Tuesday, June 06, 2006

Hostility

Why does hostility to doctors and hospitals seem to be integral to homebirth advocacy?

When doctors argue that homebirth isn't safe, they present scientific evidence and leave it at that. Usually, there is no attempt to denigrate midwives as people, to denigrate midwifery, to claim that midwifery is a plot to deprive people of a healthy baby, that midwives get personal satisfaction from pretending that homebirth is safe, etc. etc.

On the other hand, most major homebirth advocacy websites and publications are not content to merely advocate homebirth. They all include some effort to smear medicine and obstetricians. Typical messages or implications are :

Obstetrics is unscientific. It might look like it has been successful, but that's really because of public health initiatives. Doctors deliberately give unsafe drugs to women and they don't care. Obstetricians persecuted a valiant dissident (Semmelweis). Or, hospitals are so bad at providing medical care that they increase the risk of respiratory distress and death and cause decreased maternal feelings and postpartum depression. Or, midwives prevent neonatal mortality in Europe and doctors cause it in the US.

I have a theory about this:

First of all, most homebirth advocates recognize that the claim that homebirth is safer than hospital birth is, on its face, absurd. It is vitally important for homebirth advocates that others validate their claims that homebirth is safe, otherwise, they must confront the fact that they are taking a risk, albeit small, with their babies' lives. Engendering distrust of the medical profession is integral to homebirth advocacy, simply because no one is likely to believe advocates, otherwise.

Second, and less obvious, for many people, homebirth is an act of defiance. It is all about "speaking truth to power". It is an act of political and philosophical independence. It isn't simply that they want to give birth at home; it is that they are throwing off the yoke of patriarchial oppression, they are spitting in the face of the medical establishment and they are distinguishing themselves from the hordes of sheep-like women who don't know any better than to follow the advice of doctors.

If homebirth was really as safe and wonderful as advocates like to claim, there would be no need for any of this. However, deep down inside homebirth advocates believe (or recognize) that homebirth cannot stand on its own as simply a different place to give birth.

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68 Old Comments:

I'm thinking the horse is dead... You might just refer new visitors to your archives to join in on this sort of post rather than start it all over again.

By Anonymous clever ID, at 9:37 AM  

*Yawn*

This all started out as interesting but now its making me feel kinda numb.....

By Anonymous Anonymous, at 9:44 AM  

other than surgery- doctors are still guilty of not hand washing-- read the recent studies.

By Anonymous Anonymous, at 10:16 AM  

'homebirth is an act of defiance. It is all about "speaking truth to power". It is an act of political and philosophical independence'

I think it would be ok to claim the above for yourself if you'd had a home birth. But I have, and for me the choice didn't resemble anything at all what you propose here.

This sounds to me like exactly the propaganda you insist homebirthers use. A smear campaign.

By Anonymous Anonymous, at 11:56 AM  

I think you are missing a very key element. Doctors have successfully kept the practice of midwifery ILLEGAL in many states. I will admit to being hostile at times and that is exactly why. I have personally witnessed in the last year much hostility, lying, and unprofessionalism from doctors involved in opposing home birth in my midwestern state.

I frankly don't care what your opinions are except for the fact that they are having a very real impact on my ability to make decisions.

By Blogger Mama Liberty, at 12:12 PM  

I have never seen doctors provide "scientific evidence" when they testify against home birth and midwives. I have only seen doctors provide scary ANECDOTES (that are not supported by the evidence) and their OPINIONS. Not the same thing.

By contrast, I have seen midwifery advocates provide stacks of references, studies etc., but when the doctors swagger in (and yes, that's desparaging but true) and use scare tacticts to mostly male powers-that-be, and the docs are automatcially believed in spite of the fact that they don't really present valid EVIDENCE.

The whole history of doctors fighting against midwifery is full of smear campaigns. I don't understand how you could miss that. Phsyican's groups have systematically spread lies like "Midwives are unclean. Midwives are ignorant"

If all home birth moms are simply trying to "throw off the yokes of patriarchy" (to paraphrase from your post), then how do you explain that roughly half of the home birth community is Christian?

I believe you are sincere, but I don't think you are really looking at things objectively, understanding the big picture, or have the training to understand the validity of studies.

BTW -- it's true that Sammelweiss was thrown out of his country for being right about childbed fever, and it really is mostly public health improvments that have lowered mortality rates. Things like clean water, consistent food supplies, lack of polio and rickets, and the development of antibiotics have gone a lot further in lowering both infant and maternal mortality rates than the way childbirth is managed.

Perhaps you'd find the history of "active management of labor" interesting. Do you know where it began and why?

Keep in mind that, just because you went to medical school does not mean you understand how to read and understand studies. Apparently, from what you say in your posts, you don't.

Hve you tried reading Marsden Wagner? He's a phsyician and a perinatal epidemiologist. You might find his work enlightening.

By Anonymous Anonymous, at 1:11 PM  

"By contrast, I have seen midwifery advocates provide stacks of references, studies etc.,"

Well, that's nice, but since none of them show homebirth to be as safe as hospital birth, it isn't likely to help their cause.

"The whole history of doctors fighting against midwifery is full of smear campaigns. I don't understand how you could miss that. Phsyican's groups have systematically spread lies like "Midwives are unclean. Midwives are ignorant""

You're talking about things that happened more than 50 years ago. I challenge you to present any contemporary evidence that this is happening.

Finally, and most importantly, even if it were happening, two wrongs wouldn't make a right, so there is no justification for midwives behaving in a way that they clearly deplore.

By Blogger Amy Tuteur, MD, at 2:59 PM  

care to write your next blog on hosptial accidents like this one?

http://www.msnbc.msn.com/id/9818616

A routine epidural turns deadly.

This is ONE reason homebirthers want to avoid drugs and hospitals if they are not necessary to the health of mother or child. No drug, no procedure is without risk. Why introduce these risks if it is not medically necessary?

By Anonymous Anonymous, at 3:04 PM  

Oh, but wait.... the baby survived. And you've been the one to point out time and again that neonatal mortality is your only yardstick of home/hospital safety.

By Anonymous Anonymous, at 3:06 PM  

Mama Liberty:

"Doctors have successfully kept the practice of midwifery ILLEGAL in many states."

Not midwifery, but direct entry midwifery. That's because they don't believe it to be safe. What are they supposed to do when they believe that someone is practicing a form of medicine they may not be competent to practice?

Direct entry midwifery is just a small subset of midwifery. Nurse midwives are widely accepted everywhere and join physician practices and have hospital privileges. Nurse midwives represent a much more important economic challenge to doctors, yet they seem to have no problem with it.

Since doctors are accepting of and supportive of nurse midwifery, there is no other reason for them to oppose direct entry midwifery besides a question of competence.

By Blogger Amy Tuteur, MD, at 3:07 PM  

"care to write your next blog on hosptial accidents like this one?
... A routine epidural turns deadly."

I could just as easily write about the recent court case in Florida where two direct entry midwives were found guilty of practicing without a licence. A mother bled to death in front of them, while they assured the family that everything would be fine.

By Blogger Amy Tuteur, MD, at 3:11 PM  

I could just as easily write about the recent court case in Florida where two direct entry midwives were found guilty of practicing without a licence.

Um, these two "midwives" were the mother and sister-in-law of the husband. Neither are licensed or practicing midwives (meaning they agreed to do a homebirth for the woman who died, but they didn't have a midwifery practice), so they were sorely underqualified to attend a homebirth. They don't represent midwifery.

All of this woman's attendants at the hospital, though, were RNs or MDs. These people DO represent medical care - by their own admission, they acted according to the hospital standards.

Apples and oranges.

By Anonymous wasting my breath, at 3:49 PM  

"Um, these two "midwives" were the mother and sister-in-law of the husband. Neither are licensed or practicing midwives (meaning they agreed to do a homebirth for the woman who died, but they didn't have a midwifery practice), so they were sorely underqualified to attend a homebirth. They don't represent midwifery."

Yes, they are the husband's relatives, but they also described themselves as lay midwives. Several of their patients testified at their trial, some in favor, some against. They wore scrubs, that used monitoring and they carried medications. They represented themselves as midwives and people hired them as midwives.

The point is this: if you want to play horror story games, it can go both ways. That's why horror stories are a poor substitute for scientific research.

By Blogger Amy Tuteur, MD, at 4:10 PM  

"homebirth is an act of defiance. It is all about "speaking truth to power". It is an act of political and philosophical independence"

I don't even feel like arguing that with you, if you truly feel that way then it is your issue of "power" that you need to deal with, I am sorry that power is something that you are so concerned with.

I sounds to me like you may be just *a little bit* hostile.

I came here hoping to find a good debate, and I have instead found numbers being thrown around that I dispute, and no replies are made to it, perfectly innocent posts being deleted, and now this. Too much hostility and bitterness.

The more posts like this I see up, the more extreme you sound, and I find it hard to take extremists on either side seriously.

By Anonymous RN midwifery student, at 4:35 PM  

Yes, they are the husband's relatives, but they also described themselves as lay midwives.

The problem is that they weren't midwives, they had no training, and no one here is supporting untrained midwives trying to do home deliveries.

No one has brought up someone practicing obstetrics without a license as a reason to disdain doctors, because that argument doesn't make sense. But you're trying to accuse all midwives of being incompetent because two untrained women attended a home birth and the mother died.

I stand by my original statement. Let's talk about the legitimate representatives and not the illegal, nutball fringe. We all agree that no untrained, unlicensed person should be representing themselves as a professional.

By Anonymous wasting my breath, at 4:52 PM  

"Not midwifery, but direct entry midwifery."

Um excuse me Amy, are you a lawyer now in addition to your many other areas of expertise? You are familiar with the midwifery laws in every state?

In the state of Nebraska it is ILLEGAL for certified nurse midwives to attend home births. It only became legal for them to attend births in hospitals in 1983. And as far as those in hospital based practice, they face many restrictions in their practice.

Amy, on June 2nd, 2006 an obstetrician from the Nebraska Hospital Association held up a bumper sticker that said "Home Delivery. Only for Pizza" (I might be a bit off on the wording). This is just one of many unprofessional and unjust ways in which physicians in this state have been acting in opposing any efforts from consumers in trying to legally gain access to midwives. None of the physicians have even given the courtesy of reading and reviewing the EVIDENCE the consumer groups have presented. I am not complaining because they didn't agree. I'm complaining because they don't speak on the evidence. They haven't even tried to pick apart any studies, like you have done. They simply waltz in and give their word that home birth would be a catastrophe for women in this state and then its end of story. One stupid senator, a former obstetrician, even asked how homebirth could be safe when there are no warmers at home. I do pray you think that is a stupid question. The physicians in our state oppose Certified Nurse Midwives and Certified Professional Midwives.

Pertaining to direct entry midwifery, do you believe that I as a mother should not have the legal right to choose a CPM to attend me during birth?

By Blogger Mama Liberty, at 4:57 PM  

Mama Liberty:

"on June 2nd, 2006 an obstetrician from the Nebraska Hospital Association held up a bumper sticker that said "Home Delivery. Only for Pizza."

That hardly constitutes an official campaign by obstetricians against midwives.

"In the state of Nebraska it is ILLEGAL for certified nurse midwives to attend home births."

Yes, because the state of Nebraska does not think that homebirths are safe. What else is it supposed to do if that's what the legislators truly believe? It is not a campaign to ban midwives.

"do you believe that I as a mother should not have the legal right to choose a CPM to attend me during birth?"

You have the legal right to have anyone you want at your birth. However, in certain states, a CPM does NOT have the right to hold herself out as a medical professional capable of safely managing birth at home. Those are two entirely different things. That's because many people feel that a CPM is not adequately trained to safely manage birth.

It is entirely an issue of competence and safety.

By Blogger Amy Tuteur, MD, at 5:33 PM  

"That hardly constitutes an official campaign by obstetricians against midwives."

Please don't play dumb. We both know that was just one example.

"Yes, because the state of Nebraska does not think that homebirths are safe. What else is it supposed to do if that's what the legislators truly believe? It is not a campaign to ban midwives."

But our legislators arrive at that opinion based largely on the recommendations of physicians in
the health department and from physician testimony given in committee. Yes, there is an orchestrated effort here, Amy. There is a serious conflict of interest going on. The medical lobby is very powerful here and that is unfair to those of us who don't have the resources to fight it. I'm just a mother who wants to have her baby and decide who is there seeing my most intimate body parts and sharing one of my most intimate experiences. It is absolutely disgusting that any legislator or any doctor thinks they have the right to make those decisions. The medical community has the right to bring their case to the public, but they have no right to take the decision making power away from women.

"You have the legal right to have anyone you want at your birth."

Oh please, cut the crap. If midwives, both nurse midwives and direct entry midwives, are illegal, that kinda makes my "legal right" a moot point, doesn't it? The fact of the matter is that I can't have a LEGAL midwife attend my homebirth. That in and of itself creates safety problems.

By Blogger Mama Liberty, at 6:54 PM  

Mama Liberty:

"But our legislators arrive at that opinion based largely on the recommendations of physicians in
the health department and from physician testimony given in committee."

Right, and physicians, myself included, think that homebirth is NOT safe. We really, honestly and truly think that it is not safe. There is no ulterior motive, we don't need more business, most of us work with CNMs and yet most of us do not think that DEMs are adequately trained.

All of medicine is regulated. You don't get to call yourself a doctor or a nurse or a CNM unless you fulfill state regulations. I can't open a hospital in my house. I can't do surgery in my house. There are all sorts of things that I cannot do, no matter who else might think that I am capable of it.

Personally, I lean libertarian on these issues. If a woman wants a DEM or an uncertified midwife, it's fine with me if she has one. She's the one who will make the ultimate sacrifice if she guesses wrong. However, that doesn't mean that I think homebirth is safe, only that I think people have the right to do unsafe things.

By Blogger Amy Tuteur, MD, at 8:12 PM  

Amy, I don't think you are understanding me. Either that or you are choosing to deflect the issue. The medical lobby opposes allowing certified nurse midwives or any kind of certified direct entry midwives to practice at home in this state. Its not that they are testifying and saying that they don't believe homebirth is safe. Their testimony is that the state shouldn't allow midwives to practice. That effectively takes the decision away from me. This is why I am hostile. This is why I'm even taking part in your "debate". I suppose it is a way for me to vent.

By Blogger Mama Liberty, at 10:33 PM  

Mama Liberty:

"Its not that they are testifying and saying that they don't believe homebirth is safe."

Can you direct me to some of the testimony so I can see what happened?

By Blogger Amy Tuteur, MD, at 10:35 PM  

because they were religious birth attendants -- they held hands in a circle and prayed-- they were charged with practicing midwifery without a license-- they probably would have not been charged if they did not have a tank of oxygen on hand and call themselves midwives-- they also defended themselves because the felt that a lawyer could not have represented their religion/religious beliefs accurately.
both stories are tragic and chilling

By Anonymous Anonymous, at 11:59 PM  

amy wrote:::: Nurse midwives are widely accepted everywhere and join physician practices and have hospital privileges. Nurse midwives represent a much more important economic challenge to doctors, yet they seem to have no problem with it
------------
wrong again amy-- docs are fighting CNMs same ol same ol-- and usually on the financial end of things, limit scope of practice where they can be total independent practitioners -- not allow hospital admitting privileges , would you like to read the list of states where the AMA has twisted arms in office -- I have mentioned before last minute things like removing CNM from a limit to malpractice suits filed for caring for last minute walk in patients.
they are an ever diminishing presence in the state I live in- physicians who belong to "national group practices" have made national hiring and no collaboration policies . On the front of receiving medicaid funds- the AMA has blocked the CNM lobby to get direct reimbursement for care they provide- in a state where CNMs are independent - and at the same time putting forth and supporting a bill for untrained surgery tecs to receive direct payment -without needing any signatures, or malpractice coverage requirements for other directly paid medicaid workers. I could send you links and copies of the medical opposition to CNMs in this country-- take a good look at Virginia, Missouri, or even Florida for that matter---you may be trying to fish -- but I personally love CNMs and have worked elbow to elbow with them.

By Anonymous Anonymous, at 12:15 AM  

Amy many states have recordings and access to testimony given to legislatures , so you can actually hear it from them in their own words-- the lobby hired and acting on your behalf- if they are not representing you accurately you should do something about it.
--- also you should read your state political bulletins from ACOG-- or the AMA -

By Anonymous Anonymous, at 12:19 AM  

"they are an ever diminishing presence in the state I live in- physicians who belong to "national group practices" have made national hiring and no collaboration policies."

Which state is that?

By Blogger Amy Tuteur, MD, at 7:08 AM  

"the lobby hired and acting on your behalf"

First of all, I don't belong to either the AMA or ACOG. The only doctors' group I have ever joined is Physicians for Universal Healthcare.

Second, the majority of physicians do not belong to the AMA. I have heard that only one third of physicians belong; the rest are disgusted by the policies of the AMA.

Third, you vastly overestimate the power of physician lobbying groups. There are many issues of great importance to physicians, like tort reform, insurance company power, malpractice pricing, etc. They have had no success on these fronts, despite the fact that they have put a great deal of money and effort into them. Midwives may be the last group in the US that sees the AMA as powerful.

Remember, the average layperson (like a legislator, for example) is not likely to believe that homebirth is as safe as hospital birth. That's the whole reason for the "marketing" campaign that denigrates physicians. They aren't likely to see the need for another group of health care providers who have significantly less training and want to do things that the average person thinks are irresponsible and absurd (homebirth).

I suspect that the problem for DEMS is not physician lobbying, but rather the public perceptions of DEMs. Remeber, approximately 99% of American women have no interest in the service that DEMs wish to provide.

By Blogger Amy Tuteur, MD, at 7:22 AM  

'They aren't likely to see the need for another group of health care providers who have significantly less training and want to do things that the average person thinks are irresponsible and absurd (homebirth).'


Exactly why the 'marketing' is needed. The average person knows bupkis about birth. (I've read arguements that the average person doesn't 'get' how a baby is even made.... I'm not sure I'd go that far)

homebirth advocates and/or midwives need to get together and create an effective marketing campaign. (I don't see the few little websites you refer to as a real campaign.) If women knew something about birth other than what they learned in their hospital-hosted birthing class, they'd be able to make an informed decision for their familys.

By Anonymous Anonymous, at 10:28 AM  

"Mama Liberty said...
...Its not that they are testifying and saying that they don't believe homebirth is safe. Their testimony is that the state shouldn't allow midwives to practice."


This is, actually, the same thing. If you don't believe something is safe, you are logically going to advise against granting state authority for people to do it. Why is this so surprising?

It may make more sense as a general rule, and make you less annoyed, if you substitute any other procedure for home birth. As is: "doctors don't believe that anyone other than an MD can perform amputations at home. Therefore they testify that the state should not allow direct entry surgeons."


That effectively takes the decision away from me.

Well, not really. I mean, you can still have an unattended home birth. You can try to convince an OB to attend your home birth. You can give birth in another state. You can have a birth attended by non-midwives who will follow your directions.

You can even hire an "illegal" midwife, and so long as things go well (which you seem assured they will) the state is pretty unlikely to devote significant resources to bothering her.

This doesn't control your actions, because the law says nothing about YOU. YOU can do whatever you want. The law merely governs availability of something the state thinks is dangerous ("DEMs") just like law restrict lots of things the state thinks are dangerous (hypodermic needles, lawyers who haven't passed the bar, wannabe home engineers, etc).

By Blogger sailorman, at 11:24 AM  

This comment has been removed by a blog administrator.

By Blogger Mama Liberty, at 8:56 AM  

"Can you direct me to some of the testimony so I can see what happened?"

If you really want to read the testimony, call the Clerk of the Legislature and request a copy of the testimony regarding the midwifery bills brought before committee in 2003 and 2005. In 2003 there was a CNM bill. In 2005 there was a CNM and a CPM bill. I don't have bill numbers for you because my office is packed up. The more recent testimony from the health department is not available yet.

I'm not sure why you want testimony, though. The groups and individuals in the "oppose" column are the hospital association and physicians (maybe all obstetricians, but I don't remember). The hospital association actively monitors legislation and sends representatives to oppose legislation that conflicts with their interests. You don't have to read the testimony to understand that they oppose allowing midwives to practice, you merely have to see the names in the oppose column.

By Blogger Mama Liberty, at 9:02 AM  

This comment has been removed by a blog administrator.

By Blogger Mama Liberty, at 9:11 AM  

"You can even hire an "illegal" midwife, and so long as things go well (which you seem assured they will) the state is pretty unlikely to devote significant resources to bothering her."

You have shown a remarkable ability to understand the numbers clearly and now you are demonstrating your remarkable powers of clairvoyance. For your information, the state has been devoting resources to investigations, "cease and desist orders", and threatening court action. There was a period of time when there were no homebirth midwives available in our state.

"Well, not really. I mean, you can still have an unattended home birth. You can try to convince an OB to attend your home birth. You can give birth in another state. You can have a birth attended by non-midwives who will follow your directions."

Oh c'mon. I don't want any of those options. I want to give birth in my own home with a midwife of my choosing, preferably a CPM with many years of experience. Your argument is absurd. I thought you were "Mr. Logic". You and Amy are lying when you say you believe it should be a woman's choice. A legitimate choice is not restricted by law.

By Blogger Mama Liberty, at 9:13 AM  

"ot midwifery, but direct entry midwifery. That's because they don't believe it to be safe. "

I guess the American Public Health Association was wrong in suggesting increased access to state-regulated direct-entry midwives.

By Anonymous Anonymous, at 9:49 AM  

Mama Liberty said...

Oh c'mon. I don't want any of those options. I want to give birth in my own home with a midwife of my choosing, preferably a CPM with many years of experience. Your argument is absurd.

No, it's simply based on some years of law training.

The law doesn't prevent you from WANTING things.

The law doesn't even prevent you from DOING many things.

What the law does is control "dangerous tools", and some of those tools are PEOPLE

You can't sell spray paint to a 10 year old. You can't sell a handgun to a felong or an infant.

You can't hold yourself out as someone qualified to assess whether a bridge is safe without training. Even if you WANT to base all your structural decisions on a fen shui practitioner, you CAN'T.

You can't practice law without going to law school. Do paralegals know a lot? Sure! Do you really need 3+ years of training to do minor legal issues? probably not. But to protect the general public from problems, we need to have a general rule.

This should help you see why the argument is faulty:
If you think the state shouldn't be able to regulate DEMs, then ANYONE, with ANY training, should be able to call themself a DEM. If you need private certification (as opposed to a state "OK" then I can start my own DEM school. So can you.

I thought you were "Mr. Logic". You and Amy are lying when you say you believe it should be a woman's choice.

I'm not lying, I just think you are failing to understand me.

A legitimate choice is not restricted by law.
That's your problem right there.

Laws are ALWAYS general. They will ALWAYS screw some people over and will ALWAYS make some recommendations which are not perfect for everyone, in oreder to attain their ultimate goal. Laws are a lot like public health agencies in that respect.

I am sorry you happen to want someone to act in a manner which has been deemed unsafe by your state. It's entirely possible that you could find someone who was a competent DEM. It's probable, given the stats, that you'd have a safe birth.

But this has no bearing on the GENERAL question of "are DEMs safe?"

By Blogger sailorman, at 9:54 AM  

"Nurse midwives represent a much more important economic challenge to doctors, yet they seem to have no problem with it."

That is just plain wrong.

Doctors have been closing down nurse-midwifery units all over the country and women have protested it vehemently. Actually, it's a global problem but I'll only address the U.S.

Cities in which this has happened recenty include: Chicago (two cases, one eventually reopened but drastically changed), one in Boston, and one in NYC (Bronx, if memory serves me but not totally sure which part of NYC). There are other, smaller examples, which don't receive nearly as much attention in the press, but they do occur with regularity.

Why? The reason cited is always "cost". Yes, it's true that midwives produce fewer billable procedures, but that is a poor reason upon which to base policy.

By Anonymous Anonymous, at 9:56 AM  

"I could just as easily write about the recent court case in Florida where two direct entry midwives were found guilty of practicing without a licence. "

They were church members (actually I thin a christian type cult) who only pray and not trained at all as midwives. Florida actually has licensed direct-entry midwivs who are well-trained and have excellent documented outcomes. So, please don't call those women "midwives" because they are not.

Please be accurate if you're going to post.

By Anonymous Anonymous, at 9:58 AM  

"That's because many people feel that a CPM is not adequately trained to safely manage birth."

They would be in disagreement with the American Public Health Association. Interesting.

By Anonymous Anonymous, at 10:03 AM  

" would you like to read the list of states where the AMA has twisted arms in office"{

i think you mean the state medical groups. the ama does not tend to lobby on the state level. there are state medical groups for that.

By Anonymous Anonymous, at 10:05 AM  

>>If you think the state shouldn't be able to regulate DEMs, then ANYONE, with ANY training, should be able to call themself a DEM. If you need private certification (as opposed to a state "OK" then I can start my own DEM school. So can you.<<

I agree with you. That's why I think states should only regulate midwives who have shown competency and are nationally certified (CPM). Fortunately, many DEM schools are recognized by the U.S. Dept. of Education, and the CPM process is rigorous in assuring competency, so we have a way of separating the wheat from the chaff.

By Anonymous Anonymous, at 10:10 AM  

>>Since doctors are accepting of and supportive of nurse midwifery, there is no other reason for them to oppose direct entry midwifery besides a question of competence.<<

That is specious logic. There are many reaons why. And I'll tell what I think the reason is. I think it is ignornance of spontaneous birth. Doctors are trained in and almost always only see birth resulting from a labor that was actively managed.

And when discussing the possibility of licensing DEMs, I find doctors discuss anecdotes but aren't really familiar with the data (except maybe Pang which stated outright their data was not good enough for accurate conclusions).

Doctors tend to say things like "things happen fast in birth, and you need doctors present to react to that," followed by a list of complications common in the hospital. That is ironic b/c doctors don't tend to be present during the labor (yes, I know, in theory they are "overseeing" the whole hospital process but still...)

It's sad because doctors are unaware, it seems to me, that DEMs really do help prevent a lot of the things that seem to occur quickly in the hosptial, and that a lot of the complications in the average U.S. hospital birth are a direct result of active management of labor, which is not done at home.

Instead, at home, the birth is monitored but not managed. Sometimes slight measures are taken to improve some situations, but many things are either prevented (e.g. no epidural means no precipitious bp drop in mom; good, intense nutritional counselling thorughout pregnancy lowers the risk of various problems like low birthweight, preeclampsia, etc.; moms are not numbed and much better able to move about into better positions; no purple faced pushing with its myriad dangers; no pitocin for augmenting -- or worse -- cyotece, so no hypstrimulated uterus and baby not so likely to be stressed out from abnormally strong contrations; etc.etc.etc.)

I think this fear that most doctors try to impart about home birth stems from most phsysicians being ignorant about >spontaneous, (relatively) undisturbed< birth.

What I see DEMs in the U.S. emulating is the European model which strives to allow the automatic process of childbirth unfold as it is meant to be, rather than doing "active management" of labor. Big difference.

By Anonymous Anonymous, at 3:41 PM  

"That is specious logic. There are many reaons why. And I'll tell what I think the reason is. I think it is ignornance of spontaneous birth. Doctors are trained in and almost always only see birth resulting from a labor that was actively managed."

That's not true. How many deliveries have you ever seen done by an obstetrician?

"It's sad because doctors are unaware, it seems to me, that DEMs really do help prevent a lot of the things that seem to occur quickly in the hosptial, and that a lot of the complications in the average U.S. hospital birth are a direct result of active management of labor, which is not done at home."

Then why do doctors have better neonatal mortality rates for low risk women? By the way, active management of labor refers to a specific set of guidelines that are followed for every labor. It was developed at a hospital in Dublin and is used in Ireland, but it is rarely used here.

By Blogger Amy Tuteur, MD, at 9:46 PM  

"Doctors have been closing down nurse-midwifery units all over the country and women have protested it vehemently."

No, that is NOT true. The midwives themselves have been closing those practices because they cannot make enough money to meet the expenses of running a practice. In many areas of the country, a private midwifery practice is not economically viable.

Insurance companies may not want to reimburse for private midwifery costs; malpractice carriers feel that it is not profitable to insure private midwives because the risks are too great and patients do not value the services enough to pay out of pocket the fees that are needed to run a business that can meet its expenses.

By Blogger Amy Tuteur, MD, at 9:53 PM  

The midwives themselves have been closing those practices because they cannot make enough money to meet the expenses of running a practice. In many areas of the country, a private midwifery practice is not economically viable.

Putting on my Amy hat to ask, "No that's not true. How many midwives have you spoken to determine their practices have closed due to the economics of the practice and NOT politics and NOT due to obstetrics or hospital administration? One? Two? None?"

By Anonymous clever ID, at 12:06 AM  

"How many midwives have you spoken to determine their practices have closed due to the economics of the practice and NOT politics and NOT due to obstetrics or hospital administration? One? Two? None?""

By the way, I notice that no homebirth advocate has explained how the "know" that obstetricians have never seen a "normal" birth.

I have read articles and the closing of midwifery centers. I read that they were closing because they were not able to support themselves financially. Perhaps you have read other articles that support your contention. Let me know, so I can check them out.

I will point out that businesses close every day because they are not economically viable. They rarely, if ever, close because of giant national conspiracies to put them out of business.

By Blogger Amy Tuteur, MD, at 6:40 AM  

The comments in this thread really support my original assertion, that hostility toward doctors is integral to homebirth advocacy.

In contrast, obstetrics can stand on the data and doesn't have to blame and denigrate others(doctors, "uneducated" patients, physician organizations, etc. etc.) in order to convince people to ignore the actual safety data.

By Blogger Amy Tuteur, MD, at 6:44 AM  

"I'm not lying, I just think you are failing to understand me...
-A legitimate choice is not restricted by law.-
That's your problem right there."

No Sailorman, you are failing to understand me. If you believe that a woman has a right to make her own decisions about birth, then you should support her right to the legal attendant of her choosing. In my state it is illegal for CNMs to attend home birth and the attorney general's opinion is that it is illegal for DEMs to attend home birth. The DEM opinion is somewhat questionable because though cease and desist orders have been issued by the state, they haven't been tested in the courts. But the outcome of the state's action is that midwives are too scared to practice in our state, therefore women like me have few, if any, choices.

On another legal note, in the 1980s CNMs were able to prove antitrust allegations and win some practice rights. The ACNM has again hired an antitrust attorney and will be pursuing action. You may eventually see CPMs able to successfully pursue antitrust action in the future as well.

To a certain extent, I do agree with you. The state cannot take away my natural rights. I was able to have a home birth with an attendant I trusted, despite the laws.

However, given your proclaimed "pro-choice" stance, logic would follow that you should have no qualms with the South Dakota abortion ban, because after all, women can still have abortions with illegal providers or they can go out of state. And no matter that there is undue burden on impoverished women who cannot afford to travel. I am assuming that is your position. Am I correct?

By Blogger Mama Liberty, at 12:24 PM  

"The comments in this thread really support my original assertion, that hostility toward doctors is integral to homebirth advocacy.

In contrast, obstetrics can stand on the data and doesn't have to blame and denigrate others(doctors, "uneducated" patients, physician organizations, etc. etc.) in order to convince people to ignore the actual safety data."

No need to denigrate on the part of the home birth community. We merely want our right to choose a product different from the one that you are offering. Speaking on my own behalf, as soon as physicians, obstetricians in particular, decide that they have no right to dictate who is allowed to touch my vagina during birth, then all of my hostility will disappear.

By Blogger Mama Liberty, at 12:28 PM  

By the way, I notice that no homebirth advocate has explained how the "know" that obstetricians have never seen a "normal" birth.

Ah, but they see it every day in the normal they have created. Our ideas of normal are very different.

By Anonymous clever ID, at 4:37 PM  

clever id:

"Ah, but they see it every day in the normal they have created. Our ideas of normal are very different."

I have no idea what you mean by that. Furthermore, I don't understand how it is a response to my question: how do homebirth advocates have enough experience with hospital births to declare that obstetricians don't know what a "natural" birth is?

By Blogger Amy Tuteur, MD, at 6:56 PM  

I have no idea what you mean by that.

I am sure you can ponder that a while and figure out what I mean. It wasn't insulting in the least.

Furthermore, I don't understand how it is a response to my question: how do homebirth advocates have enough experience with hospital births to declare that obstetricians don't know what a "natural" birth is?

I don't know how "home birth advocates", the whole lump of 'em, get their experience and feel free to make statements like that. Maybe they have been to a lot of hospital births? I suppose given the large amount of L&D/PP nurses, physicians (FPs/OBs), neonatologists, paramedic/firefighters in my area having home births they must think it's not very normal there either. Shrug.

I have been to enough normal births at home and birth centers AND the hospital to know that what happens in the hospital doesn't "appear" to be normal birth. I'm sure if I gave up the OOH practice and went into hospital practice after a while the routine there would become "normal" to me also.

By Anonymous clever ID, at 7:53 PM  

"I'm sure if I gave up the OOH practice and went into hospital practice after a while the routine there would become "normal" to me also."

Please do not misconstue what I said. I am not implying that there is a different "normal" for you and for me. I mean that plenty of doctors do plenty of deliveries that involve no interventions of any kind (except monitoring, of course). Many homebirth advocates claim that doctors have never seen an unmedicated birth or a birth without interventions. That simply is not true.

By Blogger Amy Tuteur, MD, at 8:39 PM  

I'll share my experiences. I worked for 8 years as an L&D nurse. I saw *thousands* of deliveries by OBs. Some OBs are wonderful providers, and great friends of mine. Some are awful, and practice horrible medicine. The list of BAD things I've seen OBs do in hospital is quite long. I've seen an anesthesiologist slap a woman. I witnessed a doctor tell a woman, who was pushing her baby out, that she's the fattest thing he's seen in his life and she's disgusting to him. I've seen an African woman tell an OB that she'd rather die than be shaved, and the OB refused to allow her not to be shaved (for a c/section). The woman was on the floor, prostate, begging her to please please not shave her, kill her rather than shave her, please KILL ME INSTEAD, she yelled, but the OB refused. It was shameful, one of the worst things I've ever witnessed in my life. She 'required' general anesthesia as she would not hold still to be shaved, and was shaved after asleep (simple assualt, in my book). I've seen four residents, one after the next, put their fingers inside a woman as she cried and said no. I have heard OBs denigrade women again and again. I learned of the custom of OB residents "practicing" pelvic exams on unconscious women s/p surgery, without consent, and then witnessed it to my horror (http://www.washingtonpost.
com/ac2/wp-dyn?
pagename=article&node=&cont
entId=A36990-
2003May9¬Found=true).

I have spoken with hundreds of OBs and OB residents who freely admit that they have never seen a natural birth, nevermind a birth out of the bed or lithotomy position. I have seen OBs do thousands of things for their convenience rather than in the best interest of women or babies (and then joke about it afterward). Tell a woman she "needs" a c/section because the baby is just too big and then tell me "or because I have to be out of here by 8, ha ha, she wouldn't have delivered for hours anyway". I can't express how many times (hundreds of thousands?) I've seen OBs put down nurses, or treat them rudely.

So Amy, some of us "know" from real, depressing, maddening experience. I absolutely do not argue that all OBs are like this. From your clinical responses I suspect you were a progressive doc in a progressive facility. But you are kidding yourself to think all docs are progressive. Go watch things in Armpit, New Mexico, or Nowhere, Wisconson, types of places where one OB or one OB group serves the entire population, and make up all the rules (against evidence) and have 50% c/section rates and 100% episiotomy rates and tell me this is unfounded criticism then.

I don't think OBs should be perfect, I understand mistakes and human weaknesses too. Not one of us is above them. But obstetrics is a real power complex for many, many doctors. At the same time, it's one of the most vulnerable times in life for a woman. The two things combined are a potent, troubling mix -- and so you get stories like mine, like other voices here, and real anger.

When I left nursing for midwifery, I harbored a lot of anger towards OBs... anger that really concerned me, I wasn't sure I could get over it, worried about how I could have positive collaborative relationships in the future. I talked about it a lot with friends - nurses, other docs, OBs, midwives - and enjoyed time away, and I worked through it. I actually FORGOT about how angry I used to be until you reminded me. The docs I work with now are great (excepting one).

Please try to understand, Amy, that it's not a knee-jerk reaction, or a product of some alternative choice marketing - that anger is a product of real experience. I agree it doesn't help any of us, get us anywhere productive at all. I'd argue that your own hostility towards some midwives is equal to that of what you're complaining about. I know you have your reasons, too - I'm sure you've been on the receiving end of some pretty ugly midwife transfers, and I know that made you feel helpless, powerless, and angry - and I don't blame you. But you're acting as if hostility is "our problem", instead of a symptom of a problem in a lot of modern OB care, and something you're likewise guilty of yourself. Do you deny that? What makes your hostility more okay than the 'other sides'?

By Anonymous maribeth, CNM, at 8:49 PM  

(except monitoring, of course)

Because of course, laboring while tethered to a three foot leash is so "natural" and "non-interventive". And not even evidence-based, at that. Thanks for proving the point explicitly.

By Anonymous maribeth, CNM, at 8:52 PM  

Maribeth:

"But you're acting as if hostility is "our problem""

It is your problem because it makes you less credible.

If you want to have a homebirth, fine. If you want to tell your friends to have a homebirth, fine. If you want to tell people that homebirth is "as safe or safer than hospital birth", then you are not telling the truth.

However, rather that engaging in a scientific debate, most homebirth advocates try to deflect attention away from the safety issue and vent their anger. Once you start throwing around accusations in place of scientific evidence, the vast majority of people are going to conclude that your decisions are based on your anger and not on science.

Let's face it. You guys have a serious credibility problem. Over 99% of the women in this country aren't buying what you're selling.

I suspect that the hostility is not as much a part of homebirth advocacy in places like Australia and New Zealand. At least I can't find much of it on the websites I have read.

The decision to have a homebirth seems much more matter of fact. You have a homebirth because you want to give birth at home, not because doctors are evil, or obstetricians are "raping" women, etc. etc. I wonder if that is why women in those countries are so much more accepting of homebirth.

Anyone here from Australia or New Zealand who can comment on that?

By Blogger Amy Tuteur, MD, at 9:23 PM  

Please do not misconstue what I said.

I am not. I get what you're saying. We simply live in two different worlds. You cannot possibly know what it is like specifically in the hospitals of my area, as I can't know what it is like in yours. We can only speak in generalizations. The biggest difference between us, other than the disciplines in which we practice, is that I attend birth out of the hospital and you don't. This is the area in which you can only address the "experience" from studies, reviews, summaries, and opinion.

By Anonymous clever ID, at 10:56 PM  

It is your problem because it makes you less credible

See, I would argue the same. I think it causes bias in you that influences your interpretation of data. I don't think that data interpretation is black and white, or NO studies would be accepted for publication that were controversial. I think you have held the same point of view - that homebirth is unsafe - for years and years, regardless of new studies, and I suspect you look to data only to CONFIRM that. If you had 100% confidence in your data interpretations, you would have responded to criticisms of it (most notably, on congenital anomalies and the mortality ratios exclusive of twins and breeches) rather than ignoring posts to that end. It's no surprise to you, but you have not convinced me that homebirth of healthy low-risk women, attended by a professional midwife, is unsafe. My old feelings toward OBs are not relevant to that. Do I still think a lot of modern OB care is bad, yes, but I think you (proporting a 10% c/section rate) probably agree with that more than you'll admit.

By Anonymous maribeth, CNM, at 11:21 PM  

I had 2 hospital births- became a childbirth educator, worked on birthing room committees and attended births of women in the hospital- I have friends and assistants who work in the hospital- everydayeveryday. And if I transfer someone to the hospital I see what still goes on. See films of previous births of clients-- My children won't even let me watch the birth shows on TV- because most of the time I am ranting at the show...

how do you know what goes on in a home birth?

By Anonymous Anonymous, at 3:37 AM  

"how do you know what goes on in a home birth?"

When did I say I knew anything besides what I read about it, in the scientific literature or on homebirth advocacy websites?

Furthermore, as we tell our children: two wrongs don't make a right.

By Blogger Amy Tuteur, MD, at 9:01 AM  

Amy said: When did I say I knew anything besides what I read about it, in the scientific literature or on homebirth advocacy websites?


You accuse others of not knowing what goes on in hospitals, and when they provide you with their history, and show that they DO know what goes on in hospitals, you ignore them. Then when they ask how you know what goes on OOH, you say, 'but I never said I knew what goes on OOH'. Yet you continue insist the midwifery model of care is exactly the same as the medical model. And you insist that midwives don’t monitor FHT properly. (Under Medical/midwifery model comments) And you insist that midwifery care is less safe than hosptial care. When called on a point, you refuse to answer... just move on to write another baiting blog. On point after point you have made wild statements that you can’t back up. Furthermore, you delete comments that you don’t like.

If you don't know what goes on Out of Hosptial, you have no way to form an opinion as to it's safety.

By Anonymous Anonymous, at 3:50 PM  

"you insist that midwifery care is less safe than hosptial care"

No, what I insist upon is being honest about the SCIENTIFIC RESEARCH. Homebirth advocacy websites all say that scientific research shows homebirth to be as safe as hospital birth and it does not. Every scientific study of hospital birth has shown an excess of preventable neonatal deaths in the homebirth group.

By the way, I have not deleted any posts. Blogger had serious server problems for 48 hours and lost many posts, mine included.

By Blogger Amy Tuteur, MD, at 4:07 PM  

"That is specious logic. There are many reaons why. And I'll tell what I think the reason is. I think it is ignornance of spontaneous birth. Doctors are trained in and almost always only see birth resulting from a labor that was actively managed."

Hmm. Well, an interesting subset of doctors to look at is "doctors who work with CNMs." Those doctors see plenty of births under the care of a CNM. Thus, they havce considerable experience with non-managed labor.

I haven't done a study or read data on this. However, my wife's now had 2 natural childbirths in the care of a CNM who was associated with an OB. Both those OBs (and the CNMs, for that matter) were strongly against home birth as unsafe.

I think this whole "they'd change their mind if only they could see a home birth" is a load of bunk. It's about as useful and accurate as saying "you'd all be opponents of home birth if you worked in a neonatology unit for a month."

Mama Liberty said...
No Sailorman, you are failing to understand me. If you believe that a woman has a right to make her own decisions about birth, then you should support her right to the legal attendant of her choosing.

At least you're not accusing me of lying any more...

Anyway: No, not really. How about this: Instead of talking about "home birth" let's start with a GENERAL rule and then see how it applies.

I think people have the right to WANT anything. I think they have the right to do about anything to their OWN bodies.

However, I also think that the state has a right (and an obligation) to "watch out for" its citizens. That means that the state sometimes must restrict a process, for fear that it will be overused or exploited.

So even though I fully support the right of any competent adult to suicide, for example, I don't think the state needs to allow free sale of lethal injection machines, or "suicide packs" of pills.

I believe that medical care is a VERY appropriate area for the state to regulate. It's highly dangerous when misused. And a typical consumer is unable on their own to distinguish between safe and dangerous practitioners.

So, before you go talking about home birth again, let's talk general: Don't you think the state should regulate doctors? Dentists?

And if so, why should there be a "DEM exception"?

In my state it is illegal for CNMs to attend home birth and the attorney general's opinion is that it is illegal for DEMs to attend home birth. The DEM opinion is somewhat questionable because though cease and desist orders have been issued by the state, they haven't been tested in the courts. But the outcome of the state's action is that midwives are too scared to practice in our state, therefore women like me have few, if any, choices.
Well if a CNM isn't OK, a DEM sure as heck isn't going to be OK, no surprise there.

This is surely a safety concern for the state. Nobody wants the death rate to climb. You could (fr example) lobby for greater DEM certification and training, which might convince your legislature it was safe.

However, given your proclaimed "pro-choice" stance, logic would follow that you should have no qualms with the South Dakota abortion ban, because after all, women can still have abortions with illegal providers or they can go out of state.

My opposition to the SD abortion ban is primarily legal, as it's clearly violative of SC precedent.

Additionally, UNLIKE a ban on DEM-supervised home birth, banning abortion makes no sense: abortion is SAFER than delivering a baby, and the "alternative" to an abortion (a 'home abortion') is much MORE dangerous than the legal kind. For DEMs, it's backwards: a hospital birth is safe and freely available.

By Blogger sailorman, at 10:03 AM  

home abortions are legal dumb dumb... look at the 2 step pill method!

could be they told you what they tell everyone so they don't have to be asked to attend a home birth.. could be that they say it because it is what the job insists that they recommend. I know of miwdwives who have done homebirth for years and then get a different job doing work with an OB and not do homebirths any more- and candidly they say- it is because they want the better money- or insurance or what ever and they dissuade homebirth-- because it is their job now... "if the doc found out that I still support homebirth I wouldn't have a job" so as a consumer who knows if you got the full story- the point being that there is and has been a group of people who have home births- it is safer if they have trained attendents than non-trained/untrained some smaller portion of people will still opt for untrained or unattended home births- to not recognize it for what it is- safer for mothers than hospital births and in low risk populations as safe as hospital births for babies--there really is not leg to stand on.--
( breeches and twins are not low risk)

By Anonymous Anonymous, at 2:02 PM  

"breeches and twins are not low risk"

Then why did homebirth midwives deliver them at home?

By Blogger Amy Tuteur, MD, at 3:40 PM  

Sailor said:
Well, an interesting subset of doctors to look at is "doctors who work with CNMs." Those doctors see plenty of births under the care of a CNM. Thus, they havce considerable experience with non-managed labor.

____

Sorry Sailor, we disagree again. You assume CNMs don't manage births. I think they do. A CNM in hospital birth may be slightly different than a OB hospital birth. But nowhere near a home birth.

By Anonymous Anonymous, at 5:14 PM  

"breeches and twins are not low risk"

Then why did homebirth midwives deliver them at home?
... or maybe because the parents don't want a hospital birth- or an automatic c-section ( which is the case in alot of places) -- what I have seen is women who do unassisted because midwives don't attend breeches or twins- now I also see more vbacs doing it themselves or with untrained help... was a trial in washington recently- no on died- but the judge decided that midwives could attend breeches at home and that there is a sub-set of people want that service at home-- and with 5% of normal presentation being breech.... and I understand that there is an increase in twinning ...

By Anonymous Anonymous, at 8:04 PM  

"the judge decided that midwives could attend breeches at home"

That does not sound like something that a judge has the authority to do. Do you have any more information about this case?

By Blogger Amy Tuteur, MD, at 8:24 PM  

"You could (fr example) lobby for greater DEM certification and training, which might convince your legislature it was safe."

Seriously, Sailorman... YOU ARE NOT UNDERSTANDING ME OR YOU ARE PLAYING DUMB!!! This is what our consumer group is trying to do. The medical lobby and the legislature is opposing efforts toward this end.

"This is surely a safety concern for the state. Nobody wants the death rate to climb."

Can you provide me evidence that when states legalize DEMS, the death rate rises? Pretty please. If you can demonstrate this I will abandon my pro-homebirth position and I will have the rest of my babies in hospitals.

"Additionally, UNLIKE a ban on DEM-supervised home birth, banning abortion makes no sense: abortion is SAFER than delivering a baby, and the "alternative" to an abortion (a 'home abortion') is much MORE dangerous than the legal kind. For DEMs, it's backwards: a hospital birth is safe and freely available."

You are sooooooo inconsistent in your beliefs about women's choice issues. I wish I had time to go further into this issue with you. The debate (and your inconsistencies) aren't about place of procedure, but about a woman's ability to be the primary decision maker about which risks she is willing to take on behalf of her baby and with her own health.

By Blogger Mama Liberty, at 1:50 PM  

Isn't it just amazing you would think after reading the midwifery laws in Washington state that they could not even bring charges against this midwife... look it up judgment happened this year. The state took her to court to hopefully get a set in stone rule against breech birth at home-- they gamboled wrong... and to think all you have to worry about is malpractice. incidentally the midwife transfered care in labor - and the baby was fine and the mother was fine through out..

By Anonymous Anonymous, at 12:49 AM