Tuesday, June 13, 2006

Campaign for "normal" birth

I had thought that my colleague Dr. Crippen of NHS Blog Doctor was a bit extreme in his antipathy to "madwives", but now I am not so sure. The RCM seems determined to destroy the reputation of midwives in the UK without Dr. Crippen's help.

The RCM is prominently featuring their Campaign for "Normal" Birth on their website:
Together, we can change the way childbirth happens. The Campaign aims to inspire and support normal birth practice. It's a reminder that good birth experiences can happen despite the challenges. Intervention and caesarean shouldn't be the first choice - they should be the last.
Take a step back for a moment. Can you imagine if a US organization prominently featured a campaign for "normal" families? The outrage would be immediate and appropriate. Critics would point out that a campaign for "normal" families was a thinly veiled attempt to stigmatize gays, single parents, and blended families; all this despite the fact that a two parent and children household IS the normal family. Such a campaign would be insensitive in the extreme.

Similarly, a campaign for "normal" birth is a not so thinly veiled attempt to stigmatize women who do not give birth in the RCM approved way.

First of all, the hubris and self importance of the RCM is laughable. THEY, among eveyone in the world, are in charge of the definition of "normal" birth. Of course, "normal" birth is not birth as it occurs in nature; it is birth as it occurs with a RCM midwife. I don't agree with very much that the unassisted homebirth movement believes, but I am beginning to reasses. Laura Shanley's critique of midwives includes the following:
If a midwife tells you that she understands your body better than you do, run from her. Yes, she may have a general understanding of how "a woman's body" functions in birth. But she doesn't know how your body functions, ... Every body is different, every woman is unique, and for that matter, every birth is unique. As the woman who will be giving birth, you are in the best position to know what works best for you.
Here we have the trade organization of midwives in the UK telling everyone that they do understand your body better than you do. "Normal" birth for the RCM is obviously not an unassisted homebirth, which IS birth in the state of nature. No, "normal" birth for the RCM involves a professional attendant and all the tools of modern medicine except pain relief.

What is equally remarkable is that there is absolutely no mention in the RCM campaign of the desires and needs of women. It is as if they don't matter at all. Women are so stupid and easily brain washed that no one need even listen to them. I find it especially telling that the campaign webpages include cartoon graphics and child like fonts, visually reinforcing the notion that women are child-like creatures who need cartoons to explain "normal" birth. Evidently, the RCM does not trust women to be able to understand it otherwise.

I am often highly critical of the arrogance of doctors and the way they dismiss patient concerns. It seems like the RCM is doing its best to eclipse doctors in arrogance and self importance.

See original comments here.

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41 Old Comments:

I guess I'm pretty lost on your position on homebirthing. You seem to be very anti-homebirthing yet also have issues w/ doctors and organizations being arrogant enough to elimate choices for women. Homebirthing is a birthing choice that should not be discounted and revoked for many women, as is natural childbirth in a more medicalized setting such as a hospital or birthing center. Are you opposed to interferences with ALL birth choices or just interferences that limit medicalizing childbirth? You rant against people not honoring a woman's desires and such but yet...I don't get it. Many women desire homebirth yet you seem to be discouraging of it.

Kind of confused here,that's all.

btw,though...I'm not saying I totally disagree here on this post on some points )...but there's a baby trying to help me type soooo I guess that's it for this commmnet.....

By Blogger Rebecca, at 9:38 AM  

Every woman has the right to decide where and how she gives birth. Hopefully, that will be as a result of an informed decision. In order to be informed, you must have accurate information.

The main point of this blog is to make sure that the information is accurate. It is very important for women to know that there is no scientific evidence that shows homebirth to be as safe as hospital birth. Unfortunately, virtually all homebirth advocacy websites and publications make the claim that "scientific studies homebirth is as safe or safer than hospital birth". That is simply not true and women should know it.

That doesn't mean that no one should have a homebirth. The additional risk is small, and we accept small risks all the time. However, it is a real risk.

By Blogger Amy Tuteur, MD, at 9:57 AM  

No "scientific evidence" ...hehe. I guess so. I'm simple,I suppose.I look towards the example of the human species, not so much studies and such. The human race wasn't exactly in danger of going extinct before God invented Obstetricians. Women have been competently caring for themselves and other women for thousands of years.There's "real" risks to everything in life but that doesn't mean we stop living to avoid them.

By Blogger Rebecca, at 10:20 AM  

Wow, now we can equate normal (read physiological) childbirth with gay bashing. Just when I think I've seen it all, Amy writes more!

By Anonymous clever ID, at 10:22 AM  

Wow, this is one of Amy's most extremist and angry posts yet. Comparing promoting normal birth to polarizing gays? Maybe that makes sense afterall, as we know OBs don't understand the word NORMAL.

The link Amy provided is a wonderful website! I highly recommend a good read through it (which Amy obviously did not do).

On the point of RCM midwives not listening to women, get real. From the website...

"Sometimes we feel caught between the need to accommodate a woman's wishes and following guidelines and minimising the risk of litigation. The woman's pregnancy, labour and birth are, however, the consequence of choices she has made. And her wishes should be at the centre of the care she is given.

Unfortunately this is not often possible within the organizational cultures in which we work - we don't have the empowerment, autonomy or, very often, the confidence, with which to deliver it. And so women's wishes are frequently subordinated to organizational priorities and policies, creating great unhappiness and dissatisfaction.

Women, however, are becoming more and more vocal in demanding what they want. The consumer attitudes that have become common in many areas of our society are spreading to the maternity services, and a new generation of women increasingly want a say in the care they receive.

This may in time result in a swing the other way, towards undue deference towards what women want. But respecting women's wishes must never involve compromising standards of safety or good practice. What she says she wants may or may not be appropriate, depending on how much information she has and whether she is willing to consider the information given to her.

So woman-centred care does not mean that you should subordinate your clinical judgement to her wishes. Instead, it means that she feels you are placing her interests first and that you are hearing her point of view. For instance, if you recommend something she isn't happy with, she needs to know what the choices are and why you are suggesting that approach. This is where her confidence in your experience and judgment becomes critically important.

We need to create a culture in midwifery where women are truly at the centre of care , and this is going to mean revisiting our values and traditions and strengthening our beliefs. But it will also mean that we have to make sure that women are better informed and better prepared for labour and birth. And that the relationship they have with their midwife is a partnership of equals - not a contract between 'consumer' and 'provider'.

Tips and tricks
Listen to her - whether or not it is possible to have the things we want, it is still of the utmost importance to feel that we have been heard. And if you understand why she wants what she is asking for, you may be able to find an appropriate alternative if it is not possible.
Integrate a holistic model into your practice - try to see the big picture, of which her wishes form one part. What she is telling you with her voice may be different from what she is telling you with her body, and this needs to be taken into account.
Reaffirm the founding principles on which our profession is grounded - midwives as experienced, knowledgeable and skilled experts support women through through childbirth. Just as you must respect her wishes and autonomy, she needs to respect your expertise for the relationship to work. "

By Anonymous maribeth, CNM, at 10:26 AM  

Another great link on the RCM normal birth campaign website...

http://www.rcmnormalbirth.
net/default.asp?sID=1100614977639

One of the "top tips" for promoting normal birth...

"Listen to her
Women themselves are the best source of information about what they need. However, a medicalised culture of 'knowing best' (where the deferential 'patient' is examined mutely) means that we are not good at asking her. We are also losing our skills in being able to read her non-verbal signals: her body language, gesture, expression, noises and so on. What we need to do is to get to know her, listen to her, understand her, talk to her and think about how we are contributing to her sense of achievement. "

Thanks for the link, Amy! I will sure use a lot of this website and introduce clients to it.

By Anonymous maribeth, CNM, at 10:28 AM  

"normal" birth for the RCM involves a professional attendant and all the tools of modern medicine except pain relief"

This isn't true of course. Perhaps if you inserted the words 'different pain relief' it would be more true.

The point is, women do not need pharma pain relief IF it is replaced with other methods. I will restate a previous post. In a normal hospital birth, the epidural is necessary pain relief. In a normal Out of Hospital birth, you rarely need it. (and if you do, you can transfer!)

By Anonymous Anonymous, at 11:10 AM  

I believe your comparison between a campaign against homosexual parents and birth beliefs demonstrates your lack of understanding of the situation at hand.

By Anonymous Anonymous, at 11:24 AM  

This is laughable. What do you, Amy, know about 'normal' birth?

By Anonymous Anonymous, at 11:43 AM  

Amy Said AGAIN : It is very important for women to know that there is no scientific evidence that shows homebirth to be as safe as hospital birth.
____
Saying it over and over doesn't make it any more true.

By Anonymous Anonymous, at 11:45 AM  

I have a question... Many times you state that the reason that we can't compare the US to other places that have proven that homebirth IS Safer then hospital birth (not through studies but in the number of deaths, C/S etc) is because you believe that the US had a higher amount of people that are of higher risk... but what do you think of these places? Is homebirth as risky there as it is in the US for a white woman?... or is just that women are magically different when they cross the ocean?
Also... the C/S rate in the US is scary... isn't it true that the risk of death is higher for those who have C/S? Most C/S are done for no reason or have been caused by the interventions at the hospital... how can that be less risky then being at home?

By Anonymous aUCmom, at 11:57 AM  

>>>Rebecca said...
No "scientific evidence" ...hehe. I guess so. I'm simple,I suppose.I look towards the example of the human species, not so much studies and such. The human race wasn't exactly in danger of going extinct before God invented Obstetricians. Women have been competently caring for themselves and other women for thousands of years.There's "real" risks to everything in life but that doesn't mean we stop living to avoid them.

10:20 AM<<<

Rebecca, you crack me up. I agree with you for the most part.

This kind of speaks to my point in another comment section about getting women off their butts/backs onto their own two feet to deliver. Amy asked me for 'SCIENTIFIC EVIDENCE' by which I believe she meant studies "proving" that is is more effective to have women on their own feet.

However, I would sumbit the onus us on the medical profession to prove their recent forcing of women onto their backs, and later butts, is better than what women had done for thousands and thousands of years prior to facilitate birth -- stay upright.

Lithotomy is what? 200 years old? Semi-squatting (a misonomer for sitting) is even newer.

I would point out that in addition to 'SCIENTIFIC EVIDENCE' there are 'SCIENTIFIC PRINCIPLES' like, oh, say, the laws of physics.

So, Amy, using science -- can you explain the phsyics behind this? How can the object (pelvis) be unhindered or even helped to spread and stretch during childbirth if a large amount of the woman's own weight is resting on the pelvis? Its doesn't take medical studies to understand this concept, just a basic understand of natural sciences.

By Anonymous Anonymous, at 12:09 PM  

"The point is, women do not need pharma pain relief IF it is replaced with other methods."

According to whom? The RCM? You?

There mere fact that groups or individuals would presume to know what other women "need" is absurd. It is especially absurd that they don't find it necessary to ask the women themselves or they don't feel that women themselves can be trusted to make these decision.

By Blogger Amy Tuteur, MD, at 12:10 PM  

Rebecca:

"I look towards the example of the human species, not so much studies and such."

That's fine. You have every right to make your decisions any way you choose.

Not everyone believes in scientific evidence (take the intelligent design folks, for example). However, for those who do, it is important to know that there is no scientific evidence to show that homebirth is as safe as hospital birth.

By Blogger Amy Tuteur, MD, at 12:15 PM  

"I believe your comparison between a campaign against homosexual parents and birth beliefs demonstrates your lack of understanding of the situation at hand."

How so?

Conservative groups claim that they know what the definition of a "normal" family is and the RCM now claims that it knows the definition of "normal" birth.

I suspect that both groups would argue that their definition of "normal" is what nature "intended", before the advent of modern philosophy or medicine.

By Blogger Amy Tuteur, MD, at 12:19 PM  

However, for those who do, it is important to know that there is no scientific evidence to show that homebirth is as safe as hospital birth.

Is there any scientific proof that proves otherwise? Is there a study that PROVES that Hospital birth is safer then Homebirth? Not little parts of many studies.. but one actual study...

By Anonymous aUCmom, at 12:32 PM  

>>Is there any scientific proof that proves otherwise? Is there a study that PROVES that Hospital birth is safer then Homebirth? Not little parts of many studies.. but one actual study...<<

She won't answer correctly. She's misrepresent the two FLAWED studies as valid. Here's why they're flawed:

The Pang study used birth certificate data which makes it impossible to separate out unplanned emergencies where birth occure at home. Good studies only compared planned, attended home births with low risk hospital births.

The Australian study, I don't know as much about, but I do know that apparently there were high risk women in the group. One of the guideposts of safe home birth is having only lower risk women deliver at home, so this study didn't really address U.S. Home birth as it is normally carried out. Apples-oranged scenarios, if you will.

Amy is not rational. I believe Amy is on a personal vendetta since she has an isolated bad experience that Amy hd during her residency training with a woman who claimed to be a midwife (who knows what her qualifications actually were?).

By Anonymous Anonymous, at 1:02 PM  

Maybe the RCM is in collusion with the U.S. Dept. of Health and Human Services, which is now recommending a more aggressive breastfeeding promotional campaign.

http://www.nytimes.com/2006/06/13/health/13brea.html?ex=1150862400&en=12df20db104ff0f1&ei=5070&emc=eta1

By Anonymous Anonymous, at 1:16 PM  

"Maybe the RCM is in collusion with the U.S. Dept. of Health and Human Services, which is now recommending a more aggressive breastfeeding promotional campaign."

Not likely, since HHS is not recommending a $1000 surcharge for formula.

By Blogger Amy Tuteur, MD, at 3:51 PM  

Dr. Amy: how many of your patients deliver without any pitocin, without having amniotomy and without pain relief? How much time do you spend with your patients during labor? What is your episiotomy rate? What is your c-section rate?

Inquiring minds wanna know!

By Anonymous Anonymous, at 6:04 PM  

lets see I think that you have said your C-section rate is 15% or less-- how about unmedicated?
did I guess correctly ?
With your very clear definition of what active labor is makes for some good prevention on your part---

By Anonymous Anonymous, at 10:17 PM  

My C-section rate varied from 10-16% depending on my patient population.

By Blogger Amy Tuteur, MD, at 10:50 PM  

Hm. and the rest of your stats? I'm just curious how often you've seen a woman give birth without pit, meds and epis.

By Anonymous Anonymous, at 9:10 AM  

"I'm just curious how often you've seen a woman give birth without pit, meds and epis."

I have already said that you need to tell me what you think I have seen before I tell you what I have actually seen.

It is my experience that misrepresenting what physicians do and do not know is a fundamental part of homebirth advocacy.

By Blogger Amy Tuteur, MD, at 9:49 AM  

I'm not making assumptions. I'm asking. Any guess would be pure speculation. I would only go so far as to say what seems to be average from large scale surveys, and some birth cert data about average rates of various procedures. I understand that does not necessarily apply to you. That's why I'm asking.

Oh, and did I leave out my favorite? Women on their own two feet? How could I have forgotten that?

So.....

no pit
no meds
no episitotomy
no butt/back for pushing

sure there are others, that, if i sat down and made a list would would make it longer, but those are the major ones.

Odds nationally are slim of getting through birth without at least one of those things so I can't help but wonder.

Notice, please, though, that I asked. Do you keep track of those stats in your practice?

By Anonymous Anonymous, at 6:19 PM  

Let's be on our best symantic behavior:

>>"The point is, women do not need pharma pain relief IF it is replaced with other methods."<<

Many women report that alternative, lower tech, less invasive approaches help them to cope with the pain so that pharma pain meds become less desirable.

People often tend toward absolute terms to describe gray areas, and this is definitely a gray area.

Is a rice sock on the back for posterior "natural" by Amy's strict definition? No. However, it is fair to say it is less invasive to stick some lavender and chamomille scented warmed raw rice in some cotton than sticking a needle into your spine.

I believe people use the term "natural" for convenience sake. It's easier to say "natural" birth than "unmedicated, relatively undisturbed" birth.

I often say "god" but don't mean what most people think, but I'd rather, for the sake of understanding say "god" than launch into my personal religious beliefs.

Anyway, I also sumbit that how "natural" a birth ends up is not 100% one or the other. I see it more as a continuum, with highly technicological birth on one end of the spectrum, and u/c of an uncivilized woman on the other end.

It certainly is more natural to get a massage and move around and moan to release tension (like during a massage when they hit a sore spot but more intense) than get a pit drip and stay tethered to the bed due to the iv. (I personally have had an iv for other reasons and didn't like to get up with it, so I can't see how I'd manage to move as much as I did in my last birth with an iv sticking out of my arm.)

Where does that leave us in this so-called debate?

BTW -- I personally have never said "home birth is safer" like Amy is carping about. It's true there's not incontrovertable proof -- either way. I do feel, though, that FOR ME, home birth was safer. I would not say it objectively, accross the board. I would not say that about hospital birth, either, though. I think it approaches impossible to measure according to objective scientific method, due to ethics.

By Anonymous Anonymous, at 6:33 PM  

"I believe people use the term "natural" for convenience sake. It's easier to say "natural" birth than "unmedicated, relatively undisturbed" birth."

I am beginning to think that "natural" childbirth is a social construct. No, let me amend that; unassisted homebirths are natural in the real sense of the word. For everyone else, "natural" childbirth is a social construct.

The unassisted homebirth group shows us that natural childbirth can still be done. I would't want to do, it isn't safe, but it can be done.

Once you abandon truly natural childbirth, you are building an arbitrary definition. There is absolutely nothing natural about measuring blood pressure, checking the fetal heart rate, administering oxygen, or pit or methergine, or suturing. However, the people who built the social construct of natural childbirth ignore these unnatural things.

There is nothing natural about waterbirth. There is no analogue among primates and there is no anthropological evidence that it was regularly used by ancient human beings. The social construct competely violates any commitment to natural when it includes waterbirth in "natural" childbirth.

So basically the social construct of natural childbirth is this: anything that natural childbirth advocates want to do becomes natural. Anything they don't want to do is unnatural.

As you might imagine, you don't get to make up your own definition to suit yourself (even if you are the Royal College of Midwives). And you certainly don't get to consider yourself superior to others when they decline to accept your definition as the one by which everyone else has to judge themselves.

Think about it. One group of women sets up an arbitrary standard and then announces that anyone who doesn't live up to their standard must be "educated" or even forced to do so. If that isn't arrogance, I don't know what is.

By Blogger Amy Tuteur, MD, at 7:17 PM  

"I'm not making assumptions. I'm asking. Any guess would be pure speculation."

Okay, one more question first.

Please tell me what difference it would make if the answer were 10 or 100 or 1000? Does the homebirth movement have a magic number which you must see before you can appreciate natural childbirth in all its glory? Are we supposed to believe that if you see 78 completely "natural" births you cannot fully appreciate the wonderfulness, but if you see 79 you can? How about if you have a "natural" childbirth yourself? Do you get extra credit?

Natural childbirth advocates are always jumping up and down about this point as if it actually means something. By their reasoning, though, they automatically disqualify themselves from the debate. Even if only a tiny fraction of the thousands of birth I have been involved in were natural, I'd have many more "natural" births to my credit than you would, and of course, I have much more experience with every other kind of birth,too.

By Blogger Amy Tuteur, MD, at 7:25 PM  

I believe it would speak to your perspective.

Given your c-section rate is quite respectable, you don't sound like the worst-case scenario (which, btw, exists on both sides of the aisle -- worst case home birth unqualified lay midwife or butcher ob).

Remember, though, that a lot of home birth supporters are birth workers and do witness a lot of different types of births, so don't make assumptions yourself, either, about what the home birth community does or does not witness...you might be surprised by their perspective.

You're correct that you are waaaaaaay more experienced in hospital birth than I.

My impression of hospital birth is based on things like government stats, the "Listening to Mothers Survey" and less reliable methods (birth support boards, friends, and acquaintances in support groups I've been very active in for 12 years). I acknowledge regions have differences. In my region things are pretty extreme. That can and probably does affect my POV.

Do you think you're truly that objective? Do you really believe you don't have any bias from how you were trained and what you've witnessed? I'd have a hard time believing that of just about anybody.

So, while you have that professional perspective, and I'm sure you have many clients who are delighted with your services, and I bet you're a terrific match for tons of women, it doesn't mean you automatcially have the skill set or perspective to fairly "judge" home birth.

I believe -- that is it is my opinion -- that labor and birth are different for most women at home compared with most hospital births.

And while there is some value judgement in it, it is purely subjective that for ME a hospital birth would be a worst case scenario. That's not to say it'd be bad for my best friend or my neighbor. I HATE it if a woman knows I'm a home birth mom and tries to "justify" her epidural. I truly despise the fact that they feel they have to justify their experience to me. I don't want women to feel bad about how their babies were born!!!

On the other hand, at least three dozen women asked me who stitched me up at home, and those women had never ~ever~ heard from anyone they'd ever met that a woman can remain intact after birt. Episiotomy is close to universal in my region (in the hosptial). I am not exaggerating.

Is that anecdotal? You bet. But don't you ever wonder why home birth women "obsess" (your word) about the perineum? Maybe it's because we know that it doesn't have to be slash and stitch that so many women believe is totally necessary.

So now tell me I'm Emily Litella, although the funny thing is, you framed the whole debate when you defined the extreme position similar to what is some websites and accussed all home birthers to have taken that same extreme stance. I, for one, fell for the ruse, but I'm taking a step back and trying to be very clear in what I mean ...

Planned home birth is safe. The best available evidence we have shows it is safe IF YOU HAVE A SKILLED ATTENDANT (like a CPM) and meet certain screening criteria. I don't think you can prove definitively one way or another which route is safest accross the board, all other things being equal (and currently they're nowhere near equal). It's nearly impossible to separate out confounding factors.

You say you don't see a difference in unmed birth. So, yes, my question about how many unmed births you've seen is seeking to understand your perspective. How many women have you seen give birth of their own volition, without any pit, unmed, on their own feet.

do you honestly think that all home birth folks are ignorant/stupid and that what we observe and know to be true at home is fantasy or something? You seem to have misapprehended the competency of the home birth community. There are many home birth supporters who are doctors, graduate level up to and including PhDs in public health, and many other similar related professions.

You are trying to frame this as a scientific debate, but I strongly believe that there might not be a way to do such a good study as would be required to really "prove" it and then do it over and over again enough times to really prove beyond a shadow of a doubt. Example of one reason why it is hard to separate things out: studies done on various intervnetions use women in the hospital as the control group. But, for those of us who are of the opinion that the setting makes a difference, and know things to be different at home, how do you "prove" that there is little or no difference when 99.5% of all research is done solely on groups not fully separated out?

Am I creating a hurdle impossible to clear? Maybe. It's not to be contentious. It's based on sincere belief.

Then there's the whole angle that the home birth community is a self-selecting group. Also, I do not agree with your interpretation of the numbers of the few studies you have "analyzed" on this blog.

We obviously see things differently.

But your statement that science has proven your POV to be correct is simply unsupported.

Now I await to see what the weakest point of my "argument" is, because I'm sure you'll zero in on it. Or whatever your sore spot is and pushes your buttons (which I sincerely was not trying to do), and I await your who spiel about me not using the exalted science that is, frankly, IMO, impossible or nearly impossible to apply to this debate.

By Anonymous Anonymous, at 11:33 PM  

>>> Even if only a tiny fraction of the thousands of birth I have been involved in were natural, I'd have many more "natural" births to my credit than you would, and of course, I have much more experience with every other kind of birth,too.<<<

Hm. This is an interesting difference, and I'm sure it's illustrative of something.

What percentage of time per labor (just guess) do you spend with each birth? I mean, midwives spend most of the labor with most of their births. I know you love that precise number. LOL

Is this like seeing flowers through a pane of glass, and then at the last minute opening the door and breathing in some of the scent vs. sitting in the garden the whole time watching the flower unfold?

Can you even acknowledge that such a differenc exists? Even if you don't value it, can you see how someone with a different perspective would arrive at different conclusions than you for themselves?

I personally have never EVER tried to influence someone else to have a home birth. I believe that birth choice should be from within. I also believe that "science" currently does not understand birth as much as you seem to think it does. It's only been a few short decades since most doctors and many scientists believed that formula was better than breastmilk, or at least as good as. Look what's been uncovered since then.

By Anonymous Anonymous, at 11:39 PM  

oops! my toddler hit the keyboard and caused it to enter while I was adding something, so let me finish ....

"It's only been a few short decades since most doctors and many scientists believed that formula was better than breastmilk, or at least as good as. Look what's been uncovered since then."

And I'm sure that women (and men) from 30-40 years ago who observed that breastfed babies seemed healthier were accused of not understanding the science behind it. I guess I'm in excellent company.

By Anonymous Anonymous, at 11:42 PM  

"Do you think you're truly that objective?"

I'm not sure what you mean by that question? Who is "truly" objective? Certainly not homebirth advocates, certainly not the RCM. I will say this. I try my level best to base my arguments on the scientific research, not simply on my personal experience.

"You're correct that you are waaaaaaay more experienced in hospital birth than I."

Yes, but I am probably also way more experienced in unmedicated birth, too. I've certainly seen hundreds over the years. I am glad when women can have the kind of births they want (regardless of what kind that may be), but I am certainly not impressed with unmedicated birth over any other type of birth.

"And while there is some value judgement in it, it is purely subjective that for ME a hospital birth would be a worst case scenario."

Remember, I am not telling anyone not to have a homebirth. I am standing on one specific point. That point is that claims by homebirth advocates that scientific research shows homebirth to be "as safe" as hospital birth are not true.

In this particular thread, though, I want to explore the fact that the definition of "normal" birth is arbitrary. Therefore, no group should be attempting to shove it down the throat of any other group since NO ONE is having a "normal" birth the way that it occured in nature.

"The best available evidence we have shows it is safe IF YOU HAVE A SKILLED ATTENDANT (like a CPM) and meet certain screening criteria."

No, the evidence does NOT show that. It shows that the risks are small, but they are real. Every study of homebirth to date shows an excess of preventable neonatal deaths in the homebirth group. That's the evidence and that's what women deserve to know.

"do you honestly think that all home birth folks are ignorant/stupid and that what we observe and know to be true at home is fantasy or something?"

No, I would say that they are not fully informed, and they don't even realize it. It has nothing to do with inherent intelligence.

"You are trying to frame this as a scientific debate, but I strongly believe that there might not be a way to do such a good study as would be required to really "prove" it and then do it over and over again enough times to really prove beyond a shadow of a doubt."

No question about that. However, that does not mean that we throw up our hands and announce that we can believe whatever we want. Comparable situations exist in many other areas of medicine.

For example, it is similarly difficult to do a good study of episiotomy for the exact same reasons. That doesn't mean that obstetricians can throw up their hands and announce that as far as they're concerned episiotomy is just as good as no episiotomy. There's plenty of other evidence that can be used. A randomized, double blind study is the ultimate in research, but it doesn't mean that you can't make any assessment without it.

By Blogger Amy Tuteur, MD, at 7:17 AM  

"What percentage of time per labor (just guess) do you spend with each birth? I mean, midwives spend most of the labor with most of their births. I know you love that precise number."

I spent 100% of the time at my own unmedicated births. Is that enough?

"Is this like seeing flowers through a pane of glass, and then at the last minute opening the door and breathing in some of the scent vs. sitting in the garden the whole time watching the flower unfold?"

That is BS, pure and simple.

"It's only been a few short decades since most doctors and many scientists believed that formula was better than breastmilk, or at least as good as. Look what's been uncovered since then."

Homebirth marketing tactic #5: point out that doctors have been wrong in the past, and imply that they are always wrong.

That tactic only works on the uninformed; it does not work on me.

I have said it before, and I will say it again. You are entitled to think about birth any way you want. However, you are not entitled to assume that your personal concept of birth is privileged over anyone else's. That means that you are not entitled to call your view "normal" and relegate everyone else to the abnormal group.

By Blogger Amy Tuteur, MD, at 7:29 AM  

I agree the term "normal" is incorrect, because in this day and age it is more "normal" to be induced (or augmented) and get an epi.

Say what you want. I know home birth has advantages for women who want to stay home. Call it bs. I don't care. It's true about medicine being wrong sometimes. You are worshipping at the medicinal altar, just like some home birth moms worship at the altar of naturalness. Big deal.

I fully accept that people have divergent value systems.

So, if you think this is all bunk, then why didn't you have meds in your own birth/s? That is curious.

And it is not bunk that midwives labor sit, doctors don't. (Generally speaking.) You don't like my flower metaphor? I thought for sure that would win you over (rolling eyes).

True to form, you side-stepped the actual quesions. You did admit you personally do nothing to support women who want unmed. I appreciate that honesty. That sort of speaks to the point of at least one reason why some women stay home. Does your hospital have a good protocol for supporting unmed women? What's the nurse-patient ratio?

By Anonymous Anonymous, at 10:54 AM  

>>>No, the evidence does NOT show that. It shows that the risks are small, but they are real. Every study of homebirth to date shows an excess of preventable neonatal deaths in the homebirth group. That's the evidence and that's what women deserve to know.<<<

Only through your twisted interpretation of the data or through really crappy studies (I consider pang not fit to be published).

By Anonymous Anonymous, at 10:57 AM  

(I consider pang not fit to be published).

This would be a mistake.

See, the Pang study is notable for its accuracy and honesty. Not its accuracy as to the conclusions--but the accuracy of its ANALYSIS, which is more important.

If you read the Pang study, you will see the study itself acknowledges, and lists, all of the various potential problems which are whipped about and ballyhooed by its opponents.

It is accurate about what it studied, and honest about the problems raised by the method of analysis. This type of honesty is what makes an article like that publishable. Note that for many of the OTHER studies (including most of those cited by home birth advocates) the authors are not forthcoming aboout the flaws in their study.

It would be a lot easier if the home birth studies were as honest.

By Blogger sailorman, at 2:48 PM  

because of the flaws the Pang study- failed to actually give any information --- a number of problems occurred to infants born outside- in route or at the hospital- from 34 weeks on --- big woop no other conclusions can be drawn from it---
- hint they could have gotten better information- and it was available to them they just chose not to look at it- I believe that Washington state midwives file quarterly reports. I think that the trouble would have been the study would have shown better stats for homebirth of term infants so they stretched to include preterm birth 34 weeks on and included all births recorded.
ah but this is a good study because they told you ahead of time they contrived to misrepresent .

By Anonymous Anonymous, at 3:43 PM  

I loved Amy's article.
Pesonally think far too much is made of the "birth experience." Childbirth isn't glamorous/fun/a test of one's pain thresthold - its having a baby and it is some of the most important (and possibly risky) time of the baby's life. Surely that has to be the priority?

As for women giving birth naturally 100's and 100's of years ago - yes - humans weren't in danger of becoming extinct but childbirth had a substantially higher mortality in those days. Not to mention the numbers of women who ended up with incontinence/disabled children and whatever the complications of completely natural childbirth were.

Given how well nourished the western world is - baby's are probably getting bigger and the small pelvised women who would have not successfully reproduced are producing small pelvissed offspring.

It personally feels like a middle class competitive thing.... "my birth story... vs your birth story."

I keep thinking about my friend who had an emergency C/section after 26 hours of labour. She nearly lost her baby who had a heart rate of about 30 at birth. Had always planned water birth etc. She felt ostracised by the midwives in hospital post birth. Looked down on by her middle class friends (several of who had successful "natural" home waterbirths) ....

By Anonymous Anonymous, at 5:54 PM  

"So, if you think this is all bunk, then why didn't you have meds in your own birth/s?"

I find this question interesting. What it suggests to me is the assumption that if you think epidurals are safe and you don't have anything to prove, you would automatically get an epidural.

I chose to have an epidural with my first two children because I wanted one at the time. I did not have an epidural with either my third or my fourth child because I didn't feel like I needed it.

By Blogger Amy Tuteur, MD, at 7:49 PM  

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