Monday, June 05, 2006

The medical model and the midwifery model

There is a lot of blather about how the medical model differs from the midwifery model. I submit that there are actually very few differences and that this is just another marketing tactic.

Let's look some features of these models:

Goals
medical model - healthy babies and healthy mothers
midwifery model - healthy babies and healthy mothers

Diagnosis of pregnancy
exactly the same

Estimation of risk
exactly the same parameters

Prenatal testing
exactly the same

Prenatal evaluation of fetal health
exactly the same

Prenatal evaluation of maternal health
exactly the same

Estimates of gestational age
exactly the same

Treatment for premature labor or premature rupture of membranes
exactly the same

Treatment for placental problems
exactly the same

Treatment of gestational diabetes and pregnancy induced hypertension
exactly the same

Maneuvers used in delivery
exactly the same

Drugs used to treat postpartum hemorrhage
exactly the same

Resucitation of newborn techniques
exactly the same

Do you see a pattern here? The only substantive difference in philosophy is an emphasis on avoiding episiotomy and operative delivery. That's not enough to base an entire model of practice upon. There is, of course, a tremendous substantive difference in knowledge and training, with obstetricians having much more of both. However, in most areas of pregnancy, the model is exactly the same.

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57 Old Comments:

great with this list many states should just legalize the hell out of midwifery---
I imagine there are some midwives who have done more births than several docs.....

By Anonymous Anonymous, at 5:34 PM  

lets see what else-
continuos monitoring is not usually done in the home- intermittent
--------
disclosures on each procedure with signed informed consent for as well- ask lawyers about midwives' informed consent forms- most that I have talked with have never seen the like before from any other medical care provider-
( there are exceptions like - resuscitation efforts are instituted and we don't ask permission- but resuscitation may be explained to parents before the birth so they know what the equipment is and what it is used for) come on bring your standard up and do what we do.
also spend at least 45 minutes a prenatal will change your life and probably reduce your malpractice suits

By Anonymous Anonymous, at 6:00 PM  

I beg to differ......... I have always found the midwifery model to care for the woman as a whole, mentally, spirituall and physically. There lies the difference.

By Anonymous Anonymous, at 6:17 PM  

You don't seem very familar with the midwifery model of care.

By Anonymous Anonymous, at 6:35 PM  

I think the midwifery and medical models differ in several of these areas, but I'll pick on just one.

Maneuvers used in delivery
exactly the same

You may be thinking of CNMs here, rather than the loose usage of the term 'midwives' as we've been using it here, to mean DEMs or CPMs. If you look in varney's midwifery, (CNM) you will find the same maneuvers described. But you will NOT find the same method advocated by midwives. (check Holistic Midwifery by Anne Frye)They generally use a hands off approach unless a complication arises such as SD. For a visual, check Maribeths comment under the Boasting post.

Most in contention is the attempt to deliver the anterior shoulder by reefing (my term)on the neck.

By Anonymous Anonymous, at 6:50 PM  

I love how you all act like midwives are the only people who care about a woman as a whole person. What a crock of.....

By Anonymous Anonymous, at 7:24 PM  

Amy, great list even if I would quibble with some of the ideas about practices.

but your summation doesn't make any sense- women have babies at home- with or without midwives.
If we all agree that #1 is our priority are doctors going to pick up the slack in home births?

By Anonymous Anonymous, at 11:28 PM  

"women have babies at home- with or without midwives.
If we all agree that #1 is our priority are doctors going to pick up the slack in home births?"

Most doctors are not going to participate in homebirths because they believe that they are not as safe as hospital birth.

I have seen no evidence that suggests that substantial numbers of women have unattended homebirths. Those that do so, do it for philosophical reasons, not because they can't find a homebirth attendant.

The vast majority of women are very concerned about safety. Without an attendant claiming that she will make homebirth safe, most women would simply go to the hospital.

By Blogger Amy Tuteur, MD, at 7:00 AM  

then you are misreading the info-- that is what the Farm was about- to start with and continues to be- women who live in areas where there is no midwife- have unattended births or unskilled attendants. People who are in the position to be asked to go to more births do so eventually become skilled- better way would be to have skilled available to begin with--in states where there is no licensing, midwives still exist-- no phone book ads no open office no insurance- and still they are found - and risk doing care for women to protect them and their babies-- when the seeking public is the impetus how do you stop that and should you stop that when you are unwilling to do the work? and it may be that you are unsuitable as well.
On this list how many of the women who have felt abused, raped or harmed by medical care do you think you want as a client? I know that you believe that no patient abuse goes on - but we know what you are saying is not true, studied or unstudied-- I am also sure that part of what drives malpractice suits is just such perceptions with the kicker that they have proof of damage done--- malpractice lawyers see tons of clients/ actually screening them before hand and if you have a live intact, undamaged- mother and baby--- you are not going to be allowed to file.
I do think that I will be handing my clients from now on a sheet on how to make complaints about medical personnel and their mistreatment. What we have done is walk away- and if there is a way to stop the violence if only in the distant future we should do that as well. If they have it on film or tape if they have corroborating statements all the better put it together and send it in--also write their stories on the web.

By Anonymous Anonymous, at 10:12 AM  

Amy, I'd have to agree with the anonymous commenter who said that you don't seem to be very familiar with the midwifery model of care.

You wrote:
"Goals
medical model - healthy babies and healthy mothers
midwifery model - healthy babies and healthy mothers"

Agreed, except the midwifery model also has the goal of a positive birth experience for the entire family.

"Diagnosis of pregnancy
exactly the same"

Agreed, more or less.

"Estimation of risk
exactly the same parameters"

Agreed, more or less.

"Prenatal testing
exactly the same"

Prenatal testing in the two models is very different. As someone else has pointed out, in the midwifery model there's a very strong emphasis on informed consent. Also, fewer unnecessary tests (such as routine ultrasounds on healthy, low-risk women) are performed.

I was asked by my midwife to promise that I would not have an ultrasound unless it was medically necessary. I agreed.

"Prenatal evaluation of fetal health
exactly the same"

See above - there is a good deal less routine testing in the midwifery model.

"Prenatal evaluation of maternal health
exactly the same"

Many of the evaluations of physical health are the same - weight, BP, urine dipsticks. In the midwifery model, however, it's much easier for midwives to spot more subtle signs of suboptimal health in the mother, simply because they've spent far more time with her and know her body better.

Do her ankles look more swollen than last week? Are her eyes a little glassy? If you spent three minutes with the mother last week and three minutes again today, it's tougher to see these signs than if you've spent an hour or two each time.

"Estimates of gestational age
exactly the same"

Sure, except...in the midwifery model, women are more often given credit for knowing when they conceived and what's normal for their bodies.

Most OBs in my experience tend to rely on the gestational wheel (which is made for a 28-day cycle) without compensating for longer or shorter cycles, or an ovulation date that might have been later or earlier than usual. There's also a lot of reliance on ultrasound for dating.

If a woman says "I know I got pregnant on April 12th because that's the only weekend my husband was home from the Navy," she's taken at her word in the midwifery model. In the medical model, if the ultrasound or the wheel says she must really have conceived on the 5th, then her due date is based on that. These are generalizations, of course, but I've seen it happen again and again.

"Treatment for premature labor or premature rupture of membranes
exactly the same"

Not exactly. A midwife might suggest that a woman with preterm contractions try drinking a glass of wine, taking a warm bath, and going to bed, as a first resort. Hospitalization would be a last resort.

For PROM, a midwife might suggest that the woman stay home, among the germs she's accustomed to, and check her temperature regularly, rather than rushing right into the hospital with its associated microbes and frequent vaginal exams.

"Treatment for placental problems
exactly the same"

Sure...except that a midwife might talk to a woman who's been diagnosed with partial previa at 24 weeks, and tell her that the studies show that 95% of partial previas are resolved by term. In the medical model, her cesarean might well be scheduled right then and there.

"Treatment of gestational diabetes and pregnancy induced hypertension
exactly the same"

Heh, heh. This is a soapbox issue of mine, so bear with me. There is much discussion among midwives about whether gestational diabetes is a real phenomenon with serious adverse effects, or simply a normal variation in the way women process sugar during pregnancy.

The only documented adverse effects of GDM are possible macrosomia and an increased cesarean rate. The former (macrosomia) is not necessarily a problem, as large babies are born every day. The latter (increased cesarean rate) would seem to have some correlation with fear on the part of the medical care provider. If you're trained to believe that high blood sugar = huge baby = can't get through the pelvis, then of course you're going to perform cesareans more often.

As for pregnancy-induced hypertension, preeclampsia, and HELLP syndrome (all clinically very similar), prevention and treatment techniques are VERY different among midwives.

Go to a doctor, and you'll be told that the only cure is delivery of the baby, preferably sooner rather than later, so let's start the Pitocin now.

Go to a midwife, and you'll be asked to dramatically increase your protein intake, increase your salt intake, and soak in baths with Epsom salts. She'll still watch your BP and edema very carefully, monitor the baby frequently, and bring you in for a liver panel and/or induction if it's necessary. But with those measures (and with excellent nutrition throughout pregnancy, a major focus for midwifery care), your chances may be better.

"Maneuvers used in delivery
exactly the same"

*BZZT.* Thanks for playing. As one commenter pointed out, midwives are far more hands-off and don't see a need to tug and twist babies' heads during birth.

You yourself said in another post that midwives' only job is to "keep the baby from falling on the floor." So which is it?

"Drugs used to treat postpartum hemorrhage
exactly the same"

Yes, if you're talking about allopathic drugs: Pitocin, methergine, misoprostol. A midwife might also have in her birth kit angelica, shepherd's purse, Yunnan Paiyao, or any number of other herbs for PPH.

"Resucitation of newborn techniques
exactly the same"

Yes, except how many hospitals are following the latest research about resuscitating with room air instead of 100% oxygen? Or the research that shows that outcomes are not improved with routine suction for meconium?

For all that you claim that midwives are behind the times, in my experience they're far quicker to switch over from "that's the way we've always done it" than are large institutions like hospitals, when the research is compelling.

I think you do need to learn a bit more about what really happens in midwifery care before you make such sweeping claims about it.

By Blogger Anne, at 11:37 AM  

"I think you do need to learn a bit more about what really happens in midwifery care before you make such sweeping claims about it."

ABSOLUTELY!

The original post (the list of comparisons) almost had me spewing water all over my computer because it was so funny.

Sorry, not trying to be mean, but the idea that midwifery is that much similar to medical management of pregnancy and labor and birth is absurd. If they were that much the same, I would have gladly let my HMO pay for everything. Instead, because I valued my baby's life and did research and consulted with an epidemiologist and a research scentist about the validity of and how to understand the studies I was reading, I chose to pay 100% out of pocket to a direct-entry midwife for a home birth.

The funny thing is, I was seeing a very reputable OB for a while before switching over (and for a couple months concurrently both the midwife and the doc), and the midwife's care was so much more comprehenseive and so much more evidence based, that it "radicalized" me when my state begam persecuting midwives.

Let me state for the record: the care I received from my direct-entry midwife was vastly superior to the doctor who I fired (and this doctor has a great reputation, two offices in high rent areas, and sees a large number of doctors and their wives and is highly recommended).

One of the difference I want to highlight is maneuvers. Midwives help women do maneuvers themselves, and not just walking. Look at the Gaskin maneuver for shoulder dystocia. Midwives use the basics of anatomy and physics to work with them, instead of against them.

By Anonymous Anonymous, at 1:32 PM  

Anne:

"As someone else has pointed out, in the midwifery model there's a very strong emphasis on informed consent."

Informed consent is LEGALLY required for everything that a doctor does.

"there is a good deal less routine testing in the midwifery model."

The exact same testing is offered. There may be a difference in whether mothers choose to use it, but the testing is the same.

"it's much easier for midwives to spot more subtle signs of suboptimal health in the mother, simply because they've spent far more time with her and know her body better."

That's absurd and there is no scientific evidence for it. Since doctors are knowledgeable about the full range of human health and disease, they are far more able to spot any signs of anything, subtle or otherwise.

"women are more often given credit for knowing when they conceived and what's normal for their bodies"

Well, how helpful is that? Every study of homebirth shows unanticipated premature deliveries at home.

"If a woman says "I know I got pregnant on April 12th because that's the only weekend my husband was home from the Navy," she's taken at her word in the midwifery model. In the medical model, if the ultrasound or the wheel says she must really have conceived on the 5th, then her due date is based on that."

It is estimated that between 5-10% of women who are pregnant at any given time have committed adultery. That's what genetic testing done for other reasons shows as an accidental finding.

Furthermore, ultrasound is not accurate to the day and the rule in obstetrics is that you are not to change a due date unless a first trimester ultrasound differs by more than a week, or a second trimester ultrasound by more than two weeks.

"A midwife might suggest that a woman with preterm contractions try drinking a glass of wine, taking a warm bath, and going to bed, as a first resort."

A doctor would make an individual decision based on the patient and her particular circumstances and gestational age. Of course, I suspect that most doctors would agree that the danger of preterm birth (the leading cause of neonatal deaths) is likely to outweight the inconvenience of going to the hospital for an evaluation. The only women that are admitted to the hospital are women who need medication to stop contractions.

" midwife might suggest that the woman stay home, among the germs she's accustomed to"

Do you know which bacteria are most commonly associated with infections of pregnant women? They are the bacteria that normally live in the vagina, or may be there because of a sexually transmitted disease. They are not hospital acquired bacteria.

Furthermore, no vaginal exams are permitted in a woman with premature ruptured membranes.

"except that a midwife might talk to a woman who's been diagnosed with partial previa at 24 weeks, and tell her that the studies show that 95% of partial previas are resolved by term"

Who, exactly, do you think did the studies? Any medical knowledge that a midwife has comes directly from doctors. If a midwife is aware of a medical fact, than obstetricians already know it.

"The only documented adverse effects of GDM are possible macrosomia and an increased cesarean rate."

No, the most important adverse effect of gestational diabetes is intrauterine fetal death. That why women with gestational diabetes are monitored very carefully, and why women who have had an IUFD are always screened for diabetes and gestational diabetes. If gestational diabetes is properly managed, the chance of stillbirth falls almost to the same rate as that of any other pregnant woman.

"Go to a doctor, and you'll be told that the only cure [for PIH, pre-eclampsia and HELLP syndrome] is delivery of the baby, ..."

That's right. That's because it IS the only cure. Anything else is a temporizing measure. There are times when temporizing measures may be used, to avoid prematurity as much as possible. Don't be confused, though. This is a tradeoff between the well being of the baby, which tends to improve at increasing gestational age, and the well being of a woman with pre-eclampsia, which declines the longer she waits until delivery.

HELLP syndrome is a life threatening problem that must be treated right away. It stands for hemolysis, elevated liver enzymes and low platelets. Women with HELLP syndrome are in imminent danger of developing liver failure and severe clotting problems causing them to bleed to death.

"You yourself said in another post that midwives' only job is to "keep the baby from falling on the floor." So which is it?"

I also said that it is the DOCTOR's primary job as well.

" A midwife might also have in her birth kit angelica, shepherd's purse, Yunnan Paiyao, or any number of other herbs for PPH."

Oh, that'll be helpful. To the extent that any of them are effective, they are not nearly as effective as pit or ergot. Anyone who treats a real postpartum hemorrhage with herbs is committing MALPRACTICE.

"except how many hospitals are following the latest research about resuscitating with room air instead of 100% oxygen? Or the research that shows that outcomes are not improved with routine suction for meconium?"

Again, who do you think figures these things out? If you know it, it's because you heard if from a doctor.

If the above quotes are really what happens with direct entry midwifery than the patients are in even more danger than I thought.

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

"Let me state for the record: the care I received from my direct-entry midwife was vastly superior to the doctor who I fired"

There is a saying in medicine (about doctors, but it applies to midwives, too):

Patients judge their provider on the three A's - affability, availability and last (and least) ability.

I have no doubt that you liked your midwife more, and I wouldn't be surprised if your midwife was a nicer person. I'd even be willing to agree that the average midwife is much nicer than the average obstetrician. None of that has any bearing on safety or competence.

Fortunately, you did not have a pregnancy complication. In most situations, a direct entry midwife would be unable to help you, only an obstetrician could.

By Blogger Amy Tuteur, MD, at 3:59 PM  

"I have no doubt that you liked your midwife more, and I wouldn't be surprised if your midwife was a nicer person. I'd even be willing to agree that the average midwife is much nicer than the average obstetrician."

Just out of curiousity, do you believe that stress has any effect on labor?

By Blogger Mama Liberty, at 5:05 PM  

Mama Liberty:

"do you believe that stress has any effect on labor?"

Not much.

By Blogger Amy Tuteur, MD, at 5:35 PM  

Informed consent is LEGALLY required for everything that a doctor does.

Is it required in writing or is verbal enough?

By Anonymous Clever ID, at 6:08 PM  

It is estimated that between 5-10% of women who are pregnant at any given time have committed adultery.

I am SO grateful you wrote this. I was asked at a childbirth class recently why some things having to do with parental relationship was either pushed or left alone. I am vindicated by my explanation that the medical model doesn't trust women. Thank you.

By Anonymous Clever ID, at 6:20 PM  

Clever id:

"Is it required in writing or is verbal enough?"

There is supposed to be written documentation.

By Blogger Amy Tuteur, MD, at 8:14 PM  

Clever id:

"I am vindicated by my explanation that the medical model doesn't trust women."

No, you are demonstrating your lack of experience and naivete. Women make mistakes about conception all the time, and if you took care of a substantial number of people you would learn that. They think they had a period when they really had implantation bleeding or bleeding in the first trimester.

Some people lie, even if situations that are life threatening (for example, people lie about their HIV status or are in denial about it). I have seen patients who have had serious complications and even a death because they lied about something that they didn't realize was important and the physicians involved took their word for it.

By Blogger Amy Tuteur, MD, at 8:23 PM  

Please, Anne. My best friend and her baby nearly died from HELLP syndrome a little over a year ago.
If she had been directed to eat more cheese and peanuts and to sit in an epsom salt bath, she would be DEAD, and her baby too.

By Anonymous Joanna, at 9:46 PM  

No, you are demonstrating your lack of experience and naivete.

No, sorry, I'm not.

Women make mistakes about conception all the time, and if you took care of a substantial number of people you would learn that.

It doesn't take a busy practitioner to have "learned" that. Any woman who has ever spoken once to another about pregnancy knows "mistakes" on conception are common.

They think they had a period when they really had implantation bleeding or bleeding in the first trimester.

Yeah...?

How does those statements of my lack of experience complement (or maybe cancel it out) this one: "It is estimated that between 5-10% of women who are pregnant at any given time have committed adultery. That's what genetic testing done for other reasons shows as an accidental finding."

By Anonymous Clever ID, at 10:05 PM  

"It is estimated that between 5-10% of women who are pregnant at any given time have committed adultery."

I'm sorry the connection wasn't clear. Women occasionally lie about when they conceived because they conceived when their husband was away. That's they may be "sure" about when they conceived, but the ultrasound does not corroborate this.

By Blogger Amy Tuteur, MD, at 10:33 PM  

"They think they had a period when they really had implantation bleeding or bleeding in the first trimester."

I have no doubt that this is the case for many women, but in the name of accurate information (which you are all about), I'd like to point out that a woman can know her exact date of conception if she uses natural family planning or the "Fertility Awareness Method".

By Blogger Mama Liberty, at 10:54 PM  

well I don't think I once someone was dx with HELLP they would no longer be in my scope of practice.
Key bits of info that I have learned from hematologists--- Folate, B12 and B 6 are related to
#1 clotting factors
#2 hyperhomocystineanemia > in turn high bp
#3 pregnant women have falling levels of these nutrients in pregnancy
#4 that blood tests may not accurately reflect deficiency
------ attempts at treating ITP comes to mind first given these bits of info-have seen it change falling platelets quickly-- and other times not work at all
and perhaps as a preventive for some forms of elevated BP and falling platelets --- something to think about--

By Anonymous Anonymous, at 12:37 AM  

My personal experience with an OB and pregnancy dating: (2001)

I used a reproductive endocrinologist to get pregnant, artificial incimination, and copious doccumentation via early ultrasound. I knew exactly when I got pregnant, and records were sent to my OBs office upon transfer of care.

My OB preformed her own ultrasound, and changed the due date based upon the ultrasound... by two days. We discussed the date of conception at the appointment, so I know she was aware of it (and didn't just 'miss' my transferred records)

By Anonymous Anonymous, at 10:36 AM  

Amy Tuteur, MD said...
"No, you are demonstrating your lack of experience and naivete. Women make mistakes about conception all the time"

My wife and would have sworn that she couldn't have gotten pregnant when she did, seeing as she never had a period fter her last pregnancy, and appear to have a period after her supposed conception.

But she was. We were wrong.

Seeing as the baby (now a toddler) looks like my twin I'm not worried about the infidelity thing ;) but it serves as an anecdotal example of this.

By Blogger sailorman, at 10:56 AM  

"Or the research that shows that outcomes are not improved with routine suction for meconium?"

Again, who do you think figures these things out? If you know it, it's because you heard if from a doctor.


So, if one doctor knows it, all doctors know it, like the Borg Collective? Because at my last obstetric practice, those doctors sure as hell didn't know it. The doctor I worked for freely admitted not being able to keep up with all the research in her journals.

Additionally, how long does it take hospital bureaucracy to decide to make changes in policy and protocol to keep up with current research, implement those changes, and obtain 100% staff cooperation? How many people are treated in a way that is not evidence based because of policy, protocol, poor communication or just plain old fashioned hubris?

By Anonymous Anonymous, at 9:25 PM  

"So, if one doctor knows it, all doctors know it"

They're supposed to; that's the legal standard. You can be sued for malpractice if you hurt a patient because you are not current with the latest medical practice. If a midwife knows about it, you can be sure that the doctor is required to know about it.

"Additionally, how long does it take hospital bureaucracy to decide to make changes in policy and protocol to keep up with current research, implement those changes, and obtain 100% staff cooperation?"

The hospital does not tell doctors how to practice. It is part of every doctor's job description to read and use the latest research. No policy change is necessary; a doctor can implement a new research finding the minute after she reads it.

By Blogger Amy Tuteur, MD, at 11:38 PM  

"Fortunately, you did not have a pregnancy complication. In most situations, a direct entry midwife would be unable to help you, only an obstetrician could."

That's interesting because you are doing what I thought all along -- making ASSUMPTIONS.

In fact, I did have a (very) slight complictaion in pregnancy (a slight rise in bp and pitting). My doctor basically said "stop eating canned goods and stop salting yoru food" which we know is wrong. He did not take into account that I had walked through the downtown on a 100 degree day to get to that appointment, he assumed he knew what I ate camping the weekend before ("pork and beans and hot dogs" -- gross, never would I eat that, let me tell you). REFUSED to believe me when I said I don't eat canned products, and he took my bp immediately again on the same side, which makes the second reading less accurate according to my dad's cardioloigst.

Yes, accessibility is one major reason why midwives give better care. My midwife came with three cuffs, spent a long time (I think 2 hours), taught my husband to take my bp, arranged for a neighbor who is a nurse to check it, too, and gave me several practical options that actually applied to my situation. Thankfully, it was a one-off situation.

Now, I think there's a good possibility you're going to desparage this, but I'll put it up anyway. Then, during labor, my baby was asynclitic, and not just a little. My midwives helped me -- at 10 cm mind you -- to march around, go up the stairs two at a time (yes, with plenty of help to make sure I didn't fall), come back down swinging hips, and I was able to rest and actually fall asleep for about 20-30 min. After which time I woke up with overwhelming urge to push. Put a woman with that situatiion in the hospital, and what are the odds that (a) that staff knows those maneuvers, (b) trusts they will work and (c) the woman is physically able to do them (i.e. not numbed).

What a crock that you think stress doesn't effect pregnancy and birth. (And yes I'm aware of a study that recently said it's less important than previously believed.) That is emblematic of the differences. It shows that you are in denial. That is absurd, in the face and in reality.

By Anonymous Anonymous, at 9:27 AM  

"They're supposed to; that's the legal standard. You can be sued for malpractice if you hurt a patient because you are not current with the latest medical practice"

That is sooooo wrong. Doctors are judged legally on what is called "standard of care" and that changes from region to region, even city to city. Why? Becuase "standard of care" means the HABITS and PERSONAL PREFERENCES of the local medical community, and is not at all based on the latest medical research.

You've already demonstrated you don't understand home birth midwifery care standards. I think this demonstrates, you don't understand law.

By Anonymous Anonymous, at 9:33 AM  

The point about conception dates is midwives take the time to really listen and listen and listen some more. So, if it was literally only possible for a woman to conceive on one date (husband on leave from army let's say), she will believe it. And, even if there is a chance of something else occuring (affair), who do you think is more likely to help a woman to feel confidence to confide that? Someone who keeps the woman waiting in a cold waiting room and then in a cold exam room only to receive 5 min. of conveyor belt type care? Or someone who feeds the woman, talks with her, gets to know her and her kids (if she has any already), educates her, visits her home, explains why she needs to know certain things, etc.

Yes, there can be confusion with about dates with a midwife. Of course. No one said there never was. But deliberately covering up the truth is less likely to occur in a more trusting relationship. And believing a woman who has every reason to know for sure exemplifies the difference in care.

I don't doubt most ob's are sincere. Just that the system they're in sucks.

By Anonymous Anonymous, at 9:41 AM  

Standard of care. A great example of Standard of care is cont. EFM. A solid body of research now shows that Cont. EFM does not change outcome except to raise C rates.

Why do docs continue to insist on EFM? Because they want to do more Cs? No, because it's standard of care.

Do you suppose I could sue my OB if I had Cont. EFM and ended with a C? Nope. Even though the research proves EFM raises the risks of cesarean.

By Anonymous Anonymous, at 12:39 PM  

"What a crock that you think stress doesn't effect pregnancy and birth."

I don't think that there is any data for this.

You might be surprised to learn that some anesthesiologists agree with you. They claim that an epidural reduces the level of stress hormones in the maternal bloodstream (it does; they did the blood testing that demonstrates this} and that epidurals BENEFIT women in labor by reducing stress.

By Blogger Amy Tuteur, MD, at 10:00 PM  

"The point about conception dates is midwives take the time to really listen and listen and listen some more."

But that does not seem the right thing to do in this setting. Most homebirth studies include unanticipated premature births. Evidently the midwives believe the mothers even when some of them were wrong or not telling the truth.

By Blogger Amy Tuteur, MD, at 10:03 PM  

"A solid body of research now shows that Cont. EFM does not change outcome except to raise C rates."

No, that's not what it shows. The research shows that continuous EFM is no better than intermittent monitoring by a nurse or midwife every 5 minutes for the duration of labor. I don't think is the standard of care for homebirth.

By Blogger Amy Tuteur, MD, at 10:06 PM  

But that does not seem the right thing to do in this setting. Most homebirth studies include unanticipated premature births. Evidently the midwives believe the mothers even when some of them were wrong or not telling the truth.

But unanticipated premature births occur at the hosptial too... That doesn't prove anything at all.

A premature birth is just that. Premature.

By Anonymous Anonymous, at 10:57 PM  

No, that's not what it shows. The research shows that continuous EFM is no better than intermittent monitoring by a nurse or midwife every 5 minutes for the duration of labor. I don't think is the standard of care for homebirth.

It shows it's no DIFFERENT than intermittent monitoring, EXCEPT that it raises the C rate.

but you are right, Cont. EFM is not the standard of care at most US homebirths. intermittent is.

By Anonymous Anonymous, at 10:59 PM  

"But unanticipated premature births occur at the hosptial too... That doesn't prove anything at all."

Yes, that's right; doctors are capable of making the same mistakes as midwives make. The difference is that they would acknowledge it as a mistake (and be legally liable for it). They would not consider it a virtue.

By Blogger Amy Tuteur, MD, at 11:41 PM  

"Cont. EFM is not the standard of care at most US homebirths. intermittent is."

Intermittent monitoring every 5 minutes for the duration of active labor is the standard at homebirths?

By Blogger Amy Tuteur, MD, at 11:43 PM  

Intermittent monitoring every 5 minutes for the duration of active labor is the standard at homebirths?

Per Williams, 21st edition (ACOG 1995), it is acceptable to auscultate fetal heart tones intermittently in low risk pregnancies q30 minutes in 1st stage and q15 minutes in active labor. Decrease the intervals to q15 minutes in first stage and q5 minutes in second stage in high risk pregnancies (such as home VBACs to tie it in with this conversation).

If this has been updated I am sure you will not hesitate to correct me. The public ACOG site had no bulletins stating so.

By Anonymous clever ID, at 12:24 AM  

I said Per Williams, 21st edition (ACOG 1995), it is acceptable to auscultate fetal heart tones intermittently in low risk pregnancies q30 minutes in 1st stage and q15 minutes in active labor.

I meant q15 mintues in second stage, not active labor.

By Anonymous clever ID, at 12:27 AM  

Clever id:

"Per Williams, 21st edition ..."

I didn't say that listening every 5 minutes was required, I said that continuous EFM is no better than listening every 5 minutes.

So when advocates say that continuous EFM has been "shown" to have no value, they are wrong. Furthermore, the advocate's implication that what they do at homebirth is in some way equivalent to or better than EFM for safety purposes, they cannot justify that claim.

As I have said in the past, it makes it very difficult for people in medicine, statistics, etc. to take homebirth advocates seriously when they deliberately distort scientific information over and over again.

By Blogger Amy Tuteur, MD, at 7:03 AM  

will you please clarify where you are getting the 5 minute number to mean intermittant monitoring?

By Anonymous Anonymous, at 11:40 AM  

Anonymous asks... "will you please clarify where you are getting the 5 minute number to mean intermittant monitoring?"

What do you mean? I gave the source, Williams 21st edition (published 2003) using the 1995 ACOG recommendation.

By Anonymous clever ID, at 4:41 PM  

Amy wrote: I didn't say that listening every 5 minutes was required, I said that continuous EFM is no better than listening every 5 minutes.

Right you did say that and you also said earlier, I don't think is the standard of care for homebirth.

It is.

By Anonymous clever ID, at 4:45 PM  

"you did say that and you also said earlier, I don't think is the standard of care for homebirth."

Here's what I mean: Homebirth advocates say that there is no data to support the use of continuous EFM and that it only causes problems. Therefore, whatever midwives do at home is by definition going to be better than EFM.

That's wrong and deliberately misleading. The studies do not compare EFM with no monitoring, they compare EFM with intermittent monitoring every 5 minutes through active labor.

Since homebirth midwives have no intention for monitoring every 5 minutes, they have no basis for saying that what THEY do is better than continuous EFM. For all we know, continuous EFM might be much safer than the ACTUAL practice of midwives during homebirth.

By Blogger Amy Tuteur, MD, at 7:05 PM  

Amy, I asked you where you are getting your 5 minute data? You have ignored the question.

We agree on the point that EFM and intermittant monitoring are the same, except that EFM leads to a higher C rate.

What we are disagreeing on is the definition of intermittant monitoring. I have read three sources now (Frye, Varney, and Tucker) that agree on a definition as :

Normal labor:
Early/Latent phase every 30-60 minutes
Active labor, q 30 min.
second stage, q 15 min.

Difficult labor or risk factors:
early/latent phase q 30 min
active labor, q 15 min
second stage, q 5 min or after every contraction.

Again, please provide your source for intermittant monitoring to be every 5 minutes for the duration of labor!

intermittant monitoring is the standard of care for home births.

By Anonymous Anonymous, at 7:14 PM  

For all we know, continuous EFM might be much safer than the ACTUAL practice of midwives during homebirth.

LOL, the machine is safer than the practitioner... sounds like the medical machine at its best.

By Anonymous clever ID, at 7:44 PM  

"the machine is safer than the practitioner... sounds like the medical machine at its best."

I'd say it's pretty obvious that monitoring a baby with a machine is better that not monitoring it enough. Just because it is plugged into the wall does not make it evil.

There are many instances in which a machine is better than a person is saving a baby's life. A mechanical ventilator is much better than simply bagging a baby who needs breathing assistance, for example.

If you want to be a Luddite and insist that technology "corrupts" the state of nature, you are entitled to that view point. Not many people would agree with you though.

By Blogger Amy Tuteur, MD, at 8:45 PM  

Amy just said...I'd say it's pretty obvious that monitoring a baby with a machine is better that not monitoring it enough.

OH! Is that what you meant by saying this?"For all we know, continuous EFM might be much safer than the ACTUAL practice of midwives during homebirth." Because it didn't look to me that you were suggesting monitoring versus not monitoring. It looked like you were suggesting that the act of monitoring was better than the practice of the midwife. But then again, I am much better with passive-aggressive communication in person.

I'm one of those midwives who actually monitor the babies frequently in labor (and yes I have heard that doctors invented them).

Just because it is plugged into the wall does not make it evil.

Well of course! But I'm sure you can google a home birth advocate site that declares it evil and that will make for a good next blog subject.

If you want to be a Luddite and insist that technology "corrupts" the state of nature, you are entitled to that view point. Not many people would agree with you though.

And off we go...

By Anonymous clever ID, at 11:17 PM  

There is a difference in knowledge and training, no doubt. However, I would like to know how much training an obstetrician has had in drug-free, noninterventive birth. What percentage of obstetricians have ever even seen an unmedicated birth, let alone one where the mother is left alone except for occaisional monitoring with a fetascope? How many obstetricians stay with a laboring woman for the entire course of her active labor? What percentage of obstetricians could "manage" a labor without electronic devices? Just a few questions I have.

By Anonymous Anonymous, at 12:10 AM  

At this point Amy, we can only assume you’ve resorted to making up numbers to try and prove a point.

You made a statement that the way midwives preform intermittent monitoring is not as safe as the usage of EFM in a hospital. You have not backed up your statement with evidence, even after repeated requests to do so, and even after four medical sources have been presented to you that say differently.

Must we assume that every one of your statements must be challenged to determine if they are factually correct?

By Anonymous Anonymous, at 11:23 AM  

"You made a statement that the way midwives preform intermittent monitoring is not as safe as the usage of EFM in a hospital."

No, no, no. I never said anything of the kind and either you are misunderstanding me or mispresenting me. What I said was this: The claim that continuous EFM has been shown to be useless is NOT true.

Why? Because continuous EFM has never been tested against NO monitoring. It has only been tested against intermittent monitoring every 5 minutes throughout active labor. So the only claim that is true is that continuous EFM is NO BETTER than listening every 5 minutes.

Since most homebirth midwives do not listen every 5 minutes, they cannot claim that what they do is better than continuous EFM.

Think of it this way: if I did a study showing that amoxicillin was no better than erythromycin for treating an infection, it would not mean that herbs are better than amoxicillin. In fact it would tell us nothing about herbs at all.

Similarly, the fact that continuous EFM is no better than listening every 5 minutes in active labor does not mean that monitoring only when a homebirth midwife feels necessary is better that EFM. In fact it tells us nothing about the safety of the monitoring practices of homebirth midwives.

By Blogger Amy Tuteur, MD, at 4:20 PM  

Amy, Intermittent monitoring is NOT defined as "every 5 minutes throughout labor"

The studies show that EFM does not change outcomes over intermittent monitoring except to raise C rates.

Intermittent monitoring according to four sources presented on this list, show that intermittent monitoring is q 30 minutes, active labor, and q 15 second stage, for a low risk delivery.

Please share YOUR source of the statement "continuous EFM is no better than listening every 5 minutes in active labor"

and

"Since homebirth midwives have no intention for monitoring every 5 minutes, they have no basis for saying that what THEY do is better than continuous EFM"

By Anonymous Anonymous, at 5:34 PM  

"Please share YOUR source of the statement "continuous EFM is no better than listening every 5 minutes in active labor""

You are right and I am wrong.

I reviewed the literature on EFM vs. intermittent ausculatation, and while some studies compared EFM to listening every 5 minutes, other studies used longer intervals.

Here's what Williams Obstetrics (2005) says:

No scientific evidence has identified the most effective method, including the frequency or duration of fetal surveillance that ensures optimum results.

Here are ACOG's recommendations:

Low risk - 1st stage every 30 minutes, second stage every 15 minutes.

High risk - 1st stage every 15 minutes, second stage every 5 minutes.

Auscultation (listening) should be performed after a contraction and for at least 60 seconds in duration.

So, is this the homebirth standard as well? Is there a homebirth standard?

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

'You are right and I am wrong.'

Thank you Amy. This actually means a lot to me. I was feeling very frustrated.

Yes, In my state this William's (and Frye/Varney/Tucker) definition is the standard of care out of hospital, both birth center and home.

By Anonymous Anonymous, at 10:58 PM  

So, is this the homebirth standard as well? Is there a homebirth standard?

I listed the ACOG guidelines earlier than your post... Yes, home birth midwives use this as the standard. Yes this IS the home birth standard. Did you miss that post even though you responded to it?

By Anonymous clever ID, at 12:28 AM