Sunday, August 17, 2008

Prevention vs. pretending

One of the most important differences between obstetrics and homebirth midwifery is that obstetrics rests in large part on the idea that preventing obstetric complications is better than treating them. In contrast homebirth midwifery pretends that complications will not occur, and assumes that if they do occur, the patients can be dumped in the emergency room where obstetricians will care for them.

Consider major complications of childbirth. Let's start with hemorrhage. Hemorrhage is one of the most common causes of death in childbirth in places without access to modern obstetrics. In contrast, death from hemorrhage is rare in industrialized countries. Both prevention and treatment are used to reduce the death rate from this common complication. These measures include a hep lock for emergency IV access, a blood sample sent to the hospital lab to be available for immediate cross matching if necessary, multiple medications available to stop hemorrhage (pitocin, ergotrate, hemabate), and IV fluid to prevent shock. Treatment measures are immediately available as well, including transfusion, obstetricians available for manual removal of the placenta if necessary, and for surgical intervention in the event of life threatening hemorrhage that cannot be stopped by other means.

What does homebirth midwifery do to prevent postpartum hemorrhage? Nothing, beyond pretending that it won't happen. There is no IV access, no preparation of blood products (no blood products are even available), only injectable medications to stop hemorrhage (no IV medications), no IV hydration to prevent shock, no one to perform a manual removal of the placenta and no one to undertake surgical intervention.

Another serious complication of childbirth is group B strep sepsis of the newborn. Until preventive measure were instituted, group B strep sepsis was the single most common cause of infectious death among newborns. Obstetricians routinely screen for group B strep, and give IV antibiotics in labor for prophylaxis. The rate of group B strep sepsis has dropped dramatically in response.

In contrast, some homebirth midwives simply pretend that group B strep sepsis won't happen. They don't culture for group B strep, or they don't treat it if they find it. They pretend that the incidence is "too low" to justify preventive care.

A less common cause of neonatal death is breech delivery with a trapped head. Obstetricians try to prevent this outcome by recommending external version to turn the baby to head first position, or C-section to prevent trapped head by preventing breech delivery. Homebirth midwifery simply pretends that trapped heads won't happen. If they do happen, the baby simply dies. There is no time for transport to the hospital and there is no one to perform expert resuscitation if the baby is delivered after a period of entrapment.

Obstetrics tries to prevent complications, homebirth midwifery cavalierly dismisses the possibility of complications or pretends that it is just as safe and easy to treat life threatening complications as it is to prevent them. On this issue, homebirth midwives are dead wrong.

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