Saturday, June 03, 2006

Reconciling normality and risk

How do homebirth advocates reconcile the concept of risk with the normality of birth? If birth "normally" proceeds uneventfully, why do midwives use so many different tests to determine who is at risk? Why are so many patients transferred to hospital care before the start of labor? Why are a substantial portion of patients transferred to hospital care during labor?

For example, in the Janssen and Davis study 7258 women intended to give birth at home, but 1840 (25%) were transferred to hospital care even before labor began. Then an additional 655 were transferred during labor or immediately after delivery. So fully 34% of midwife patients intending homebirth could not or did not have an uncomplicated homebirth.

If 1/3 of "normal" patients develop complications, what does "normal" mean?

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35 Old Comments:

so lets look at that article again - page #3
there is a chart inset that has a break down of clients and who left care and why--
------------------------
Left care( n=1038, 14.2%):
Registered on initial visit but never
returned ((n=133)
Social reasons (n=436, 6.0%):
Chose hospital birth (n=142)
Moved (n=119)
Changed midwife (n=53)
Other (n=87)
Medical reasons (n469, 6.4%):
Referred for pregnancy complications(n=205)
Miscarried (n=171)
Preterm labor- referred for obstetrical care (n=58)
Stillbirths before labor; >/=20 weeks (n=19)
Sets of twins (n=16)
-------------------------------------------
then it goes on to describe women who continued care with midwife (n=6248, 85.8%) [by midwife they mean CPM ]
further broken down into --intending home birth at start of labor-- 5418 --- this number includes 8 intended birth center births and 8 intended hospital births with women who decided to have a home birth

intending birth center birth with a CPM at the start of labor (n=667)
intending hospital birth at the start of labor(n=163)
--------------------------------
so not all of the women in the study were transfers because of health reasons and some were intentional birth center or hospital births-(because some CPMs can work in hospital or a birth center). out of the remaining women in the midwife study that number would be 830 who were not intending a home birth and 5418 who were.
so no 1840 did not transfer to the hospital for care.

By Anonymous Anonymous, at 6:45 PM  

so lets look further in the study because it is all spelled out
reasons for transfer

looks to me like quiet a few first stage transfers 227 non-urgent failure to progress or 2nd stage failure to progress non-urgent 80-
pain relief-- 119-- 4 considered this to be urgent?
on the chart containing reasons for transfer- it explains that there were multiple reasons for some transfers--
-----------------
I will add my own 2 cents on this and that is in certain states there is a transfer requirement in the laws regulating midwifery--- some midwives are not allowed to suture and must transfer all cases- or may not be allowed to offer things that are standard of care like IV antibiotics for GBS prophylaxis

By Anonymous Anonymous, at 7:21 PM  

'why do midwives use so many different tests to determine who is at risk? Why are so many patients transferred to hospital care before the start of labor?'

Amy?!?! Midwives don't practice in a vaccum! They practice alongside obstetrics. I don't get your questions! What are you inferring??

By Anonymous Anonymous, at 9:33 PM  

"Midwives don't practice in a vaccum! They practice alongside obstetrics. I don't get your questions! What are you inferring??"

Midwives often accuse doctors of medicalizing a "normal" event. Many claim that midwives respect the "normal", whereas doctors only see risk. I am asking if the rhetoric reflects the reality. Aren't midwives just as concerned about risk as doctors? If one third of patients who come to midwives are referred away for hospital care, isn't risk part of "normal" birth?

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

what does 'normal' mean?
That's a good question. You might as well say what does 'uncomplicated' look like? What complications can be fixed with non-invasive interventions, and which require invasive ones? Can pre-E be controled with diet? What level of anemia is normal? Are ultrasounds always correct? What is the false positive rate of AFP tests? If you have a + AFP does that risk you out of midwifery care? What about glucose intolerance? Or GBS, VBAC or primi?

This is a very complicated subject.

By Anonymous Anonymous, at 9:50 PM  

I think there is a wide range of 'normal' and midwives need to recognize their individual training and limitations, as well as licensing requirements and state regulations. Which are all different in every state.
Anon 950

By Anonymous Anonymous, at 9:53 PM  

"1840 did not transfer to the hospital for care."

We don't know why they transfered to the hospital. For example, 133 registered on the initial visit but didn't return. Why would that happen? The most obvious reason would be that they were told that they were not candidates for midwife care because of risk factors.

Furthermore, women who ultimately chose birth center or hospital birth may have done so because risk factors made it the safer choice.

I agree that the 119 women who moved and the 53 women who changed midwife should not have been included in that original group. Nonethess, the basic point is the same: somewhere between 20-30% of the women who had considered homebirth were no longer candidates for homebirth. Remember, these women were midwife patients, so they are the lowest of the low risk patients. If such a large proportion of midwife patients were not eligible for homebirth, how "normal" is normal?

By Blogger Amy Tuteur, MD, at 10:16 PM  

So you read a study and cannot read? aprox 15.4%
once again out of 7258- 469 left care for medical reasons, before labor began.

205 were referred for preg complications
171 Miscarried
58 preterm labor referred to OB
19 stillbirths before labor
16 sets of twins
---
469 total transfered before labor 6.4%
+655 add transfers during labor or post partum -
-------
1124 total transfers to the hospital but still not all of them complications- some for pain relief

15.4 % less than half of what you are claiming
-------------------------------
I have read studies enough to know that this is actually a pretty good accounting of what happened - often many are "lost to follow-up" hard to know why people leave and don't come back -- I wouldn't assume that they were all transfers to the hospital- they may have moved, liked another midwife better but did not want to even say anything to the first midwife- do you and your colleagues get every patient who walks in the door? I do know that people really shop around and interview several midwives-- and they don't always tell you they are going to do that and some people sign up and have unassisted births as well... and use midwives care as a way to document the pregnancy- they do this to doctors too.

By Anonymous Anonymous, at 11:14 PM  

If a woman is told she is not eligible on the first visit
that would mean she was no where near low risk.

By Anonymous Anonymous, at 11:28 PM  

a risk factor in Canada -- is distance from hospital-- in order to have a homebirth in parts of Canada you have to live with in 30 miles of a trauma center-- so some women would automatically be slotted into birth center or hospital births. without a health risk.

choice is not a risk factor either

By Anonymous Anonymous, at 11:32 PM  

I regestered with my OB, then switched caregivers at 28 weeks. I wonder what group my OB would place me in, as I didn't explain to her where I was going. Would she assume I saw another OB? Miscarried? Moved?

By Anonymous Anonymous, at 11:41 PM  

I notice that you avoid discussing the actual POINT and keep trying to divert attention away from it? Why?

This is the question:

How can you reconcile so many complications with the idea that birth is "normal"? (This is just in a low risk group, we haven't even mentioned women who are not low risk at the beginning of pregnancy).

Is there anyone who can actually address this philosophical issue?

By the way, this is not a question that I though of. There are a number of papers in the midwifery literature that attempt to address this very point.

By Blogger Amy Tuteur, MD, at 10:46 AM  

And how do they address it?

I think transfers and labeling of risks is wound up with politics and state/licensing requirements.
If a state says a transfer is mandatory when x happens, then the transfer happens.

Each state is different, which confounds the issue.

By Anonymous Anonymous, at 11:10 AM  

Amy, clearly birth is "normal". It is normal for species to procreate and give birth. It has been happening for millions of years. "Normal" does not always equate with "risk free". In fact, I can think of very few normal human experiences that are risk free.

By Blogger Mama Liberty, at 11:57 AM  

"Mama Liberty said...
Amy, clearly birth is "normal". It is normal for species to procreate and give birth. It has been happening for millions of years. "Normal" does not always equate with "risk free". In fact, I can think of very few normal human experiences that are risk free."

You seem to be switching the subject of the debate: we're not talking about "risk free or not risk free."

We're talking about "normal" and the fact that even in a highly selected population with midwives, a pretty significant proportion of births are considered to be "abnormal" enough (or have that possibility) to need a hospital birth.

You haven't addressed any of Amy's numbers, so I'll assume for the moment that you don't dispute them. So let's say 1/4 to 1/3 of THESE patients need a hospital transfer.

Why, then, do home birth advocates often appear to try to polarize the debate against hospitals to such a degree, especially as applied to women in general and not ultralowrisk women?

I mean, you hear things like "birth is not a disease" and "people are trying to use medicine to reat a normal procedure" as examples of how medicine is "bad" and homebirth is "good."

If midwives accept--as you seem to--that you're often going to need medicine (or at least want it for insurance) quite a bit, even in the best of times, why the polarity?

By Blogger sailorman, at 12:38 PM  

I think it is a different approach to gathering the same information. An example--several and possibly most midwives have informed consent for many of the "standard tests" a signed consent- with risk/benefit information written out as well as why the test is done and even a discussion on how care could change in light of the results. You know when you have appointments that can last 1-2 hrs many things can be discussed. I also think that it falls back to RESPECT for your clients- and their families. We are equals to the women we serve and we have specialized training in a particular field, we advise and help to protect but we do not know everything , cannot fix everything.
----- you know that driving down the road can be a life threatening experience, we all agree to drive down the road on the right hand side, and stop at stop lights and signs-- now we might not all approach driving like any second we are going to have an accident so we drive in a hyper-vigalliant way-- we may all be using the same road and rules and be paying attention but enjoying the ride as well.

By Anonymous Anonymous, at 12:48 PM  

The same question could be asked about why someone should choose you as a provider over any other OB provider-- since you all do the same tests and ...... what do you bring to the pregnancy and birth experience that cannot be done by dozens of other providers?

By Anonymous Anonymous, at 12:52 PM  

"Normal" does not always equate with "risk free".

HAH! She got you to say it! Debate is finally over! Let's recap:

- Normal is not without risk

- Home birth is NOT safER than hospital

- Home birth IS safe for SOME women and babies, so long as they understand the ultimate risk is a dead baby.

- Hospital birth sucks a lot of the time but it's still the place to be for the lowest risk to a bad outcome.

- PTSD is in your head and is not caused by the doctor.

- We do not give out awards for big babies birthed vaginally, at home, or by VBAC in any setting so change your signature lines NOW!

- Doctors invented technology and midwives use it unapologetically and never said thank you and that really hurts.

- Scientists (some of whom were simultaneously medical doctors) invented public health, NOT midwives and most of them never said thank you and that really hurts.

- Midwives might've been around since the beginning of people but they did NOT invent obstetrics.

- Home birth advocates are big, fat liars who twist statistics in their favor.

- Most home birth midwives don't have enough education (which reminds me of the time my own OB told my husband to cut the cord quickly because she won't breathe until it is!), therefore they can't possibly know how to assess risk.

Phew. Anyone have any questions? Anything to add?

By Anonymous anonymous wannabe sailorgirl, at 12:58 PM  

I have a question!
Does Anon 1258 represent your arguements Amy? Sounds familiar, although I'm not sure.

By Anonymous Anonymous, at 1:11 PM  

If birth "normally" proceeds uneventfully, why do midwives use so many different tests to determine who is at risk?

Well, of course professional midwives use prenatal testing to help establish low-risk status. We can't look at someone and magically tell! Under the right to informed choice, midwives do tend to use less testing than OBs do - for example, only 9% of our clients last year had ultrasounds - but standard of care testing is an important part of prenatal care, along with good history taking, and normal clinical assessments.

Why are so many patients transferred to hospital care before the start of labor? Why are a substantial portion of patients transferred to hospital care during labor?

I don't agree that the women who left midwifery care after the first (or even a subsequent) visit can be fairly included in the risk-out or transfer rate. That's just presumption. As pointed out, many homebirth families are highly vested in their birth experience, and do certainly "midwife shop" for the best personal and philosophical fit. Midwives also seem to get a lot of referrals from, for example, pregnancy crisis centers, but many of these women want hospital care. Same goes for women who want exclusively female providers, but can't get that in their local OB group. Some women chose the closest care. Some are collaboratively managed by CPMs and either OBs or hospital-based CNMs; for example, women with a history of c/section or known congenital anomaly. They still want the time and education intensive midwifery model for prenatal care, but can’t birth at home. In the Johnson Daviss study of CPMs, the percentage of "drop outs" after the first visit is also likely highly related to a discovery that insurance does not cover CPM care in most places.

Some percentage of both antenatal and intrapartum risk-out from midwifery care is of course necessary and appropriate. There’s no “right” number or rate, and even previous posters have elucidated the complex reasons why: provider differences (CNM vs. DEM, various experience and comfort levels among individual caregivers as well as the varied practice guidelines), state to state differences, different elective choices by families, the population served, etc, etc. So of course an overall national midwifery rate, inclusive of all homebirth providers and clients, remains something to investigate further. We can perhaps average the Johnson Daviss (CPM) rate and the Murphy Fullerton (CNM) rate, but that, as I’m sure Amy and Sailorman would point out, is inexact science.

“Risk assessment”, all professional providers know, is likewise not a black and white issue, though we’d all like it to be. A recent transfer of mine comes to mind: a primiparous mom had heavier than normal bleeding, or show, early in labor (2 cm). FHTs sounded great, I gave it an hour of close observation to ensure it wasn’t just a result of rapid cervical change (it wasn’t). We transferred to hospital – EFHM showed a reactive tracing, bleeding stopped, there was not a thing high risk about it after all. Mom had a lovely, natural birth, minimal monitoring, no wires or tubes, standing over the toilet with dad catching and me watching with joy. (We are lucky to have hospital privileges and manage our transfers and still attend these ladies in hospital).

I’d imagine you’d prefer a higher transfer rate Amy! Though the quoted 34% is blatantly erroneous, the truth is that even that would not seem to me to be beyond the scope of reason. No one ever claimed that OOH birth is appropriate all of the time, certainly no professional midwife ever promises a family that their ‘idealized’ birth will be realized.

If 1/3 of "normal" patients develop complications, what does "normal" mean?

Normal means that most of the time, pregnancy and birth are healthy and without complication. I think we have all agreed on that. It does reconfirm for me that many obstetricians aren’t exactly sure WHAT normal is, which is exactly part of the problem of modern obstetrics.

By Anonymous maribeth, CNM, at 1:18 PM  

reminds me of the time my own OB told my husband to cut the cord quickly because she won't breathe until it is!

Huh? Can you tell more what you mean Anon? Do you mean your husband wasn't actually qualified by education to cut the cord?! Bwaaahaahaaaaa!

By Anonymous maribeth, CNM, at 1:20 PM  

And on behalf of all midwives, I want to officially say THANK YOU to all the broad shoulders (physician, midwife, nurse, and so on) that we stand on today.

I for one was never NOT grateful to all of them, though, and to me, that's a similarly false assumption or MYTH that Amy criticizes proponents of the midwifery model of care for.

By Anonymous maribeth, CNM, at 1:24 PM  

Huh? Can you tell more what you mean Anon? Do you mean your husband wasn't actually qualified by education to cut the cord?! Bwaaahaahaaaaa!

No, anyone can cut a cord silly. The point was that it had to be cut immediately because otherwise the baby would not take her first breath until it was done. I'm not an expert in anatomy and physiology so this very well may have been true but I'm skeptical.

Anon 12:58

By Anonymous Anonymous, at 1:24 PM  

The point was that it had to be cut immediately because otherwise the baby would not take her first breath until it was done

HUNH? Your doctor told you that? (or do you mean he or she needed more education?). Delayed cord clamping is now advocated by even medical groups, and amazingly, all the babies are still breathing!

By Anonymous maribeth, CNM, at 1:52 PM  

Seems coerced to me...

I understand, but it's absolutely genuine. I just didn't know it needed to be said here. For me, it's a foregone conclusion. I never, ever, thought differently. Maybe some do, can others comment? I am a nurse-midwife, was a nurse for years before I even knew about midwifery, so maybe it's my background, but it's just an assumption that everyone knows this. That does not mean all women need physician or medicalized care, of course...

By Anonymous maribeth, CNM, at 1:56 PM  

"I understand, but it's absolutely genuine. I just didn't know it needed to be said here. For me, it's a foregone conclusion. I never, ever, thought differently."

I agree, Maribeth. It seems to me that Amy is presenting this debate as an either or question. I have asked several times why in this country we cannot work toward an integrated system of care where midwives and OBs work together.

I know for me that home birth was never an option for me with my second pregnancy. I had a very large fibroid (discovered by my nurse MIDWIFE). I had a transverse baby with the fibroid below his head and I knew there was a very good chance of needing a c-section. So, I chose an OB who I knew was an excellent surgeon. He was actually quite a jerk with a horrible bedside manner but I was very thankful for his skills.

All in all my second pregnancy was very unpleaseant right on through delivery. But, things were abnormal and out of my control. With my third, I was very healthy, my baby was very healthy and I don't know why I should have subjected myself to the unpleasant hospital experience if it wasn't necessary. Treating me in the same high tech way as I was treated in my second pregnancy was unnecessary and since everything was NORMAL, I thought that the hypervigilance would turn into a self fulfilling prophecy.

By Blogger Mama Liberty, at 2:31 PM  

"- Normal is not without risk"

Show me where homebirthers say there is no risk with normal.

"- Home birth is NOT safER than hospital"

I feel that it is as safe as the hospital, but I admit that I need to reread the studies and see Amy's interpretations. But to me "safe" means many different things.


"- Home birth IS safe for SOME women and babies, so long as they understand the ultimate risk is a dead baby."

And there is no risk of a dead baby in the hospital? Do OB's explain to their "patients" that they have increased risk of cesarean, episiotomy, instrumental delivery, etc while birthing in the hospital? Because as a midwifery student, I can tell you that we do give informed consent to our clients that there are situations that come up where being in the hospital would have been best, because transfers even by ambulance do take time, and time is very important when something emergent and sudden has happened. We don't just tell people that homebirths are safe and not without risk, there are risks, and we explain them. Some people will choose homebirth, and others will not.

"- Hospital birth sucks a lot of the time but it's still the place to be for the lowest risk to a bad outcome."

Different people define bad outcome differently. If you believe that it has the lowest risk for neonatal mortality, say that, but bad outcome is too broad of a word. There are many different things considers bad outcomes, some may be considered worse than others, but people look at the risks of many different bad outcomes and weigh the risks and benefits for themselves.

"- PTSD is in your head and is not caused by the doctor. "

Show me the data. Are you saying that PTSD could never be caused by a doctor?

"- We do not give out awards for big babies birthed vaginally, at home, or by VBAC in any setting so change your signature lines NOW!"

Get over it. You are quite bitter about this as well. Why are you so concerned with what someone has in a signature line, I think that would be your issue to deal with, it definitely sounds like a sore spot for you.

"- Doctors invented technology and midwives use it unapologetically and never said thank you and that really hurts."

I don't know where you are from, but here, many midwives and doctors get along. The midwives I know here are not unthankful for the technology. This is a very broad statement, and seems very extremist to me.

"- Scientists (some of whom were simultaneously medical doctors) invented public health, NOT midwives and most of them never said thank you and that really hurts."

Again, things are not like that here. I know many midwives who went on to get their MPH's. They are not ungrateful for public health.

"- Home birth advocates are big, fat liars who twist statistics in their favor."

Okay, you are quite extreme and it's hard to take anything you say seriously now. Statistics have been twisted around by Amy as well, but once that has been pointed out it is not addressed. You again make very broad generalizations, and your statement is very childish.

"- Most home birth midwives don't have enough education (which reminds me of the time my own OB told my husband to cut the cord quickly because she won't breathe until it is!), therefore they can't possibly know how to assess risk. "

I agree that there are some home birth midwives who don't have enough education, I do agree on that.

"Phew. Anyone have any questions? Anything to add?"

Yes. Your cutting the umbilical cord story was great. Thank you. I do feel that cutting the cord sometimes can help trigger breathing. But all the babies I've seen born who have had delayed cord clamping have breathed.

By Anonymous RN midwifery student, at 2:33 PM  

RN Midwifery Student, I think you missed that anonymous 12:58 was summarizing all of Amy's points, not making additional points.

By Anonymous Clever ID, at 3:00 PM  

Anonymous wanna be sailorgirl was being satirical. I think.

It's funnier read straight, though.

By Anonymous Joanna, at 4:11 PM  

Personally, I don't think homebirth midwifery can reconcile the concept of "normal" with the reality of so many complications. Homebirth advocates don't even attempt to reconcile this conflict; they simply pretend it doesn't exist.

It's not that homebirth midwifery is unaware of complications. Quite the contrary. Homebirth midwives understand that pregnancy and birth involves a substantial number of complications. They screen for those complications and they divert complicated patients to hospital care.

So homebirth midwives "market" birth as being "natural" and "not a disease", but their actions show that they know that this is not true.

By Blogger Amy Tuteur, MD, at 5:36 PM  

Why was my last post removed, and there was another post also that was removed? What were the reasons?

By Anonymous RN midwifery student, at 10:56 PM  

"So homebirth midwives "market" birth as being "natural" and "not a disease", but their actions show that they know that this is not true. "

Actions by midwives show that they KNOW it's not true that birth is natural? Is that really what you are saying?

Midwives are aware their are risks, obviously, even you said so. Just because something is natural does not mean there are not risks involved. Birth can have risks, yet also be a natural event.

By Anonymous RN midwifery student, at 11:00 PM  

transfer rates 15 % several were for pain relief-- So if we were in Great Britain ( as you have so kindly shared with us) we could give moms nitrous I guess and that number would be less-- and your worries about pain in labor would be allayed.
You know there is an older book out that might help you to understand the different choices women make- A GOOD BIRTH A SAFE BIRTH is the title,

By Anonymous Anonymous, at 12:04 AM  

Amy I would like to hear from you about why posts are being deleted.

By Anonymous Anonymous, at 12:42 AM  

If midwives accept--as you seem to--that you're often going to need medicine (or at least want it for insurance) quite a bit, even in the best of times, why the polarity?

Well, we've all met extremists. But truly, in the community where I am fortunate enough to work in, I don't see any polarity at all. Most pregancies will progress normally. But if they are not, you need medical care. End of debate.

Sweeping statements are so frustrating. Lumping all "Home Birth Advocates" in one pool is so unfair to the majority of midwives. And in my experience, the generalized and foolish opinions (of the home birth fanatics) that you are posting belong only to a small (but vocal) minority. I come across them myself occasionally. And you and I stand on the same side of that debate. Of COURSE it is ignorant to say that "Birth is normal, no matter what."

A couple of years ago an doula told me, "Maybe if we just believed strongly enough, all births would go perfectly." Yeah right. And nature also makes all the apples grow perfectly and none of them rot.

By Anonymous Diane West, LM CPM, at 12:52 AM