Boasting
Women who have had a homebirth often boast about it long after the fact. What's up with that?
When I search on the keyword "homebirth", it often comes up in situations that are not about birth. Weight is usually included. A woman will refer to a child as "my homebirthed son, all 9 lb 9 oz of him", as if the fact that she has an ample pelvis is some sort of personal achievement for which she can take credit.
I don't think I've ever seen a woman who gave birth in a hospital make reference to her child as "hospital birthed". I've never seen a woman who had natural childbirth for philosophical reasons refer to her child as "my natural childbirth born daughter", either. It is striking to me that women are shoe-horning references to homebirth in when they discuss a child who may be a toddler or older.
Labels: feeling superior
Should doctors provide back up for homebirth?
Homebirth midwives cannot and should not practice without obstetrician back up. However, many obstetricians, myself included, refuse to back up homebirths.
Most of the time a homebirth will go well and no assistance of any kind is needed. However, it is virtually guaranteed that there will be some serious problems (10% or more of homebirths). So when an obstetrician backs up a homebirth midwife, he or she is agreeing to handle only serious problems. Furthermore the problems are often compounded by the fact that there is a delay between discovery of the problem and transfer of the patient, turning some of these problems into life threatening situations. In addition, the obstetrician has no prior relationship with the patient and enters a situation that the patient had been determined to avoid.
Given the fact that backing up a homebirth represents everything an obstetrician wants to avoid (a serious complication, a delay in properly managing it, and a patient who considers the doctor a stranger), doesn't it make sense for the doctor to refuse to back up a homebirth?
Isn't a high rate of interventions a small price to pay for a live baby?
One thing that has become quite clear from reading the homebirth papers is that no one, not midwives and not doctors, can predict a certain subset of serious emergencies. Our diagnostic tests and skills often cannot predict which women will have an abruption or which babies will have significant meconium aspiration, for example.
Most parents feel that the death of a baby in childbirth is an intolerable and unacceptable outcome. They are willing to do virtually anything in order to insure the health of their baby. Doctors feel the same way and have been constantly trying to lower the neonatal death rate to zero. At the beginning of the 20th century, there were a series of medical breakthroughs that began to substantially reduce neonatal mortality. These included anesthesia, blood banking, antibiotics and the entire field of neonatalogy. Each new medical advance lowered the neonatal death rate further, but as we get closer to zero, there is going to be less and less return on the addition of new technology.
Doctors and parents do not want to give up at this point and say that we have achieved the lowest neonatal deaths rates possible. They don't want a single baby to die unnecessarily. In response, the use of technology has crept ever upwards and the threshhold for acting on information has dropped lower and lower. In a very real way, the rising C-section rate reflects this. There is no more fetal distress now than there was in the past. Now, however, borderline cases are being examined more closely, and many women who never would have had C-sections for fetal distress in the past are having them now.
We have some tools for assessing fetal distress in labor including electronic fetal monitoring and fetal scalp sampling for checking the pH of the baby's blood to determine if it lacks oxygen. Unfortunately, though, these tools are not very specific. They are accurate in that they pick up all cases of fetal distress, but they include many more cases in which fetal distress is not really present. In the future we may have a tool similar to the oxygen saturation monitors (clipped over the end of a finger) that adults and children use when under anesthesia or during a hospitalization for serious illness. Oxygen saturation monitors can tell us in real time whether a person is getting enough oxygen and can show us in real time if different maneuvers improve the level of oxygen in a patient's blood stream. Until we have such a tool for babies in the uterus, we will have to make do with the indirect tests that we have now.
A similar situation applies to breech babies. Most can be delivered vaginally without a problem. However, there is no way to accurately predict which ones will have trapped heads and die or sustain serious damage as a result. In response, we offer C-section to all women with breech babies.
There is no doubt that c-sections for breech have saved lives and this is reflected in the dropping neonatal death rates. It is much more difficult to assess the effect of the rising C-section rate because we are only talking about the occasionally baby. The result may be a drop of a fraction of a percentage point, and it may get lost in the vast number of deliveries each year.
Like most obstetricians, I am inclined to think that a high rate of interventions is a small price to pay for a healthy baby. I think that most parents do, too.
Homebirth and the disadvatages and wisdom of hospital birth
The studies of homebirth can tell us a lot about hospital birth. A lot of things that happen in the hospital have been instituted because they presumably insure better outcomes. By looking at the homebirths, we can see that much of the technology is not needed.
Obviously the C-section, forceps and vacuum delivery rates are too high. Most women do not need or benefit from electonic fetal monitoring. Most deliveries will never require any resucitation.
However, homebirth also tells us something very important about birth that goes a long way toward justifying the overuse of certain procedures in hospitals. No matter how carefully midwives screen for risk, 10% or more of low risk women in labor will develop complications that necessitate transfer to the hospital. That undoubtedly applies to hospital deliveries, too. No matter how carefully the hospital staff screens low risk patients, 10% or more of them will go on to develop serious complications. There does not appear to be any way for midwives or doctors to tell in advance which patients will make up that 10%.
Homebirth midwives and doctors deal with this uncertainty in strikingly different ways. Homebirth midwives essentially assume that nothing bad will happen; these complications will make themselves known long before they can harm the baby, and the midwife will be able to transfer the mother to the hospital before any damage is done. The doctors go in the other direction. They institute procedures like electronic fetal monitoring to pick up the 10% complications as early as possible. They reason that although 90% of low risk women never need EFM, we can't figure out in advance who they are so we should monitor everyone.
The studies of homebirth tell us something important about the assumptions of homebirth midwives: when it comes to the ability to handle complications, they are wrong that place of labor makes no difference. The strikingly high neonatal mortality rates among patients transferred during homebirth attest to the fact that if a complication occurs at home, the chance of a bad outcome is dramatically increased.
There is no doubt that homebirth has advantages. If you have a homebirth you will dramatically reduce the risk of an unnecessary C-section or forceps delivery; you will not have EFM, you will not have an episiotomy. In exchange, you only put one thing at risk at homebirth: the life of your baby.
Urgent transfers
Not all the studies broke down the transfer rate by urgency. I could find three that gave enough information to determine which transfers were done on an emergency basis. As might be expected, the neonatal deaths came from this group. If you look at the death rate for emergency transfers from homebirths, the results are even more dismal.
Johnson & Davis: 11 deaths in 252 emergency transfers for a death rate of 44/1000.
Murphy & Fullerton: 4 deaths in 36 emergency transfers for a death rate of 111/1000.
Janssen: 8 deaths in 142 emergency transfers for a death rate of 56/1000.
These death rates are enormous and confirm obstetricians most serious criticism of homebirth, that babies in need of emergency care will die for lack of such care at home.
Labels: neonatal mortality
Transfers
One of the things that I have emphasized repeatedly is that most homebirths will proceed without any problems, and in that case, it doesn't matter who is there. It only matters when something goes wrong. Of most concern to me is situations in which a complication occurs that requires an obstetrician or neonatalogist to save the baby. Homebirth advocates counter that they can recognize such situations in time and transfer the mother or the baby to the hospital.
Let's take a look at what happens in these situations. Below is a table created from data from four major studies that claim to show homebirth as comparable in risk to hospital birth. This table shows the percentage of attempted homebirths where the mother was transferred in labor or where the baby was transferred after birth. It also shows the death rate of babies in the transfer group.
The transfer rate in labor or immediately after delivery is between 10-16%. So even in situations in which the mothers are considered perfect candidates for homebirth, more than 1 in 10 will require transfer to the hospital. This is not a trivial number. It means that anyone contemplating homebirth must anticipate that there will be a significant need for transfer to the hospital.
Of course, we expect the midwives to transfer patients to the hospital when they encounter a problem. The assumption is that the transfer will ensure that the baby will be healthy, because it will receive needed medical treatment in time. The truly startling result is the death rate in the transfer group. It is extraordinarily high, ranging from 21-74/1000. Put another way, the need for transfer in labor or immediately after delivery resulted in the deaths of 2.1%-7.4% of the babies transferred.
These numbers call into question some of the central claims of homebirth advocates. The first claim is that they can accurately predict which women are of such low risk that homebirth will be safe. The second claim is that their ability to recognize problems during labor and transfer patients ensures the safety of all babies. These extraordinarily high death rates suggest that if something does go wrong in labor, a disaster is may well ensue.
Labels: neonatal mortality
Drugs at homebirth
I just learned something that surprised me. I thought that there were never any medications for pain relief at a homebirth. I was perusing Angela Horn's
Home Birth Reference Site and read the section on pain relief at home:
Entonox [nitrous oxide and oxygen] appears to be a harmless drug which is quickly cleared from the mother's body. It is inhaled by the mother from a mouthpiece or mask. Midwives will routinely bring it to home births in many areas of the UK. The only problems associated with it seem to be if the mother gets too 'high' and cannot push effectively in the second stage, or if she finds herself depending on the drug and then the canister runs out.
It is fairly common for supplies of Entonox to run out at home births and you may have to wait some time for a new canister to arrive from the hospital. It is also fairly common for canisters and mouthpieces to be faulty, so if you feel very strongly that you want to have Entonox available, perhaps your birth partner could ask the midwife to test her stash when she first arrives. The National Birthday Trust study found that Entonox was used at 50% of home births surveyed, and 73% of the hospital births.
I wonder why there is opposition to epidurals. The medications in epidurals do not enter the bloodstream at all or in very small amounts, but nitrous definitely crosses the placenta and affects the baby. It also calls into question the assertion that childbirth at home is less painful than in the hospital, or that natural childbirth techniques make the pain manageable.
Labels: pain
Check out the story of the New Zealand CNM
Check out the story of the New Zealand CNM about her homebirths on the
Birth Experiences message board. Very impressive!
Competitive mothering
Opinion alert: The following is my
opinion. I have no references to offer in its defense.
It seems to me that discussions about homebirth and natural childbirth are often driven by competitive mothering. Other women sense that and are really angered by it.
Competetive mothering is hardly exclusive to homebirth and natural childbirth. It is a pervasive feature of mothering among women of all philosophies. I remember when my children were small, I could not go to the playground without some mother spying one of my children and remarking with apparent sympathy and regret: "Still wearing diapers. That's too bad. My Sam was toilet trained before his first birthday." or "Isn't it a shame that you didn't get much sleep last night because one of your children woke up with nightmares and you brought him into bed with you. I'm afraid that this will go on and on until you put your foot down and teach him to comfort himself in his own bed." I would think to myself: Yeah, right. If I'm going to put my foot down anywhere, it'll be on your smug face.
Mothering is a very difficult job and one of the most difficult things about it is that you don't know how you're doing until your children are much older, and maybe not even then. This engenders tremendous insecurity in mothers and they try to compensate by arbitrarily selecting some practice or practices and insisting that doing them a certain way automatically assures that they are a good mother. So refusing to give a child a pacifier, or early toilet training, or banning TV are elevated to the level of sacred duties. If you do it that way, you are a great mother and if you don't you are bad.
Natural childbirth (and homebirth as a variant of it) are often wielded by women in the same way. That's why there is fierce insistence that natural childbirth isn't just a "choice", it the safest, best choice that a good mother can make, and anyone who doesn't make that choice is by definition a "bad" mother. There is really no evidence that natural childbirth is better for babies, but you aren't going to get certain advocates to acknowledge that. Often they need to believe it, just like other mothers need to believe that early toilet training or banning TV automatically elevates you above the mothers who do neither.
Labels: feeling superior
You've gotta admit ...
While there may not be many people who have changed their minds about homebirth, you've gotta admit that this discussion has really honed your skills. The level of debate has risen very dramatically. People are now picking apart papers like pros. I'm impressed!
Of course, it makes a lot more work for me. Now I really have to scramble to keep up.
The skills that people are acquiring are the skills that are needed to put direct entry midwifery on a more scientific footing. These skills will lead eventually to studies that may, indeed, show the safety of homebirth.
Are natural childbirth advocates honest about pain?
There is a fair amount of antipathy from other women toward advocates of natural childbirth. I think some of this comes from the fact that many women feel betrayed by their natural childbirth educator who downplayed the nature of labor pain. I certainly have had quite a few patients who said "no one ever told me what it would really be like". I wonder why natural childbirth educators are often not honest with the women they teach.
I came across this humorous take on the subject. From
"Natural" Childbirth--the Big Lie:
To my untutored mind, the words "natural childbirth" conjured up visions of the brainwashed masses whose childbirth experiences had been unnatural: distorted and deformed from God's intent by the immoral overuse of pain relief. I saw in my mind's eye hoards of cowardly, superficial crybabies hooked up to IVs and epidurals in chemically sterile tombs. Those women, the unnatural ones, had fled from the miracle that is birth and had sold their souls to the corporate modern devil in order to escape a little bit of temporary discomfort. I had no respect for them and refused to join their ranks. I, the authentic woman, was going to do it the Natural Way.
Oh, they had me all right.
When I got to the class, my instructor was a very lovely, friendly woman who had either given birth multiple times herself or who had seen hundreds of other women do it. She had all the couples sit in a cozy circle and told us how simple it was for strong women to control and enjoy the birth experience, and congratulated us for choosing to be there. "I can tell you really care about your babies," she said. After a few weeks of such treatment, if she had told us all to go rob abank we would have done it and believed it proved how much we loved our babies.
She had a name, but I will call her Liar.
Liar wanted us to believe that her so-called "natural" method would allow us to really experience birth and thereby become closer to our babies. She taught us to breathe in a regular rhythm and stare at some symbolic object, in order to focus our minds elsewhere and take our focus off the discomfort (there was never pain in Liar's class-- only discomfort). Now, years later, I see the contradiction in that. If one can only get through the birth experience by thinking about something else, one is emphatically NOT getting closer to one's baby during the experience. But I digress.
Labels: "natural" childbirth, pain
Dr. Durand and the Farm study
Several weeks ago, Jamie mentioned that she had corresponded with Dr. Durand, the author of the Farm study. I asked her to invite him to participate in this discussion, but she felt that he would not be interested given his other substantial time commitments. She promised to share what she learned from him, and now she has. She has reprinted (with his permission) a lovely
letter on her website.
I was disappointed to see that there was no specific defense against the criticisms that have been raised against the Farm study. Here is the relevant passage:
Dr Tuteur is mistaken in her reading of the Farm paper- even after controlling for the differences in race between the Farm and comparison (National Natality Survey) populations, the infant mortality rate was actually less in the Farm group, though not significantly so by statistical testing (and since the statistical tests fail to show a significant difference we cannot say with confidence that either group had better results for this outcome measure).
Unfortunately, there is no explanation for the statistical problems with the study including failure to quote the actual neonatal death rate from the homebirth group and the use of NNS/NFMS group as the control group Essentially, Dr. Durand compared the results at the Farm with the results of all American deliveries, including all races, all gestational ages and all medical complications, except those specifically excluded at the Farm. Most importantly, Dr. Durand does not acknowledge that there is actual data about the true neonatal mortality rates of low risk white women at term from the time period, and they are very substantially lower than the neonatal mortality rate from the Farm.
Labels: neonatal mortality
What would the baby think?
I am starting to notice a new fallback position: Well, there may be an increased risk of neonatal mortality at homebirth, but mortality isn't the only standard.
I agree that neonatal mortality is not the only maternal standard, but what would the baby think?
If the baby were able to think about this and convey its thoughts, would it really care about anything beyond its life and health? There are all sorts of experiential factors like epidural and episiotomy and C-section, but wouldn't the baby rate those a very distant second behind the possibility that it might be asphyxiated to death during labor or that it might be born with a medical problem and no expert medical help available?
Labels: philosophy
From Sailorman: What would it take?
Sailorman asks the following question:
WHAT WOULD IT TAKE?
We have identified two studies which have been a matter of much debatebetween those claiming that home birth death rates are higher thanthose in the hospital, and their opponents. Those studies are the
Johnson and Daviss study, and
the Farm study.
Dr. Amy's and my argument essentially boils down to this: "the data were faulty. If they did proper study analysis, their answer would have been different".
Their opponents argue, in essence: "there is nothing wrong with the data. The analyses were properly done, and the printed conclusions are reliable".
If you're a supporter of these studies, WHICH OF THESE OPTIONS is most correct?
A: I would change my mind about the results of the studies if a well known home birth advocate did so publicly.
B: I would change my mind about the studies only if the authors retracted the study.
C: I would change my mind about the studies only if an epidemiologist told me the authors interpreted the study incorrectly.
D: I would change my mind about the studies only if a statistician (not an epidemiologist) explained that the authors interpreted the study incorrectly.
E: None of the above options would cause me to change my mind about the studies.
Previous assault, childbirth, PTSD
I'd like to explore this remarkable connection a bit further. There definitely seems to be a notable association of these phenomena: a history of previous sexual assault, a bad childbirth experience, and PTSD. Here's my question:
Why is there such a ferocious insistence that it was the childbirth experience that caused the PTSD and not the previous sexual assault? Afterall, sexual assault is almost by definition a horrific, frightening, demeaning experience. PTSD is a well known phenomenon after sexual assault. Childhood molestation is equally horrific, frightening and demeaning. It represents a terrible betrayal of a vital trust and often occurs repeatedly over a number of years. Again, PTSD is a well known result after such a trauma.
Yet here we have a group of women who have been sexually assaulted in some way, and they are adamant in their insistence that the assault did not have serious psychological repercussions. They were fine until they had a baby. The psychological issues became apparent then and, therefore, it must have been the doctor's fault.
I'm not sure that I would have even noticed this if even a few people had said "yes, I had a really bad birth experience, but I know my experience was affected by the assault in my past." Yet no one has said that. Instead they have insisted, absolutely insisted, that the original attacker bears no responsibility for their current psychological issues; the doctor bears all the responsibility.
What is going on here? No matter what the doctor did (and while I have a very hard time believing some of the reports, it is certainly possibly that at least some of what is claimed is true), it could not begin to compare to the original assault. I am almost forcibly struck by the level of anger toward the doctors. I can practically feel the hostility through my computer. Yet there is a curious lack of emotion toward the original assailant. The level of anger directed toward the doctor seems startlingly high, and the level of anger toward the assailant seems curiously low.
It feels like there is a psychological need to blame the doctor INSTEAD of the original attacker. Why should that be?
Sexual assault and homebirth advocacy
I am repeatedly struck by the high level of self-reported childhood sexual abuse and rape in homebirth advocates. I just put in the words "rape survivor homebirth" into Google and found 15 separate instance of phrases like "since I am a survivor of rape, I wanted a homebirth" or "as a survivor of rape I knew that the way my OB treated me what just like rape". On this message board, on NHS Blog Doctor, and on personal blogs I have come across additional stories of childhood sexual abuse and rape among homebirth advocates.
Are there any figures on the numbers of homebirth advocates who have been sexually assaulted? I have cared for thousands of women over many years, and seen much more sexual abuse than I ever knew existed, and yet I have never come across such a high incidence of previous sexual assault in any other group before.
I wonder about the significance of this. Are women attracted to homebirth advocacy because of past sexual abuse? I have already suggested that women who claim to have PTSD after childbirth probably have PTSD from previous abuse, not from the birth experience. The extraordinary level of previous sexual abuse among homebirth advocates seems to confirm this. Frankly, I am startled by this connection. I had never considered homebirth advocacy as in any way related to a history of assault.
How do we determine an acceptable level of risk?
Everyone acknowledges that some situations are high risk and some are low risk. Risk, of course, exists on a continuum.
At what point do direct entry midwives and homebirth advocates consider that the risk in a situation justifies moving a woman from low risk to high risk? Is it a specific number (the chance of a problem in this situation is x%) or is it based on rules about particular situations? Why is it that some DEMs place certain women in the low risk group (postdates, for example), while obstetricians would consider them high risk?
Labels: risk
Episiotomy
Obstetricians change their practice based on clinical research. Episiotomy is a case in point.
Has the Use of Routine Episiotomy Decreased? Examination of Episiotomy Rates From 1983 to 2000
Obstetrics & Gynecology 2002;99:395-400
Jay Goldberg, MD, David Holtz, MD, Terry Hyslop, PhD and Jorge E. Tolosa, MD, MS
ABSTRACT
OBJECTIVE: To determine if practice patterns have been altered by the large body of literature strongly advocating the selective use of episiotomy.
METHODS: An electronic audit of the medical procedures database at Thomas Jefferson University Hospital from 1983 to 2000 was completed. Univariate and multivariable models were computed using logistic regression models.
RESULTS: Overall episiotomy rates in 34,048 vaginal births showed a significant reduction from 69.6% in 1983 to 19.4% in 2000. Significantly decreased risk of episiotomy was seen based upon year of childbirth, black race, and spontaneous vaginal delivery. Increased association with episiotomy was seen in forceps deliveries, and with third- or fourth-degree lacerations. In deliveries with known insurance status, having Medicaid insurance was also associated with a decreased episiotomy risk.
CONCLUSION: There was a statistically significant reduction in the overall episiotomy rate between 1983 and 2000. White women consistently underwent episiotomy more frequently than black women even when controlling for age, parity, insurance status, and operative vaginal delivery.
Do homebirth advocacy websites inform or misinform?
The Farm Study has been extensively discussed here and most of us agree that it shows an unacceptably high neonatal mortality rate and that the conclusions of the paper are in no way justified by the results.
So why is it that every major homebirth advocacy website cites this paper and often quotes the abstract in support for the safety of homebirth? The paper has been thoroughly discredited and I have not seen a homebirth advocate offer an effective defense of its methods or conclusions when directly confronted with the results.
How can the average woman trust the information on a homebirth website when some of the most basic information it provides isn't even true?
Birth trauma, how should we talk about it and how should we interpret it?
The debate about homebirth is still going on over at NHS Doctor. As inevitably happens, a homebirth advocate equates the experience of hospital birth as "like a rape". Here is the response I posted to that comment:
"I find that comment extremely offensive. It trivializes the trauma of women who actually have been victims of rape. It is grotesque to compare being disappointed in your birth experience to the reality of physical and sexual violence."
I was surprised to get several private e-mails about my comment, some of which tried to explain to me why hospital birth can indeed be like rape.
I certainly stand by my original comment, but I want to amplify it. There are two specific issues that concern me, the irresponsible use of language, and the association of these feelings with previous sexual assault.
I do not deny that birth could be traumatic, but I feel very strongly that we need to be more sensitive and aware in our use of language.
We live in a culture where shock is used to market products and where shock is used to make oneself noticed. I fear that that has contributed to a degradation of the way we use language that should be reserved for certain specific instances. For example, many groups blithely complain that this or that act is "like a lynching". No, unless someone was lynched, the use of that term is grotesque. In this country a real lynching was often about hanging innocent black men from trees in the middle of the night, just to express a vitriolic form of racism. It demeans the suffering of so many black men and boys to use the term "lynching" in a rhetorical way.
Similarly, rape has a certain specific connotation. If someone wants to say that the way their doctor treated them felt like an assault, fine. However, to describe it as a rape or like a rape, in my judgment, is to appropriate the term for its shock effect. It is demeaning to women who have been victimized by this specific type of violence.
Second, I have begun to look into the apparently close association of birth trauma with previous sexual assault. It is an association which has been suggested to me primarily by women who consider themselves victims of birth trauma. In their minds, the sequence of events seems to be childhood history of sexual assault, birth trauma, PTSD brought on by the events of the birth. People have simply assumed that the doctor's treatment was equivalent in some way to the original assault.
This not really consistent with the way post traumatic stress syndrome is known to occur in others. I would like to suggest that the sequence is more like this: childhood history of sexual assault, PTSD aggravated by the sexual connotations of reproduction and birth, birth trauma as a manifestation of PTSD from previous events.
In other words, birth trauma does not cause PTSD. Rather PTSD leads these women to experience birth like their previous sexual assault, even though
an outside observer, even a homebirth advocate, would not find the doctors behavior objectionable.
I am reminded of a friend who was a victim of incest by her father over many years. As an adult, she needed to have an ultrasound, and in that situation a vaginal ultrasound would typically have been recommended. She was honest with her doctor, however, and told the doctor that she could not tolerate anything in her vagina because it brought back her original experiences. The doctor and the radiologist made special arrangements to do a slow and detailed abdominal ultrasound rather than subject her to the vaginal ultrasound which would have been quicker and easier (for them).
If my friend had not been brave enough to confide in the doctor, she might have undergone a very traumatic vaginal ultrasound. She would have experienced it as reminding her of the original assault. That does not mean however, that the technician would have been unkind or unprofessional or brutal. Her subjective experience would have been transformed by her memories.
Incest, particularly, is a difficult crime to reconcile psychologically. The assault may have been committed at the hands of a beloved parent and it is hard to hold two such contradictory views in one mind. The effects never end. How much easier, then, to psychologically off-load the original assault onto the head of the doctor, a stranger. Perhaps women who have been victimized in the past blame the doctor as a way of redirecting their original anger in a more psychologically tolerable direction. In their minds, they are no longer suffering from PTSD because of assault by a beloved relative; all of a sudden, they are suffering PTSD because the doctor, a stranger, violated them.
When a former soldier with PTSD reacts violently to those around him in a shopping mall parking lot, believing himself to still be under gun fire, no one actually thinks that the people in the parking lot were shooting at him. Similarly, when a woman with PTSD reacts strongly to a doctor, believing herself to still be in the deeply abhorrent state of being victimized by sexual assault, we should be extremely wary about concluding that the doctor was actually assaulting her or treating her badly.
I want to be very clear in what I am saying:
1. Victims of childhood sexual assault may develop PTSD.
2. PTSD may lead women to experience events in childbirth in a way that is not consistent with what is actually happening. There is nothing traumatic going on at the time of birth (similar to the soldier who believes himself to be under gunfire in the parking lot when there is none).
3. The doctor has done nothing to precipitate PTSD (just like the people in the parking lot of done nothing to even remotely suggest that they are shooting at the former soldier).
4. The reaction of the woman to the birth tells us about her, and her psychological state. It tells us nothing about the doctor's behavior.
5. The appropriate response is psychological counselling which explores the original assault and its current psychological manifestations. It is inappropriate to conclude that the woman was treated poorly during labor and delivery.
This sequence is consistent with what we know about PTSD and what we know about the effects of childhood assault.
The alternate world of homebirth advocates
Homebirth advocates are well aware that doctors do not approve of homebirth. They are unwilling to take doctors' explanations at face value. Yes, doctors, such as myself, cite evidence that homebirth midwives simply don't have the qualifications necessary to prevent neonatal deaths in the case of complications. Homebirth advocates cannot and will not acknowledge the evidence. Instead, they have created a alternate world where obstetricians are so benighted by their lack of experience with normal birth that they are incapable of understanding it.
In this alternate world, all hospitals have epidural rates of 90%. In the alternate world, epidurals create lots of complications. That's good as far as obsetricians are concerned, because they like complications.
In the alternate world, obstetricians have rarely if ever seen natural childbirth. In fact, it is so rare, that obstetricians don't even know what natural childbirth is and, therefore, have no appreciation for how sublime and wonderful it can be.
Evidentally, there are no female obstetricians in the alternate world, since no obstetricians have any first hand knowledge of birth.
In the alternate world, obstetrics textbooks don't mention natural childbirth since it doesn't happen. Obstetrics textbooks are filled with ways to manage the complications that obstetricians like to cause.
In the alternate world, obstetricians have no patience. They invent reasons to complicate childbirth so they can intervene and get back to making more money. They are very afraid of midwives, too. That's also about the money. The obstetricians think that homebirth midwives will threaten their income stream.
What really remarkable is that homebirth advocates have never actually worked with obstetricians. Most have never worked in hospitals either, but they have such acute perception that they know what goes on in hospitals without actually being there.
Well, I'm an obstetrician and I come from the real world. The alternate world that homebirth advocates have created in their own minds simply does not exist. They are wrong about the pre-obstetrics mortality rates; they are wrong about the epidural rates; they are wrong about what obstetricians do and do not see in their training; they are wrong about what is in obstetrics textbooks; they are wrong about the "golden age" of midwifery; they are wrong about why midwives and homebirth were displaced, the list goes on and on.
Most importantly, they are wrong about the thinking and motivations of obstetricians themselves. Many obstetricians are women. Not only do they have extensive professional experience, but many have personal experience as well. We argue against homebirth because we have seen evidence that it is not safe. There is no other reason; there is no conspiracy; there is no ulterior motive.
Direct entry midwives and hospitals
Although the terms are occasionally used interchangeably, there are really two different kinds of midwives, certified nurse midwives (CNMs) and direct entry midwives. On this board, we have generally been discussing direct entry midwifery.
There is a lot of talk about doctors being unsupportive of midwifery, but that is not really true. The number of CNMs in the US is growing rapidly. They are incorporated into physician practices large and small, and they have hospital privileges (as long as they have physician back up). So doctors are actually quite supportive of midwivery.
On the other hand, there are women who would like to assist in childbirth, who do not have the education and training of CNMs. Some of them simply call themselves lay midwives. Others get certification from degree granting programs run by direct entry midwives. Most doctors (myself included) will not work with them and they cannot get hospital privileges. This gives rise to several important questions.
1. Are direct entry midwives forced to be committed to homebirth no matter what the data is, because they are out of a job otherwise?
2. Do direct entry midwives misinterpret the hostility of doctors? There is a lot of talk that the doctors' hostility reflects a preference for intervention, or a failure to understand the way that birth should be. However, isn't it more likely that doctors object to direct entry midwifery simply because they don't think that direct entry midwives are adequately trained?
3. Is it really possibly for a direct entry midwife to be adequately trained since she is exposed to very few birth complications? If she does not train in a hospital, she cannot ever observe management of the most common emergencies during labor and delivery?
4. Wouldn't it make a lot more sense for all midwives to become certified nurse midwives?
Labels: midwifery
A new message board
A blog, by its very nature, is dominated by the author. I write the posts and I guide the discussion. A blog offers only limited space for reader comments. I'd like to provide a place where participants can communicate with each other and where everyone can share their birth stories, from the perspective of the mother or the midwife. I'd love to learn more about everyone by reading about the personal experiences that have led them to the convictions that they have today.I also think a message board could be a valuable resource for women contemplating homebirth. Therefore, I have created the
Birth Experiences Message Board.
I will not participate in the message board, but I will monitor it and delete any offensive posts. In addition, I will monitor for people assuming multiple identities on the board. I want eveyone to feel safe here and that means knowing that the person that they are corresponding with is who she appears to be.
The Friedman curve
I have noticed a great deal of misunderstanding in the homebirth community about the Friedman curve, what it is, how it was developed and what it means. That is a shame because homebirth advocates share more with Dr. Friedman than they realize.
I happen to know quite a bit about it because I trained with Dr. Friedman himself. To say it was not a pleasant experience, is a gross understatement. Nevertheless, I would acknowledge Dr. Friedman as the greatest obsetrician of modern times, if not of the entire history of obstetrics. Why? Because he was one of the first to clearly articulate the idea that obstetrics MUST be based on science.
Dr. Friedman did his residency in the 1950s. He was not a man to suffer fools gladly and he considered a lot of his superiors to be fools. He felt that they made medical judgments based on their intuition and not on science, and he set out to accumulate the research data necessary to give the profession a firm scientific foundation.
During his residency, when he was on call every other night, he used his "spare" time to compile detailed observations about every laboring woman who came through the hospital. The goal was no less than to find out what normal labor looked like. Using observations from tens of thousand of women, he created a curve. Women who followed the curve were almost certain to have a vaginal delivery. Women who fell off the curve were more likely to need a C-section.
Dr. Friedman was the first to say that you should not section a woman in latent phase because a long latent phase was not a sign that the baby doesn't fit. He insisted that you should not section a woman in the active phase of labor unless she failed to make a certain amount of progress in a certain amount of time. When Dr. Friedman used to tell stories about the genesis of the curve, he would express the utmost disgust for doctors who would say, "she looks like a C-section to me".
Dr. Friedman went on to win the undying enmity (in some cases, hatred) of his colleagues because he compiled a database about forceps deliveries. He concluded, correctly, that forceps hurt babies and should be banned. He used to travel around the country testifying for the families of children who had been injured by forceps. When he would appear, the family would win.
Dr. Friedman was exceptionally difficult to work for or with, but I always admired his insistence on research evidence. We were never allowed to do social inductions, C-sections without an explicit research-based medical reason, forceps deliveries, etc.
The ultimate Dr. Friedman story was told to me by a doctor who had trained with him. At the end of his residency, after the paper describing the Friedman curve was published to great acclaim, he attended an awards banquet for the residents who were finishing the program. He was introduced with great flourish and took to the podium to say a few words. He said very few words indeed. As it was related to me, Dr. Friedman stood and said: "Thank you for the opportunity to learn so much from the patients in this program. It is a shame, however, that all the doctors are ignorant fools."
Homebirth in Ireland
The following study of homebirth in Ireland showed that the risk of a normal, term baby dying from hypoxia (lack of oxygen) at a homebirth was 50 times higher than at a hospital birth!
Safety of Home Delivery Compared with Hospital Delivery in the Eastern Region Health Authority in Ireland in the Years 1999-2002Author : P McKenna, T Matthews
The Irish Medical Journal, July/August 2003 Volume 96 No 7.
Abstract
A comparison was made of deaths from intrapartum hypoxia of normally formed babies >2.5kg born at home (N =346) and those born in hospitals (N=61,215). If the intended place of birth is home the chance of dying due to intrapartum hypoxia is 1:70 (5 in 346). If the intended place of birth is hospital the chance of dying is 1:3600 (17 in 61,215). Although the sample size of home births is smaller, the difference is significant (<0.01 level of significance). In view of the small number of home births, the need for ongoing monitoring of home births over a longer period is essential.
The need for ancient midwives
My previous post (
Were ancient midwives the obstetricians of their time?) was inspired by an article in Scientific American on the Evolution of Human Birth. This article appeared in a special edition of Sci Am devoted to Human Evolution (2003). The authors of the article, Karen Rosenberg and Wenda Trevathan, explained their scientific work on the subject. Rosenberg is a paleoanthropologist and Trevathan is a bioanthropologist and is also trained as a midwife!
I cannot link to the article because it requires payment, but I can quote some interesting, relevant passages:
"only recently have anthropologists begun to realize that the complex twists and turns that human babies make as they travel through the birth canal have troubled humans and their ancestors for at least 100,000 years. Fossil clues also indicate that anatomy, not just our social nature, has led human mothers—in contrast to our closest primate relatives and almost all other mammals—to ask for help during childbirth. Indeed, this practice of seeking assistance may have been in place when the earliest members of our genus, Homo, emerged and may possibly date back to five million years ago, when our ancestors first began to walk upright on a regular basis."
They go on to describe the differences between humans and their closest evolutionary relatives, the monkeys. Monkey babies are born facing forward, and actually assist in their own birth by pulling themselves out and up once their arms are free.
Rosenberg and Trevathan assert:
"If human babies were also born face forward, their mothers would have a much easier time. Instead the evolutionary modifications of the human pelvis that enabled hominids to walk upright necessitate that most infants exit the birth canal with the back of their heads against the pubic bones, facing in the opposite direction as the mother ... For this reason, it is difficult for the laboring human mother—whether squatting, sitting, or lying on her back—to reach down and guide the baby as it emerges. This configuration also greatly inhibits the mother’s ability to clear a breathing passage for the infant, to remove the umbilical cord from around its neck or even to lift the baby up to her breast. If she tries to accelerate the delivery by grabbing the baby and guiding it from the birth canal, she risks bending its back awkwardly against the natural curve of its spine. Pulling on a newborn at this angle risks injury to its spinal cord, nerves and muscles."
Assisted childbirth has spread to all cultures:
"Of course, our ancestors and even women today can and do give birth alone successfully... Today virtually all women in all societies seek assistance at delivery... So, though rare exceptions do exist, assisted birth comes close to being a universal custom in human cultures.
Knowing this—and believing that this practice is driven by the difficulty and risk that accompany human birth—we began to think that midwifery is not unique to contemporary humans but instead has its roots deep in our ancestry. Our analysis of the birth process throughout human evolution has led us to suggest that the practice of midwifery might have appeared as early as five million years ago, when bipedalism constricted the size and shape of the pelvis and birth canal."
So, although, midwives provided important psychological support, they also provided an evolutionary advantage. Women who had assistance in childbirth were more likely to survive and have infants who were more likely to survive.
"The triple challenge of big-brained infants, a pelvis designed for walking upright, and a rotational delivery in which the baby emerges facing backward is not merely a contemporary circumstance. For this reason, we suggest that natural selection long ago favored the behavior of seeking assistance during birth because such help compensated for these difficulties."
I wonder if the advantages persisted to the third stage of labor as well. Jamie asked me a question about active management of the third stage (delivery of the placenta) and in thinking about it, I realized that obstetricians almost always assist the third stage by clamping the cord, and applying very gentle traction to it. Postpartum hemorrhage has always been a major cause of maternal death. It is not difficult to imagine that assistants who shepherded delivery of the placenta and then manually massaged the uterus to encourage it to contract, dramatically improved the chances of survival of the women they tended.
This is the genesis of my question about ancient midwives being the obstetricians of their time. According to Rosenberg and Trevathan, technical assistance at delivery (not just psychological support) gave the midwives' "patients" a tremendous survival advantage. So from the beginning of midwifery, possibly millions of years in the past, the assumption was not that birth is simple and only require support, but the assumption was that birth is inherently complicated, that neonatal and maternal death are all too common, and that a trained assistant is needed to increase the chance of neonatal and maternal survival.
Labels: midwifery
Were ancient midwives the obstetricians of their time?
There is ongoing research about the evolution of human childbirth. One of the remarkable things that researchers have noted is that human beings are the only animals that have assistants at deliveries. All other animals can deliver their own babies, deliver the placenta, and care for their newborns by themselves. Research has concentrated on determining what factors about human labor and delivery might have made human delivery more difficult than animal delivery and there are a variety of candidates including the large size of the infant skull, the need to keep the female pelvis relatively narrow in order to support walking and the complete helplessness of human babies.
Regardless of the ultimate reasons, these investigations raise an important question. Did midwifery arise because ancient midwives developed techniques to "manage" delivery and thereby decrease maternal and neonatal death? They must have been doing something extremely important, because midwives or specialized birth assistants spread to every culture.
Were ancient midwives the obstetricians of their time? Were they women with "advanced training" (in the form of apprenticeships and oral transmission of previously accumulated knowledge) who took childbirth from being "natural" to being midwife managed and therefore safer? If they were able to talk to us today, would they be shocked at the nature of homebirth midwifery with its focus on shunning technology? Would they instead be rushing off to hospitals to marvel over the latest equipment and techniques, and expressing regret that the technology they had at their disposal was so primative?
Homebirth midwives often assume that they are the heirs of ancient midwives. Isn't it equally possible that obstetricians are actually the true heirs of ancient midwives, women who applied whatever technology they could learn or devise to prevent maternal and neonatal death?
Labels: midwifery
When does natural = bad?
In the article about homebirth philosophy that I referenced in a previous post (O'Connor BB, J Med Philos. 1993 Apr;18(2):147-74.) the author describes the homebirth movement in the United States as:
"an alternative health belief system that promotes a model of pregnancy and childbirth contradictory to the conventional biomedical model... [This belief system] assigns primacy and goodness to the Natural ..."
Is this important part of the homebirth belief system really true? What does it mean for something to be "natural"? Why should natural always be considered good? Under what circumstances is natural bad?
I ask these questions because there is absolutely no doubt that high maternal mortality and very high neonatal mortality is clearly a "natural" part of pregnancy and childbirth. Since death is a natural part of human reproduction, why should "natural" automatically be viewed as better than medical interventions?
Labels: "natural" childbirth, philosophy
Dr Crippen posts an anecdote
Dr Crippen, whom I linked to below for a post about "madwives", now posts an
anecdote:
“Two-o'clock in the morning, and I was in the late stages of labour with a midwife struggling to save the life of my baby boy as an ambulance rushed us through the deserted streets of south London to Lewisham Hospital.
I was seven centimetres dilated and she had pushed her hand right up into my vagina, trying in vain to keep his head from crushing the umbilical cord carrying oxygen to his brain.
She kept her hand there for 56 minutes, even as I was being wheeled at high speed along the corridor into theatre, and right up until the moment my baby was lifted up and delivered by Caesarean”
The baby died.
What I find most remarkable about this tragedy is that the mother, a midwife, made the following comment in an article that she wrote: [The baby]“would not have been saved even if I had given birth in a hospital”
That is an absurd comment to make, but I don't think it is difficult to figure out why she said it. Obviously, the baby might have been saved in a hospital. When I was in training, the goal for "crash" C-section was 5 minutes into the operating room and 120 seconds from skin to baby. We didn't always reach the goal, but we were usually not very far off. In contrast, this baby went at least 56 minutes without adequate oxygen.
If the mother acknowledges that this baby could have been saved in a hospital, she would have to assume some guilt for her decision to deliver at home. She cannot accept the burden that she contributed to the death of her own baby. She doesn't simply persist in a private fantasy that the baby could not have survived in a hospital, which undoubtedly gives her comfort. She actually wrote about it in a newspaper, as if to convince the public at large that she was not responsible. How very, very sad.
Midwives and research
I have remarked repeatedly on the fact that midwives do not understand research and therefore persist in beliefs and practices which have no scientific foundation. Furthermore, they get incredibly angry when others point this out to them. Evidentally obstetricians are not the only people who find it troubling that midwives have so much difficulty understanding and using scientific research.
Midwifery professionals recognize "
there remains a considerable amount of clinical activity which relies only on historical ritual rather than on rational scientific evidence." They see this (appropriately) as a serious problem. The following paper explores the reasons: "
One widely accepted reason for midwives' non-use of empirical findings is simply that a large proportion of the workforce does not have the knowledge and training in the necessary skills to enable them to assess the value of published articles" and suggests ways to remedy this deficiency.
Bridging the gap between research and practice: an assessment of the value of a study day in developing critical research reading skills in midwives.Hicks C. , Midwifery. 1994 Mar;10(1):18-25.
Despite increasing professional pressure on midwives to make their clinical practice research based, there remains a considerable amount of clinical activity which relies only on historical ritual rather than on rational scientific evidence. This apparent failure to integrate research into practice has generated a lot of debate regarding its cause. One widely accepted reason for midwives' non-use of empirical findings is simply that a large proportion of the workforce does not have the knowledge and training in the necessary skills to enable them to assess the value of published articles. Clearly the cost in time and human resources involved in providing a thorough training for the entire midwifery workforce in research skills would probably be unnecessary for the majority of midwives who simply want to be able to translate published research into their clinical practice. Consequently, a more pragmatic approach might be to assess the value of brief training days in developing midwives' competencies in reading research articles critically as a precursor to facilitating the integration of theory and practice. If the value of such courses could be demonstrated, then it is conceivable that study days of this type might be made more widely available for all midwifery personnel. This study investigated the effectiveness of one such study day in (a) modifying the participating midwives' evaluations of a published research article in accord with those of expert judges and (b) influencing the longer term use by the participants of published research. The day provided a brief introduction to basic research techniques both in theory and in practice, as well as a set of structured guidelines for evaluating research articles.
Labels: midwifery
Homebirth philosophy
I thought we might switch gears for a moment and talk about the philosophy of the homebirth movement and whether the basic philosophy of the movement might interfere with the ability to understand and accept scientific research.
Here is the abstract I found from an article by O'Connor in the Journal of Medical Philosophy (J Med Philos. 1993 Apr;18(2):147-74.) :
The home birth movement in the United States is an alternative health belief system that promotes a model of pregnancy and childbirth contradictory to the conventional biomedical model. The alternative model stresses normalcy and non-intervention and is informed by an ideology that promotes individual authority and responsibility for health and health care. It is founded in an epistemological system that assigns primacy and goodness to the Natural, fuses moral and practical injunctions in the arena of health behavior, and valorizes subjective as well as objective sources of knowledge. (Natural = as found in nature without technical intervention). Differences of opinion with the conventional medical model of childbirth do not spring from misunderstanding of this model, but from disagreement with it. Members of this movement are typically educated, middle class, and white.
This sounds to me like a pretty accurate description of homebirth philosophy and would explain why homebirth advocates to not appear to understand what the scientific community is saying, or even the importance of science itself. It also provides a reason why the homebirth community supplies a constant stream of anecdotes in place of scientific evidence.
Labels: philosophy
Why don't homebirth midwives have pediatrician backup?
Every study of homebirth safety has shown that a significant number of the avoidable deaths were due to inability to resucitate a baby born with unanticipated respiratory distress or congenital anomalies. Why don't homebirth midwives use pediatrician backup? In discussions on this website, many homebirth advocates have emphasized the fact that homebirth midwives carry resucitation equipment. However, that is not particularly meaningful if they don't have extensive experience in using it, and the deaths in the studies attest to the fact that the midwives aren't successful in neonatal resucitation. Why not simply have a pediatrician there?
Labels: midwifery
Looks like I'm not alone
Doctor Crippen posts about homebirth on his blog
NHS Blog Doctor: Home delivery lunacy.
Here is an excerpt:
Dr Crippen would love to have a system of home deliveries but home deliveries are only safe if there is a fully equipped obstetric flying squad which can respond and arrive in a matter of minutes. An obstetric flying squad needs two doctors, one for the mother and one for the baby, an incubator and lots of other kit.
There are no obstetric flying squads where Dr Crippen works. There are very few in the country.
Home deliveries will be supervised by madwives, often the so called “independent” madwives. "Independent" madwives have "chosen to work outside the NHS" primarily because the NHS does not support their practices.
Some of the militant home-delivery brigade of madwives are the most arrogant and dangerous health care workers in the NHS. They do not understand that a catastrophic post-partum haemorrhage can result in the death of a mother within minutes, and that it cannot be predicted. They are not trained to resuscitate flat babies; they have neither the competence nor the equipment. And, as so often with specialist nurses, they do not know their own limitations, they do not know what they do not know, and they resent any attempt by the medical profession to try to educate them.
They want to jump into the birthing pool with the pregnant mother, the husband and the vicar, sing ten green bottles and then eat the placenta. They ignore the risks. And when disaster strikes, as it surely will, it will be Tom Reynolds [an EMT] who has to try to pick up the pieces.
Dr Crippen is a bit more biting than I, but I am in sympathy with the essence of his post.
If I ran health care
From
Jamie:
If you were in charge, how would you structure health care for pregnant women in this country? Do you think OBs should be the default providers? (And BTW, do you have reservations about family practitioners providing obstetric care? They have so much else to cover in residency that surely they don't get a ton of time handling complicated OB cases either.)
If I ran health care, here are some of the things I would do. Let me say in advance that my plans have little to do with homebirth. That's because my chief goal would be to bring down the perinatal mortality rate for infants born to women from minority communities.
1. I would institute a single payer system to guarantee that all pregnant women had prenatal care and that there were no barriers (paperwork, etc.) to accessing that care.
2. I would make federal assistance (welfare) contingent on getting that care. In other words, if you don't show up for your prenatal appointments, you wouldn't get a check.
3. I would reform the tort system by instituting no-fault insurance. In other words, anyone whose baby was impaired would be compensated, regardless of whether it was anyone's fault or just an accident of nature. (This would hopefully decrease the amount of defensive medicine, since you wouldn't have to prepare every chart as if you might ultimately face a law suit.)
4. I would dramatically strengthen the power of Boards of Registration by increasing their funding and providing them with investigators. Right now most Boards are essentially toothless and cannot get rid of bad doctors.
5. I would ban social inductions and elective C-section for social reasons.
6. I would fund research that would try to understand if there are racial differences in pregnancy and birth. Perhaps we are treating minority patients improperly.
That's just a beginning. I'm sure I'll think of a few more and if so, I will post them inside.
The challenge: How do we decide?
This post is reserved for a discussion of a specific issue. What would homebirth advocates need to see in order to believe that homebirth is not as safe as hospital birth? The answers should be restricted to science and statistics. This will be an insult and accusation free zone. No posts about " all obstetricians" or "you're twisting things".
Is anyone up to the challenge of explaining the scientific and statistical criteria that it would take to convince homebirth advocates of anything that they do not believe in advance? I'm willing to bet this is going to be a very short thread. I suspect that there really isn't any evidence that would be convincing, because homebirth advocacy is based in large part on personal beliefs and personal beliefs are not swayed by science.
Confessions of a tired obstetrician
I am always amused when I read comments like these because they are so incredibly far from the truth:
"Does that mean that doctors respect normal birth? Do they support unmedicated birth? Or do they end up seeing the birthing process itself as pathological and treating all births as high risk?... it is a rare doctor that can resist interfering in a labor that's going perfectly well."
I could not have been happier if most of my patients had spontaneous vaginal deliveries without interventions of any kind. I think most obstetricians feel the same way. We went into it to participate in the miracle of birth and it is a lot more fun to cry "It's a girl!" as a mother pulls her new daughter up for a first look, than it is to be elbow deep in someone's bloody abdomen desperately trying to stop a mother's hemorrhage.
There are other, more practical reasons to respect normal birth. It is faster and it is easier for the doctor. All you have to do is stand there and make sure the baby doesn't fall on the floor; half the time the parents think you are a genius for doing nothing. For almost all of my career, I worked at night so I could be home with my children during the day. I was required to be in the hospital, but if things were quiet, I could sleep. In addition, I was "protected" by two midwives who delivered most uncomplicated patients. So, theoretically, if all the births were uncomplicated, I could sleep all night, unless there were more uncomplicated patients than the midwives could handle by themselves. The midwives I worked with were fabulous; I can't imagine that anyone could have done their job better and their patient satisfaction was very high.
The people who refused to cooperate with my deep and abiding respect for natural birth and my deep an abiding desire for sleep were the mothers and their babies. There was always someone, or a few someones, with pre-eclampsia, with premature labor, with a shoulder dystocia, with fetal distress, with a post partum hemorrhage, or with something. So I would get up and try to fix it and hope that I could manage it without doing surgery. Surgery was a guaranteed two or more hours before I could go back to bed, but if I could put off doing surgery, I could go back to bed right away. Then when it was time for the delivery, the whole thing, paperwork included, would take me less than an hour.
It is a cherished myth of some branches of midwifery that doctors cause pregnancy complications because they enjoy them or because they can't recognize normal when they see it. Far from it. Most doctors are hoping for normal each and every time they see a laboring woman. It's the patients (through no fault of their own) who sometimes refuse to cooperate.
Alternative health or medical subspecialty?
Should we consider homebirth midwifery a form of alternative health since many mainstream providers do not agree with its objective? Or should we more properly consider it just another medical subspecialty because it clearly emulates traditional medical practice in its use of medications, prenatal testing, risk assessment and referrals to doctors and hospitals?
Labels: "alternative" medicine
Psychological birth trauma
Back over on Neonatal Doc, several people commented on the psychological trauma that they experienced when they had a hospital birth. I wonder if these experiences are truly traumatic in the psychological sense, or whether they represent guilt and disappointment at not being able to meet unrealistic ideals of natural childbirth advocacy.
Isn't it unreasonable for the natural childbirth movement to downplay the pain of labor, thereby preventing women from making realistic plans in advance of the birth of a first child? Why, for example, does the natural childbirth movement encourage women to make birth plans refusing pain medication
in advance. In any other setting (prior to having a hysterectomy, for example), you would never ask a person to assess her need for pain medication before she actually feels the pain. Why encourage it in this setting?
Shouldn't the natural childbirth movement (and the people who run the websites and write the books encouraging childbirth without pain relief) bear some of the responsibility for psychological birth trauma?
Patient Satisfaction
One thing that is not debatable is that patients of midwives are far more satisfied with their experience than patients of obstetricians. I suspect that this is due in part to the fact that midwives spend far more time with patients than obstetricians. This is especially true in labor when the obstetrician probably spends less than 5 minutes with a patient per hour whereas a midwife might be present and providing support the entire time.
There may be more to it, though, than simply support. Patients tend to pick their midwives specifically because of compatible philosophy. Moreover, patients who choose midwives tend to be white, well educated and from a Western culture, in other words, very similar to the midwives themselves.
I always found that one of the hardest parts of practicing medicine was meeting expectations when I didn't know what the expectations were going to be. I could spend time with one patient in labor who would make me promise not to offer an epidural, then go across the hall and try to explain to another patient why she couldn't have an epidural at 1 cm because it would make her labor stall.
Do you think that the very high satisfaction with midwives is due to the support they offer, the compatibility with their patients, or a combination? Do you think patient satisfaction would be as high if the midwives cared for all patients, as opposed to those who specifically chose them?
Metromidwife submitted this article about newborn mortality
Thank you to Metromidwife who submitted the following article from CNN for discussion:
US Has Second Worst Newborn Death Rate in the Modern WorldHere are the first two paragraphs of the article:
"An estimated 2 million babies die within their first 24 hours each year worldwide and the United States has the second worst newborn mortality rate in the developed world, according to a new report.
American babies are three times more likely to die in their first month as children born in Japan, and newborn mortality is 2.5 times higher in the United States than in Finland, Iceland or Norway, Save the Children researchers found. "
Is natural childbirth an achievement?
It seems that this question follows logically from the notion of pain as empowering. Also, it is a source of much contention between advocates of natural childbirth and other women. Many women complain that natural childbirth supporters judge them and find them wanting. The implication is subtle (or not so subtle) that childbirth without medication is an achievement, and that women who do opt for pain relief have failed in a quest for that achievement.
Let me say emphatically that I am not talking about the notion of reaching a personal goal. Reaching a personal goal is always an achievement whether it is losing weight, quitting smoking or simply running around the block. I am talking about the idea of an objective achievement. In other words, I think we all agree that running a marathon is an achievement because it is very difficult and most people could never do it. On the other hand, while we recognize that running around the block might be a personal achievement for a woman who has never exercised, we would not consider it an objective achievement since it isn't really that difficult and most people can do it if they try.
So can we consider natural childbirth an achievement? We tend to be so embedded in our own culture, that we often forget that things can and often are done other ways. In our culture, many women have pain relief in labor, so it can appear that it is unusual to forgo an epidural. However, anesthesia is only about 150 years old. Over 99.9% of women who have ever existed have had natural childbirth. Right now, at this moment, virtually all the laboring women in a host of countries and on a variety of continents are having natural childbirth. There is simply no other alternative.
Natural childbirth is, essentially, the default mode. It is the rare woman who can and does choose pain relief in labor. Certainly natural childbirth can represent a personal achievement. However, could we or should we consider it an objective achievement?
Labels: feeling superior, pain, philosophy
A few words about scientific studies
I posted this in the comments section of "Birth of a Forum". Since it is very important to any discussion of the safety of homebirth, I am also posting it here.
I want to make two general claims, first. It is very important to understand that just because a paper appears in a peer review journal, that does not make it true. In fact, that's the entire point of peer review journals. One group presents their findings. Other groups then present findings that either corroborate or contradict the original findings. As a general matter, the truth only becomes apparent over time and multiple studies.
There are plenty of lousy studies. The chief offenders are drug companies that pay for studies to promote their drugs. Often the data in the studies is manipulated to get to the desired outcome. Others can fall into the same trap. Either deliberately, or more often out of an excess of enthusiasm, researchers subtly (or not so subtly) "massage" the data so it says what they want.
That brings me to my second general point. It is necessary to read the actual paper, not the just the abstract. The abstract contains a brief description of the study and the claims of the authors. Only by reading the paper itself can you find out whether the study was done properly, whether the results are statistically significant (exceedingly important) and whether the results actually justify the claims made by the authors.
American doctors are very suspicious, primarily because of their experience with drug companies. So when I criticize a paper, it's not because I disagree with the findings. Often what I am saying is that the results of the study either violate the rules of statistics (which render the results useless) or the authors make conclusions that are not justified by the results.
What are the red flags that should make you suspicious? In the homebirth studies there are several specific types of red flags. First, the researchers must compare apples to apples. That means that if the homebirth group contains only low risk women with babies in the vertex position, the hospital group MUST contain only low risk women with babies in the vertex position.
Second, researchers are forbidden from excluding bad data. You can't subtract the people with bad results from the homebirth group. They must stay in the group. You certainly cannot subtract people with bad results from the homebirth group and put them in the hospital group, even if they ultimately delivered in the hospital. For example, a woman in the homebirth group who is transferred to the hospital for an abruption and undergoes a C-section after which the baby dies is STILL in the homebirth group.
Keep in mind that these are not my personal rules for evaluating a study. They are the rules of statistics that exist precisely to tell you whether the results of a particular study are accurate and reliable.
Is pain empowering?
One of the often touted benefits of natural childbirth in general, and homebirth in particular, is that tolerating the pain of labor without resorting to an epidural is empowering. I wonder about that.
The meaning of pain is culturally mediated. Different cultures and different religions have vastly different ideas about the meaning of tolerating pain. Some see pain as enobling or even cleansing. Most don't apply any positive value to tolerating pain when relief is available.
Of course, if a woman feels empowered by tolerating pain, that's fine. She is perfectly entitled to do that. However, she should not assume that other women share her values. I suspect that the majority of women would rate tolerating labor pain without medication as akin to tolerating a root canal without novocaine. Sure, you could do it, but why would you want to?
Perhaps this is where some of the disconnect arises between advocates of natural childbirth and other women. It may be that other women are not impressed and might even react with disdain (which they shouldn't do because it is rude) to the notion that tolerating labor pain could ever be empowering. That value is simply not a part of their cultural or religious background.
Labels: feeling superior, pain, philosophy
Water birth
I've always wondered about the place of water birth in the homebirth movement. One of the cornerstones of the homebirth movement seems to be the feeling that natural is "best" and that birth should occur the way nature intended. So where does water birth fit in? It is emphatically not natural! Human babies are not supposed to be born underwater. No primates give birth underwater. How can this completely artificial (and apparently dangerous) way of giving birth be reconciled with the homebirth movement?
Labels: water birth
Birth of a Forum
This forum has its genesis in a post by
Neonatal Doc about a baby harmed during a homebirth. The post has generated 160 comments and counting, most about the safety of homebirth. The passions aroused, and the evident enjoyment of the debate by the participants suggested to me the possibility of a forum dedicated to this issue and related mothering issues.
I am happy to host this forum and to offer the opportunity for midwives, doctors and anyone else to post discussion points that people can comment on. If you have an idea for a topic, just send your complete post to me at DrAmy5 at AOL dot com (replace the at with @ and replace dot with a period).
