied state regulations and scope restrictions.

Let's fact it, the real reason why you don't have pediatric back up is that you don't think is is necessary.

You're thinking for me know? If I didn't think it necessary I would not require my clients hire their pediatricians in advance of their births.

In every hospital where I ever worked there was always a neonatalogist in the hospital, and several NICU nurses no matter what time of day or night. If I wanted a neonatologist at a delivery, all I had to do was ask.

I should hope so in a HOSPITAL.

By Anonymous MetroMidwife, at 9:53 PM  

since unsuccessful resucitation appears to be a major cause of homebirth death in every study we have seen?

Amy could you show evidence of that? I have not seen that anywhere.

In every hospital where I ever worked there was always a neonatalogist in the hospital, and several NICU nurses no matter what time of day or night

MOST hospitals do not have this Amy! Most don't even have peds in house. NURSES do resuscitation.

By Anonymous maribeth, CNM, at 10:14 PM  

Metromidwife:

"We'll all quit home birth as a protest for inadequate back up doctor support. That will really help to improve neonatal mortality."

Actually, it would. That's my point.

By Blogger Amy Tuteur, MD, at 10:25 PM  

Amy, do you know of the unassisted childbirth movement? I encourage you to find out more about it. Because that's what would happen.

By Anonymous maribeth, CNM, at 10:40 PM  

Actually, it would. That's my point.

It's never going to happen. And what makes you think that if midwives would cease to attend births out of the hospital that families would follow? The families inclined to give birth at home would continue to do so without prenatal care and even the minimally qualified attendant.

We can't secure our borders and you want to restrict the places of birth? Call in the National Guard, ACOG will need help enforcing this pipedream.

By Anonymous MetroMidwife, at 10:50 PM  

in a 100 mile radius from where I live maybe even 150 mile there is only one hospital that has neonatologist on call 24/7 but far more than that who do births

By Anonymous Anonymous, at 11:37 PM  

If I couldn't find a midwife to attend my birth, I would simply go without. I would not go into the hospital for the birth. I am an informed mother and understand the risks and benefits to staying at home for the birth of my child. So, the idea of driving midwives out because they don't have a ped. show up at the birth.... well, it won't do anything except drive more women to birth unassisted.

By Anonymous Anonymous, at 11:47 PM  

what are all those hospital birth deaths of babies of low risk moms attributable to? the inherent violence there?

it's hard to understand what you don't know. the differences are vast, indeed. the 3rd stage is physically different at home. you probably won't believe that. i understand you have no point of reference to understand what a truly "spontaneous" indpendent birth is like since your experience is birth that is managed by a hospital staff.

one anecdote that illustrates just one minor part of the difference and how little doctors seem to understand about women birthing on their own innate strength follows. my wonderful, open and humble physician asked me about my home birth stories. she was astonished that when i told her about my first baby, who was asynclitic. the thing that astonished her was that i was able to correct her position by getting up and moving around a lot by walking and climbing stairs two at a time to open my hip bones (with loving people surrounding me in case I needed support). my doctor -- who has given birth herself -- didn't know women could walk, much less swing their hips around and climb stairs, while 10 cm dilated. i don't know if you're going to try or are open minded enough but think about the ripple effect of that one seemingly small difference. no violent mechanical or pharmaceutical invasive or risky stunts needed to be pulled. my baby didn't have to be yanked or cut out of me. my body was fine because it wasn't numbed. and then i took a 30 minute nap to recoup for my first joyous, albeit tiring, pushing. (and yes, labor did hurt but it was a good productive pain not pathological).

amy, you are jumping to unfounded conclusions. having a statistic of a very low death rate at home with midwives in no way gives any clue to the reasons those individual babies died. you are making a huge assumption about the skills and training of home birth midwives (erroneously i might add). you are also making a huge assumption that babies need reviving similarly to in the hospital since you only have participated in that spectacle.

being a doctor does not automatically mean you understand studies. it seems to me as if you didn't even read this one very carefully.

By Anonymous Anonymous, at 2:12 AM  

"i understand you have no point of reference to understand what a truly "spontaneous" indpendent birth is like since your experience is birth that is managed by a hospital staff."

Insults are ALWAYS a sign that you have already conceded defeat. You don't have any idea of what I have seen.

Insults and conspiracy theories (which also abound in the homebirth movement) are meant to hide the fact that advocates have no EVIDENCE for their point of view.

The minute I see a personal insult or a conspiracy theory, I know I have already won in the eyes of anyone who is capable of understanding scientific research. I also know that the person who wrote the insult is incapable of marshalling scientific evidence, and that is why they are sending up smokescreens in the form of insults.

Remember, the plural of anecdote is anecdotes, not data. (Someone posted that on Neonatal Doc, and it's true.) Until you can come to the table with data, no one with any understanding of science is going to take homebirth advocates seriously.

By Blogger Amy Tuteur, MD, at 7:42 AM  

The minute I see a personal insult or a conspiracy theory, I know I have already won in the eyes of anyone who is capable of understanding scientific research.

Thank you for finally revealing what this was about Amy. It's about winning. Maybe you can take some time off the "debate", get back into practice and start helping families win. Go teach the midwives in your area who are in your opinion poorly prepared and raise the bar.

By Anonymous MetroMidwife, at 9:08 AM  

Amy, I don't know who you think you have won against. You have not changed anyone's mind. There was scientific data that was shown over and over again, but you shot it down.... that doesn't mean it doesn't exist or that people don't believe it to be true. You believe your data and I will believe mine. You were never open to even looking at the other side and for some reason think that it is the job of homebirthers and advocates to change your mind about it. Why should I care if you don't approve of the way I bring my babies into the world? I am done playing here, you are consistently doing the things you are asking others not too..... throwing insults, making generalizations, speaking on issues and experience you know nothing about, etc. To me this shows me that I have won as you have nothing left but to toot your own superiority horn.

By Anonymous Anonymous, at 9:37 AM  

I said:

"The minute I see a personal insult or a conspiracy theory, I know I have already won in the eyes of anyone who is capable of understanding scientific research."

Metromidwife:

"Thank you for finally revealing what this was about Amy. It's about winning."

Q.E.D.

By Blogger Amy Tuteur, MD, at 9:56 AM  

I said:

"The minute I see a personal insult or a conspiracy theory, I know I have already won in the eyes of anyone who is capable of understanding scientific research."

Metromidwife:

"Thank you for finally revealing what this was about Amy. It's about winning."

Q.E.D.


Thanks for the confirmation of your continued need to "win".

By Anonymous MetroMidwife, at 11:39 AM  

I am in this for improvement-

By Anonymous Anonymous, at 9:37 PM