Monday, June 05, 2006

Homebirth Debate is Expanding

Homebirth Debate is expanding. I've often noted the fact that all the informational sites about homebirth are pro homebirth and many contain inaccurate information. I am expanding the site in the hope that it can serve as a resource for parents researching homebirth. The risk of increased neonatal mortality at homebirth is small, but it is real and people deserve to know about it in order to make an informed choice. The resources of the website, including scientific papers, analysis and philosophical issues can be found at Homebirth Debate.com.

32 Old Comments:

under the heading accurate information is just a list of your opinions---

By Anonymous Anonymous, at 7:20 PM  

Wow, expanding into your own "marketing" now are you?!
I'm impressed, as we can all see the birth story sharing space went over so well....
Ever amazed at the sheer arrogance... wow.

By Anonymous Anonymous, at 1:52 AM  

I wonder if you would please share for prospective home birth families the course of care for pregnancy, birth, and postpartum. Specifically what happens at home births. Information you know. I don't see any practical information.

By Anonymous clever ID, at 9:39 AM  

"accurate information"?

You just list some of your previous posts without the comments. ?

Are you growing as weary of the "debate" as the rest of us?

By Anonymous wasting my breath, at 11:29 AM  

Amy, I can't resist trying to write an "unbiased" addition to your webpage, and posting it here for review.

Comments are encouraged.

WHY CHOOSE HOSPITAL BIRTH?
Research suggests that there is a small but identifiable reduction in neonatal death if you give birth in a hospital. This is probably because some things which occur during birth are impossible to predict--and if you are really in an emergency, you're better off at the hospital than at home.

Even most home birth studies do not suggest that home birth is safer than the hospital. Even those which are statistically questionable suggest it is as safe as the hospital. if you want to be certain that your infant has the absolute best chance of surviving, you are better off delivering in a hospital.

Hospitals themselves are also not the same. To maximize the safety, you would ideally select a hospital which has a skilled infant care facility. But even so, the procedures and equipment which are only available in a hospital.

The following procedures are some examples of those which are only available in a hospital:

*Caesarian section (removal of the infant through surgery; can be elective or done in response to emergency conditions such as a cord abruption)
*Epidural (spinal anethesia)
*Certain types of anethesia and/or pain relief
*Emergency surgery for infants who require it post birth
*Administration of certain complex drug combinations to treat emergencies.

WHAT ARE THE DOWNSIDES OF HOSPITAL BIRTH?
Some women feel that their desires are not fully respected in a hospital. Especially if you are attended by a person with whom you do not have an ongoing relationship, you are more likely to have your doctor focus on your birth instead of you.

Some people find this experience unpleasant and occasionally demeaning. However, you should not forget that YOU have the FINAL SAY in what happens to you, and to your baby. While someone may try to convince you to do something, or push you towards a decision, the final decision is, ultimately, yours. Do not forget that.

Many people have found that having an assertive "advocate" can be a major asset at a large hospital birth. This allows them to deal with the ongoing discussions which may arise, and allows you to focus on giving birth.

At a hospital, you are almost certain to be offered pain relief. You may also be advised to have a C-section if the doctor feels that one is medically advisable. You will not have much control over who enters your room, and you may not personally know the people who attend you and/or deliver your baby (these are not the same people.)

WHY CHOOSE HOME BIRTH?
In theory, home birth provides a comfortable and secure birthing location, usually at significantly reduced cost (though insurance rarely will pay for a home birth.)

At a home birth, you will almost always know your midwife well prior to the birth, and s/he will attend you (and only you) during the birth process. The constant presence of the midwife means that s/he can manually perform fetal monitoring, which generally means that you will not be reuired or advised to wear a fetal monitor.

You will give birth and recuperate at your home, which can be a more pleasant location for some women. Because your midwife has been in constant contact with you, and probably taken part in planning your birth, s/he will be more likely to avoid challenging your previsously conceived birth plan.

WHAT ARE THE DOWNSIDES OF HOME BIRTH?

The downsides are simple but major. The difference in statistics comes primarily from home birth midwives' difficult position if an emergency arises. This apparently leads to an increase in the rate of neonatal deaths.

If you experience an emergency which requires immediate treatment for you, you will need to transfer to the hospital. Depending on the transfer time this can increase the risk of death or serious to you or your baby.

Similarly, your midwife, like any medical professional, may "mismanage" your pregnancy and increase your problems. The degree to which this happens is a matter of much debate. Some people feel that midwives are less skilled in general than OBs. It is certainly true that they have far fewer years of overall training,. It is also true that many midwives, especially direct entry midwives, are not trained in general health management (they are trained only in management of birth.)

Some people also feel that many midwifes are not qualified to regocnize emergencies, or to administer the "uncommon" range of medications and/or life-saving interventions for which they are putatively trained.

Irrespective of your beliefs on this issue, a partial solution is probably to ask about the specific case history and experience of the midwife in question.

WHAT OTHER OPTIONS ARE THERE?

Hospital Birth Centers

One popular and growing option is to give birth in a birth center which is "attached" to a hospital. These centers commonly allow you to give birth in a more relaxed setting which is different from the hospital environment, and to do so under the care of a midwife. If problems should arise, the hospital is a mere elevator ride away.

In theory, these centers offer many of the benefits of a home birth--primarily personalization and a "non-medical" attitude--while retaining almost all of the safety benefits of a hospital delivery.

Hospital-Midwife Birthing
You may find that your area offers CNS (Certified Nurse Midwives) who practive in conjunction with an OB. Often you may see the midwife instead of the OB as your primary caretaker.

CNMs who practice with OBs tend to be somewhat less "granola" than many freestanding midwives. If you deliver in the hospital under the care of a CNM, you will probably have an experience which is somewhere between a "normal" hospital birth and a "hospital birthing center" birth.

HOW SHOULD I MAKE MY CHOICE?
You should evaluate what is important to you, both in terms of what you want to acheive, and what you want to avoid.

Then, you should make your decision by comparing your desires and concerns with the various pros and cons of the different alternatives.

For example, if your primary goal is the ultimate safety of your baby, and you are willing to undergo any experience to acheive this goal, you would be best to deliver in a major, urban, infant-specific hospital. You may find the experience impersonal, but you and your infant will certainly be as safe as you can be.

If your primary goal is having a pleasant "birth experience," you may well be happiest delivering at home.

Make your own choice, and don't let ANYONE--whether a doctor or a midwife--make your choices for you.

By Blogger sailorman, at 11:51 AM  

good post sailor. run it through a spell check and put it up.
You forgot to add a freestanding birthcenter. One that is in close proximity to a hospital, and yet which is not operated by the hospital. This way you get the out of hospital care philosophy, CPMs and CNMs, and are close to a hospital when you need one.

The benifit of a free standing birth center is that it need not be influenced by the CYA (cover your ass) policys of a hospital.

This is a definate drawback of an attached birth center.

By Anonymous Anonymous, at 12:17 PM  

The debate section might work better under a bulletin board format than a blog format. There are some good free BBs out there.

http://www.thefreecountry.com/php/messageboards.shtml

Hope this helps.

By Anonymous Amka, at 3:42 PM  

though insurance rarely will pay for a home birth.

Actually insurance regularly pays for home birth, but since the vast majority of home birth midwives are not CNMs and who do not have legal insurance payment mandates reimbursement is often at the out-of-network rate. HMOs will not cover a home birth because "homes" are not "facilities" in the network.

freestanding midwives

You mean direct-entry midwives.

One popular and growing option is to give birth in a birth center which is "attached" to a hospital.

The only growing and popular thing about a hospital birth center is the idea of a hospital "birth center". These are nothing more than the maternity wards that were already there for years, newly remodeled and refurnished with concealed equipment, OR suites, and renamed "birth centers". There is nothing that remotely resembles the idea of a birth center as modeled by the American Association of Childbearing Centers (boy the really screwed up by not trademarking the name to prevent hospitals from marketing birth centers in their facilities!). When true to the set-up and description, a birth center is not attached to a hospital in any way and the primary caregivers are midwives. It's a "free standing birth center".

Good first try but it comes across as lacking in meaty substance on the subject matter as the many frustrating posts you've seen on numbers crunching.

By Anonymous Clever ID, at 6:38 PM  

Sailorman,

I agree with almost everything you said. The only important thing I would add is that hospitals usually have pediatricians or neonatalogists who are experienced in resucitating babies.

By Blogger Amy Tuteur, MD, at 7:36 AM  

Clever ID said...
Actually insurance regularly pays for home birth, but since the vast majority of home birth midwives are not CNMs and who do not have legal insurance payment mandates reimbursement is often at the out-of-network rate.

I have no vested interest in it being either way, and I was basing my statements on what I thought other midwives had posted here. Are you sure you're right? I'll correct it but would like to be accurate.

HMOs will not cover a home birth because "homes" are not "facilities" in the network.
OK. that makes sense.

freestanding midwives

You mean direct-entry midwives.

No, I don't. By "freestanding" I mean "midwives who do NOT practice with OBs, in hospitals." This includes other midwives than DEMs.

The only growing and popular thing about a hospital birth center is the idea of a hospital "birth center". These are nothing more than the maternity wards that were already there for years, newly remodeled and refurnished with concealed equipment, OR suites, and renamed "birth centers".

No. What you describe is simply an example of a more 'modern' and 'birth friendly' hospital. A hospital "birth center" OTOH is a separate (usually attached) suite which is entirely designed for a different type of birth.

In Rhode Island, for example, Women's and Infant's hospital is the top infant care center. however, you can deliver in the ABC (alternative birthing center) under the care of a midwife. You'll get different rooms, birthing showers/tubs/balls, different attendants, differnt music; you'll have bars on the walls for standing labor, etc etc. None of this is available in the hospital itself.

Not only will nobody offer you an epidural, you aren't even allowed to get one in the ABC, you have to be transferred upstairs. And you must be under the care of a midwife, NOT an OB, to deliver in the ABC.

But obviously if something goes wrong, you're an elevator away from one of the top children's hospitals in New England, which is a nice place to be.


There is nothing that remotely resembles the idea of a birth center as modeled by the American Association of Childbearing Centers
I am not familiar with this group.

When true to the set-up and description, a birth center is not attached to a hospital in any way and the primary caregivers are midwives. It's a "free standing birth center".

This seems oddly arbitrary. So long as you're getting midwife care in a center, and the center is appropriately staffed and furnished, what difference does it make whether it's physically attached? Cooties?


Good first try but it comes across as lacking in meaty substance on the subject matter as the many frustrating posts you've seen on numbers crunching.

Other than the above comments, what subject matter do you think is lacking? Let me know and I will consider adding it to the final version.

By Blogger sailorman, at 11:12 AM  

'So long as you're getting midwife care in a center, and the center is appropriately staffed and furnished, what difference does it make whether it's physically attached? Cooties?'

Good discription, Cooties is what I'd call it! Ha ha.
Actually, when a birth center is attached to a hospital, it is owned and operated by the hospital. All hospital policys and procedures apply. The rooms are pretty, and have birthing balls... but no philosophical changes have been made. The midwives are under supervision of the same OBs on the other floor.

A 'free standing' birth center is owned and operated by the midwives themselves. The midwives set policy and procedure, and a hospital does not have a say in it's operation.

Big difference for the consumer.

By Anonymous Anonymous, at 7:42 PM  

sailor man good post-- I knew you could be not just a tool....
in any case Amy is wrong again in her assessment about peds who resuscitate a baby-- that is not available everywhere-it just isn't now maybe they can be reached on a phone- by the nurse in the nursery -- the one who would be doing the resuscitation along with a very slightly trained tec-- now dr Amy should really take heed of what I am saying here because this is probably part of the cutting cost to increase profits system
so CPMS are aware of the common drugs used for birth- but not all states that license midwives make them available to midwives-- Alaska, Vermont, Washington, Oregon, California, Utah, Canada all have access to meds needed there are other states this is not a complete list-- Weird stupid places like Colorado - that don't allow for midwives to carry oxygen-- let me see altitude and it can help to save a life... what are they thinking...

By Anonymous Anonymous, at 12:20 AM  

"Big difference for the consumer."

How many hospital birth centers have you visited? How many hospital birth centers have shared their policy and procedures with you, so you could reach this conclusion?

I am going to guess zero. Am I right? Or was it one or maybe two?

By Blogger Amy Tuteur, MD, at 7:04 AM  

Comments are encouraged.
THE EDITED VERSION:

WHY CHOOSE HOSPITAL BIRTH?
Research suggests that there is a small but identifiable reduction in neonatal death if you give birth in a hospital. This is because some things which occur during birth are impossible to predict--and if you are really in an emergency, you're better off at the hospital than at home.

Even most home birth studies do not suggest that home birth is safer than the hospital. Even those studies which are statistically questionable suggest it is as safe as the hospital. However, advocates of hospital birth feel that the studies of home birth are biased and/or statistically flawed in a way that renders their conclusions invalid. As a result, thy believe the true analysis of the data in the home birth studies demonstrates the increased safety of hospital birth.

Even if you read the home birth studies, if you examine the data you will be hard pressed to think home birth is safer than hospital birth. So long as you remain in any doubt about the validity of the studies on home birth, if you want to be certain that your infant has the absolute best chance of surviving, you are better off delivering in a hospital.

Hospitals themselves are also not the same. To maximize the safety, you would ideally select a hospital which has a skilled infant care facility. But even so, there are many types of personnel, procedures, and equipment which are only available in a hospital.

The following procedures are some examples of things which are generally available only in a hospital, not at home. Not all of these are available at every hospital. But NONE are available at home:

*Pediatricians, neonatologists, surgeons, internists, and obstetricians
*Individuals with detailed training and frequent experience in treating infant emergencies requiring resuscitation and insertion of IVs
*Newborn intensive care units (NICU) and associated nurses
*Caesarian section (removal of the infant through surgery; can be elective or done in response to emergency conditions such as a cord abruption)
*Epidural (spinal anesthesia)
*Certain types of anesthesia and/or pain relief
*Emergency surgery for infants or mothers who require it post birth
*Administration of certain complex drug combinations to treat emergencies.

WHAT ARE THE DOWNSIDES OF HOSPITAL BIRTH?
Some women feel that their desires are not fully respected in a hospital. Especially if you are attended by a person with whom you do not have an ongoing relationship, you are more likely to have your doctor focus on your birth instead of you.

Some people find this experience unpleasant and occasionally demeaning. However, you should not forget that YOU have the FINAL SAY in what happens to you, and to your baby. While someone may try to convince you to do something, or push you towards a decision, the final decision is, ultimately, yours. Do not forget that.

Many people have found that having an assertive "advocate" can be a major asset at a large hospital birth. This allows them to deal with the ongoing discussions which may arise, and allows you to focus on giving birth.

At a hospital, you are almost certain to be offered pain relief. You may also be advised to have a C-section if the doctor feels that one is medically advisable for you or your baby. You will not have much control over who enters your room, and you may not personally know the people who attend you and/or deliver your baby (these are not the same people.)

At a hospital, you may be asked to adhere to certain hospital safeguards, such as starting an IV for potential emergency use. During labor, you will likely be asked to wear a fetal monitor to track your fetus' heart rate. During the final stage of delivery, the OB may wish to perform an episiotomy, and will occasionally perform one without discussion, unless you are explicit about your preference for tearing over an episiotomy. Your infant may be delivered with vacuum suction or forceps: though OBs will try to avoid those techniques if possible; they will use them if they feel you or your infant are at risk.

A hospital is a complex place, filled with many people. As a result, the chances are somewhat higher that you or your infant will become ill or receive care which is not ideal. The hospital appears to have a lower fetal death rate even given those comparison; however, you must make your own choices of priorities.

WHY CHOOSE HOME BIRTH?
In theory, home birth provides a comfortable and secure birthing location, usually at significantly reduced cost. (Note that insurance coverage of home birth varies widely, and that in some instances is may be cheaper for an insured patient to deliver in a hospital. Check with your company to find out.)

At a home birth, you will almost always know your midwife well prior to the birth, and s/he will attend you (and only you) during the birth process. The constant presence of the midwife means that s/he can manually perform fetal monitoring, which generally means that you will not be required or advised to wear a fetal monitor.

You will give birth and recuperate at your home, which can be a more pleasant location for some women. Because your midwife has been in constant contact with you, and probably taken part in planning your birth, s/he will be more likely to avoid challenging your previously conceived birth plan.

WHAT ARE THE DOWNSIDES OF HOME BIRTH?

The downsides are simple but major. The difference in statistics comes primarily from home birth midwives' difficult position if an emergency arises. This apparently leads to an increase in the rate of neonatal deaths.

If you experience an emergency which requires immediate treatment for you, you will need to transfer to the hospital. Depending on the transfer time this can increase the risk of death or serious to you or your baby. In any situation which requires emergency surgery, you will be in trouble. Additionally, many women find an ambulance ride during labor to be very unpleasant.

Many women reason that they are "close to the hospital if anything goes wrong." Make an informed decision: a call to your local ambulance service may give you information on both ambulance arrival times (to your house) and transport times (to the hospital) for your area. When considering the time required, do not neglect to ask about and include "loading time", which is the time required to stabilize a patient and move them to the ambulance before departing for the hospital.

Because there is no doctor at a home birth, the midwife is in charge of managing your pregnancy. Although s/he can relay information to an OB over the phone, this is somewhat different from seeing an OB in person. Your midwife, like any medical professional, may "mismanage" your pregnancy and increase your problems.

The degree to which this happens is a matter of much debate. Some people feel that midwives are less skilled in general than OBs. It is certainly true that they have far fewer years of overall training. It is also true that many midwives, especially direct entry midwives, are not trained in general health management (they are trained only in management of birth.) As a result of this lack of training, some people also feel that midwives are not qualified to recognize many health emergencies, or to administer the "uncommon" range of medications and/or life-saving interventions of which they are putatively capable.

Irrespective of your beliefs on this issue, a partial solution is probably to ask about the specific case history and experience of the midwife in question. Within any class of people, more experience and training is preferable.

WHAT OTHER OPTIONS ARE THERE?

Hospital Birth Centers

One option is to give birth in a birth center which is "attached" to a hospital. These centers commonly allow you to give birth in a more relaxed setting which is different from the hospital environment, and to do so under the care of a midwife. If problems should arise, the hospital is a mere elevator ride away.

In theory, these centers offer many of the benefits of a home birth--primarily personalization and a "non-medical" attitude--while retaining almost all of the safety benefits of a hospital delivery. In addition, hospital birthing centers can often get an OB to consult on the pregnancy in person, should something arise which in theory could result in a transfer. (In other words: in some cases, expert medical advice from OBs is available without leaving the hospital birth center at all.)

Hospital / Midwife Birthing
You may find that your area offers CNMs (Certified Nurse Midwives) who practice in conjunction with an OB. Often you may see the midwife instead of the OB as your primary caretaker. These midwives will deliver your child in a hospital.

CNMs who practice with OBs tend to be somewhat less "granola" than most midwives who practice without M.D. supervision. If you deliver in the hospital under the care of a CNM, you will probably have an experience which is somewhere between a "normal" hospital birth and a "hospital birthing center" birth.

Freestanding Birth Centers
These are standalone birthing locations which are not connected to a hospital. They provide a woman a somewhat more clinical and controlled environment than a home birth, though they are not hospitals. They also have the capability to have and maintain somewhat more equipment than a home midwife can easily transport.

In a freestanding birth center, you will be treated by a midwife; no doctor is onsite. Because a free standing birth center is not connected to a hospital or directly under the supervision of an OB, it may have different standards of treatment which depend on the philosophical views of the midwiwives running the center.

Freestanding birth centers are usually (though not always) located relatively close to a hospital. The reduction in transport time for centers close to a hospital makes them safer than a home birth, though a transport is still required to reach the hospital.

If a freestanding birth center does not have an OB on site during your delivery, then any potential medical complications will be dealt with by the midwife, as in a home birth.

HOW SHOULD I MAKE MY CHOICE?
You should evaluate what is important to you, both in terms of what you want to achieve, and what you want to avoid.

Then, you should make your decision by comparing your desires and concerns with the various pros and cons of the different alternatives.

SOme women find doctors reassuring; some women find them terrifying. Some women are only concerned about the ultimate fate of their baby; some are extremely concerned about the process by which the baby is born.

For example, if your primary goal is the ultimate safety of your baby, and you are willing to undergo any experience to achieve this goal, you would be best to deliver in the normal ward of a major, urban, infant-specific hospital. You may find the experience impersonal, but you and your infant will certainly be as safe as you can be.

If your primary goal is having a pleasant "birth experience," you may well be happiest delivering at home.

If you enjoy the care of a midwife but also want the safety of a hospital birth and the opportunity to consult with an OB during delivery, you may prefer a CNM-managed hospital delivery.

If you want a midwife to handle delivery and you want to deliver in a more 'alternative' fashion, and you do not expect to want pain relief or an OB consult, you may be happiest at a hospital birth center.

If you want the care of a midwife and do not wish to deliver at home, but are nervous about hospitals, medicine, or doctors in general, you may prefer a free standing birth center.

Make your own choice, and don't let ANYONE--whether a doctor or a midwife--make your choices for you.

By Blogger sailorman, at 10:08 AM  


I have no vested interest in it being either way, and I was basing my statements on what I thought other midwives had posted here. Are you sure you're right? I'll correct it but would like to be accurate.
.

Yes I am correct because Direct-Entry Midwives, licensed by their states regularly bill for insurance reimbursement for their clients as a "global" charge. Clients are regularly reimbursed at out of network rates.

You mean direct-entry midwives.
No, I don't. By "freestanding" I mean "midwives who do NOT practice with OBs, in hospitals." This includes other midwives than DEMs.


Then you should say in private practice, because NO ONE calls themself as a freestanding midwife.

No. What you describe is simply an example of a more 'modern' and 'birth friendly' hospital. A hospital "birth center" OTOH is a separate (usually attached) suite which is entirely designed for a different type of birth.

No, what I am describing is a free-standing birth center. Believe that after working in "hospital birth centers" and "free-standing birth centers" I understand the difference. A true birth center is not in the hospital, on the grounds of a hospital, and in some cases several miles away. It is not owned, affiliated, or contracted by a hospital though it may have collaborative or consultatory agreements with the birth center. It does not have hospital technology.

Good for Rhode Island to attempt to give the hospital a birth center-like atmosphere.

I am not familiar with this group.

Well then you should read about the American Association of Birth Centers. Many states require their model of set-up (from staff to office QA to protocols) as the standard for state licensing.

This seems oddly arbitrary. So long as you're getting midwife care in a center, and the center is appropriately staffed and furnished, what difference does it make whether it's physically attached? Cooties?

Cooties in the form of a hospital administration and legal department imposing the medical model of care.

Other than the above comments, what subject matter do you think is lacking? Let me know and I will consider adding it to the final version.

I will direct you to my website when I have it finished ;)

By Anonymous clever ID, at 10:31 AM  

*They also have the capability to have and maintain somewhat more equipment than a home midwife can easily transport.*
And what equipment would that be???
__
*no doctor is onsite*
__
Wrong again. There is often a OB hired by the birth center to provide care/consult. Although this is not the case with every freestanding birth center.
__
*The reduction in transport time for centers close to a hospital makes them safer than a home birth, though a transport is still required to reach the hospital.*
__
I'd like to see your evidence for the statement that freestanding birth centers are more safe than homebirths. or for that matter, that freestanding birthcenters are less safe than attached ones.

By Anonymous Anonymous, at 1:34 PM  

"I'd like to see your evidence for the statement that freestanding birth centers are more safe than homebirths."

Why should anyone go to the trouble of citing references when you ignore any references that do not ratify your beliefs?

The fundamental requirement of scientific debate is that YOU are familiar with the scientific references. If you want to dispute his claim, YOU have to read the references so that YOU can cite them or YOU can claim that based on your extensive reading, YOU know that no such references exist.

People are not going to take homebirth advocates seriously as long as they continue yelling "Prove it!" and then drop the subject entirely when it is proven.

By Blogger Amy Tuteur, MD, at 7:10 AM  

'The fundamental requirement of scientific debate is that YOU are familiar with the scientific references. If you want to dispute his claim, YOU have to read the references so that YOU can cite them or YOU can claim that based on your extensive reading, YOU know that no such references exist.'

Amy, this is not how you've been running this blog. You've insisted that the person who makes the statement backs it up with proof. NOT the person who challenges the statement.

By Anonymous Anonymous, at 11:43 AM  

Amy asks: How many hospital birth centers have you visited? How many hospital birth centers have shared their policy and procedures with you, so you could reach this conclusion?

I am going to guess zero. Am I right? Or was it one or maybe two?'
___

Two personally. I've also had two OOH birth centers share their policy and procedures with me. But most of my understanding on birth centers comes from reading.

How many OOH birth centers have you personally visited Amy, who have shared their policys and procedures with you?

By Anonymous Anonymous, at 4:04 PM  

"How many OOH birth centers have you personally visited Amy, who have shared their policys and procedures with you?"

YOU made the statement. I challenged YOUR assertion that you "know" what goes on in hospital birthing centers. I said nothing about what I do or do not know about them. I don't see why what I know has anything to do with what YOU claim to know.

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

I think I've lost the question, what was it exactly? I am familiar with many freestanding birth centers.

The only equipment we have at the birth center and not at our home births are the four person jacuzzis! We carry everything else with us.

I'm not sure our back up doc has ever graced our halls. We go to him for chart review, etc.

Our birth center is 12 miles from a Level 1 hospital (with no OB, anesthesia or peds in house and no nursery), 22 miles to the closest tertiary hospital, and 30 miles from our main referral hospital, where we have privileges. We're rural, and if a family's house is closer to the hospital than our birth center would be a case by case question.

All insurances cover birth center delivery, and very very few cover home delivery.

We are accredited by the national organization (CABC, partner to AABC) and licensed by the state. We also have licensed laboratory facilities.

We do have an EFHM machine available for non-stress tests, but we do not ever use it in labor. We do have IV pain medication available at both the birth center and in homes, though it's hardly ever used.

Questions?

By Anonymous maribeth, CNM, at 3:32 PM  

Dear Amy, I apologize I wasn't able to reply to you earlier.

I read your comments with great interest. You talk of being objective and giving women accurate information, but my understanding is there have not been enough good studies into home and hospital birth to give an accurate picture one way or the other.

You assert, as a fact, that there is a slightly greater risk of infant mortality at a home birth. But in July 2003, the UK's Royal College of Obstetricians and gynocologists reported, "Choice is important in all areas of health care, but women must be provided with information on which to base their decisions. We do not currently have definitive evidence on the safety of home births, or free-standing midwifery-led units. Without this information we as health professionals are unable to provide women with the necessary information to allow them to make informed decisions. More research is urgently required in this area."

I don't get the impression from the wording, that the authors are hoping / expecting to find evidence that home birth is as safe or safer than hospital birth!

Do you also discuss with women evidence of risks associated with hospital births? The National Birthday Trust confidential survey of home births in the United Kingdom (This survey report presents an analysis of 4,500 home births and 3,300 hospital controls) found women were twice as like to have a cesarean if they planned a hospital birth.

With a Maternal mortality of 6/100,000 for cesarean delivery in the USA, this is something that many women may also wish to consider when making their decision.

You quote the Farm Study frequently, and there has been here much debate as to how the figures should be interpreted.

Though perhaps interesting to look at the details, in reality it is in the end a very small study, and I wouldn't really see it as worth including it's statistics one way or the other.

And what can we learn about the relative benefits and risks of home birth from Holland, which I understand has a home birth rate of around 40%?

With the dearth of good studies into the relative benefits and risks of hospital and home birth, isn't it more helpful for women to look at the pro and cons of home or hospital birth for their own circumstances?

As larger and better studies come along, they can only add to helping women make an informed decision.

There is a great deal of emotion tied up in the home birth vs. hospital debate. Could you say, hand on heart, that you now participate in the debate objectively?

Jane

By Anonymous Jane, at 6:27 PM  

Jane:

"Could you say, hand on heart, that you now participate in the debate objectively?"

Yes, I believe that I can. That's because I have only one claim. This is my claim:

There are no scientific studies that show homebirth to be as safe as hospital birth, even for low risk women.

That's it, and in your post you essentially acknowledge that this is true. Therefore, I think it would be far more truthful for homebirth advocacy websites and publications to say that there are no scientific studies that show homebirth to be as safe as hospital birth, rather than proclaiming, as virtually all of them do, that "scientific studies show that homebirth is as safe as or safer than hospital birth."

Would you agree?

By Blogger Amy Tuteur, MD, at 8:21 PM  

This is my claim:There are no scientific studies that show homebirth to be as safe as hospital birth, even for low risk women.

By your claim it's equally true that there are no studies which show it to be LESS safe than hospital care, true?

How does that mesh, Amy, with the numerous times you've claimed homebirth to be proven unsafe and dangerous for the baby?

By Anonymous maribeth, CNM, at 2:43 AM  

And that, Amy, is my point!

I do agree, heartily, because I am looking at the debate objectively. Personally, I have no axe to grind.

You have stated however, that you advise women that home birth carries an increased risk of infant mortality and, as yet, there is no weight of evidence to support this advice. It is just your personal point of view; there is no medical consensus on this.

Of course there are home birth advocates who claim erroneously that is proven that home birth is safer than hospital birth, just as there are obstetricians who claim erroneously, that hospital is proven safer than home birth. It is misleading of both to make such claims.

There are obstetricians, strange as it may seem to you, that advise some women in their care that home birth is as good a choice as hospital birth, in that womens circumstances.

Personal circumstances and culture can make a difference. A women who has a healthy straightforward pregnancy in a culture where home birth is supported by a fully integrated secondary health care system and highly qualified and well-equipped midwives (such as found in the UK and Netherlands) may indeed be advised that home birth is a better option for her.

Evidenced by reports such as "Wiegers T A, Keirse M J N C, van der Zee J, Berghs G A H. Outcome of planned home and planned hospital births in low risk pregnancies in the Netherlands. BMJ 1996;313:1309-13"

For a summary see http://bmj.bmjjournals.com/archive/7068e.htm

And the Birthday Trust report.

The same my not be said perhaps for a women with pregnancy complications, or a women in a culture where midwives, if they exist at all, have limited training and / or have limited equipment and drugs, or where the secondary health care system is not well integrated or set up to support home birth.

In the end however, there will be some personal interpretation on the advice any doctor gives a women, because as yet, there simply has not been enough research to say definitively which, if any, is a safer option.

Don’t you agree?

Jane

By Anonymous jane, at 5:48 AM  

"You have stated however, that you advise women that home birth carries an increased risk of infant mortality and, as yet, there is no weight of evidence to support this advice."

To date, all the existing studies show an excess of preventable neonatal deaths in the homebirth group. Sometimes the paper offers an explicit comparison; other times there is no comparison, but we can compare the results to statistics for low risk white women in hospitals.

I'm just covering my bets, in case a study showing homebirth to be as safe as hospital birth is ever published. However, for now, it is accurate to say that there is NO scientific evidence that homebirth is as safe as hospital birth (this includes Weigers and the NBDT).

The fundamental point is this:

To make a health decision a woman needs and is entitled to ACCURATE information. I have yet to find a homebirth advocacy website or publication that tells the truth about the scientific research. The additional risk is small, but it is real, and it is unethical to hide it from women.

By Blogger Amy Tuteur, MD, at 6:55 AM  

Jane,

The Wiegers study is a paradigmatic example of what is wrong with many homebirth studies. For most women contemplating homebirth, the most important consideration is the risk of neonatal death.

Look over the study. Can you find neonatal deaths? It is hidden away as the 28th variable among 40 in a chart. When you look at it, you can see why: there were 4 neonatal deaths in the homebirth group and 2 in the hospital group.

All you have to do is glance at the study to know that the data have been unacceptably manipulated. First, presenting the data as a "perinatal index" tells you right away that something is being buried. No woman decides about homebirth based on a "perinatal index" that gives equal weight to neonatal deaths and third degree tears.

Second, the data is presented in a way to make it difficult to find the single most important outcome: deaths. You really have to search for it to find it in the chart. Furthermore, as far as I can see, there is no explicit mention within the text that the homebirth group had DOUBLE the amount of deaths compared to the hospital group.

The conclusion of the paper is absurd and not justified by the data: "Our research has shown that, for women with low risk pregnancies in the Netherlands, choosing to give birth at home is a safe choice with an outcome that is at least as good as that of planned hospital birth."

No, they haven't shown that at all, they've shown precisely the OPPOSITE.

By Blogger Amy Tuteur, MD, at 7:34 AM  

I will reply to your latest point first Amy.

"For most women contemplating homebirth, the most important consideration is the risk of neonatal death."

Well, I think the risk of there own death comes quite high too, though not as likely, it does still occur. But yes, infant mortality is usually up there at the top.

"Look over the study. Can you find neonatal deaths? It is hidden away as the 28th variable among 40 in a chart. When you look at it, you can see why: there were 4 neonatal deaths in the homebirth group and 2 in the hospital group.

All you have to do is glance at the study to know that the data have been unacceptably manipulated."

I think you are looking for misdeeds and deviousness which doesn't exist; I expand below.

"The conclusion of the paper is absurd and not justified by the data: "Our research has shown that, for women with low risk pregnancies in the Netherlands, choosing to give birth at home is a safe choice with an outcome that is at least as good as that of planned hospital birth."

No, they haven't shown that at all, they've shown precisely the OPPOSITE."

I disagree Amy, the data are too small to come to this conclusion. May be this is why the neonatal death rate has not been given a high profile - with such small numbers is not possible to draw any conclusion.

The National Birthday trust survey recorded 5 stillbirths and neonatal deaths in the 5,971 planned home births and 5 in the 4,724 planned hospital births, but you haven't drawn any attention to this. Rightly so however, the same problem exists, the numbers are too low to draw any conclusion.

More research is needed.

Jane

By Anonymous Jane, at 10:01 AM  

“To date, all the existing studies show an excess of preventable neonatal deaths in the homebirth group.”

Are you sure the emotion of the argument has over taken your objectivity? I have yet to see a comprehensive review of all the evidence by a recognized body that supports your point of view.

I have seen reports that conclude that home is as valid a choice as hospital in women with low risk of complications in an adequately supported situation.

“However, for now, it is accurate to say that there is NO scientific evidence that homebirth is as safe as hospital birth”

And equally NO scientific evidence that hospital birth is safer than home birth in women with low risks and home birth is adequately supported.

"(this includes Weigers and the NBDT).”

These studies were too small to detect any difference. If there is a difference, either way, it is small. Who knows, if the studies were expanded, they may show home birth is a safer! Equally, they may show hospital is safer, or no difference at all. They may show that hospital and home are safer in different situations. More research is required.

The fundamental point is this:

To make a health decision a woman needs and is entitled to ACCURATE information. They need to understand what is YOUR opinion of the publishes studies and what the wider scientific community say (which is, we don’t know!) In YOUR opinion, the additional risk is small, but it is real.

Wouldn’t you agree?

I find your opinion extreme and emotionally loaded. Also narrow.

Is it ethical I wonder, to hide from women that they have a significantly increased risk (sometimes double) of cesarean in some hospital settings, and that there is a small, but real risk they may die as a result of the procedure?

This is only one example of the many aspects of childbirth that a women may wish to consider before making a decision. The skill of the obstetrician, to my mind, is her ability to help women pull out the relevant issues for them and make a decision that is best for them and their family. They will after all, have to live with the consequences of that decision. Whether the obstetrician is able support that decision is up to her, whether it be elective cesarean, induction, epidural, a water birth, a hospital or a home birth.

I understand Amy, that you have spent much time thinking about and defending the conclusion you have drawn from the published studies, and I respect that. But I do feel it is YOUR opinion, which is not shared by the wider scientific community, who are still sitting on the fence. I do feel it’s a little deceptive to imply otherwise.

But, I don’t imagine for one moment that you would agree.

Jane

By Anonymous Jane, at 10:03 AM  

Jane:

"I disagree Amy, the data are too small to come to this conclusion. May be this is why the neonatal death rate has not been given a high profile - with such small numbers is not possible to draw any conclusion."

Well, Jane, why did YOU cite it? Am I to believe that what you meant to say was:

Amy, homebirth can be safe for some women. Take a look at this BMJ study that shows data so sparse that no one can draw a conclusion about homebirth safety.

Let's be honest here, Jane. You DIDN'T KNOW that the death rate for homebirth in the Wiegers study was double that of hospital birth. You didn't know because you never read it.

This is precisely what I have been railing against.

By Blogger Amy Tuteur, MD, at 10:19 AM  

clever ID said...
Yes I am correct because Direct-Entry Midwives, licensed by their states regularly bill for insurance reimbursement for their clients as a "global" charge. Clients are regularly reimbursed at out of network rates.

I will make the change.

Then you should say in private practice, because NO ONE calls themself as a freestanding midwife.
I will make that change as well.


...what I am describing is a free-standing birth center. Believe that after working in "hospital birth centers" and "free-standing birth centers" I understand the difference....

I am not really sure about the disagreement? I am ALSO discussing freestanding birth centers, so it's not as if anyone will be confused.

However, it seems to me that you are trying to say "if it's in a hospital, it's a hospital birth." We both know that isn't true. The delivery you will get in a hospital maternity suite attended by an OB or a CNM is entirely different than the delivery you will get in a hospital birth center which is attached to a hospital.

Is it exactly the same as in a freestanding birth center? No, of course not, which is why I spearate them.

Cooties in the form of a hospital administration and legal department imposing the medical model of care.

Legal departments don't "impose a medical model of care." TRAINING "imposes" that model, which is based on the best known data about safety.


Anonymous said...

*They also have the capability to have and maintain somewhat more equipment than a home midwife can easily transport.*
And what equipment would that be???


I'm talking about capability...
1) Think of ALL the equipment which a midwife is qualified to use.
2) Think of the equipment which a midwife actually brings to a typical home birth.
3) Subtract #2 from #1. There's your list.

*no doctor is onsite*
__
Wrong again. There is often a OB hired by the birth center to provide care/consult.


"consult" is not the same as "onsite." I will change it to "rarely onsite" to cover the possibility.

*The reduction in transport time for centers close to a hospital makes them safer than a home birth, though a transport is still required to reach the hospital.*
__
I'd like to see your evidence for the statement that freestanding birth centers are more safe than homebirths. or for that matter, that freestanding birthcenters are less safe than attached ones.


Generally? It's simple:

SOME number of infants/moms get into trouble. There's no difference between sites.

(hopefully no disagreement there)

Of these, SOME must be transported to the hospital for care. Again, there's not a whole lot of difference between sites. You'll get about as many babies in trouble in a freestanding center than at home.

(hopefully no disagreement there either)

Of these, for SOME the transport time is VERY VERY VERY important. SOmetimes it doesn't matter--but when it matters, shorter is always better.

Which is to say: a short transport time to hospital care is either neutral or beneficial. A long transport time is either neutral or bad.

If you read my post more carefully, you'd have noticed I qualified my "safety" comment with "close to a hospital".

It is primarily the reduction in "waiting period to get expert help" which distinguishes between the sites. It is the exact same reason which makes an onsite delivery (elevator and gurney gets you to the NICU) safer than an offsite delivery (call ambulance, arrive, load, transport, unload, to ER, triage, to ICU).

I'm not sure if you're seriously debating this or if you're just a troll. Don't you know that ambulance response time has an enormous effect on mortality in a varitety of situations?

By Blogger sailorman, at 10:29 AM  

I find it puzzling Amy.

You seem to understand statistics well, but I see a blind spot when it comes to interpreting studies such as Weigers and the NBDT.

This is why have come to suspect that you have become emotionally drawn in to the debate, clouding your objectivity. If this is the case, I feel quite sure your opinion unlikely to ever change.

And this is the issue I wanted to draw out.

Well, who knows, your opinion may be validated in the future. Personally, I suspect the relative safety of home and hospital birth will always remain ambiguous, because there are so may different factors involved.

Wishing all the very best Amy.

Jane

By Anonymous jane, at 11:08 AM