Homebirth midwives are quacks

quacks
There’s very little that makes me angrier than the unnecessary deaths of babies. That’s why homebirth often makes me very angry indeed.

In the US, most doctors and certified nurse midwives refuse to attend homebirths because of the danger. Therefore, most US homebirths are attended by “direct entry” midwives (DEM), aka certified professional midwives (CPM). These are just fancy names for midwives with no medical training. The statistics on neonatal death at homebirth are so appalling, that Midwives Alliance of North America (MANA), the trade union for homebirth midwives, refuses to release the death statistics to the public; they are available “friends” of midwifery.

American homebirth midwives are grossly undereducated, grossly undertrained, and downright dangerous. The national and state statistics bear this out, but nothing illustrates it better than a real life example. This tragedy was brought to my attention by a commenter who had been following the story on the mother’s website.

Carri, a mother of 8, had been planning an unassisted homebirth. I recently wrote about this appalling stunt and its high death rate (Stuntbirth). Carri had had 4 successful unassisted deliveries and was planning a 5th. As the due date approached, even Carri, as deluded as she was about the safety of unassisted childbirth, could not deny that her uterus was much larger than expected, and she sought the “advice” of Brandi, a CPM, at Central Indiana Home Birth Midwives.

Brandi diagnosed twins (without the aid of ultrasound), and noted elevated blood pressure. She advised the typical homebirth midwives quack “treatment,” a high protein diet, which, not surprisingly, accomplished nothing. As the pregnancy advanced, first one week beyond the due date, then two weeks, then almost three, Brandi counseled waiting for nature to take its course.

And nature did take its course. Carri’s baby is dead, and she is now fighting for her life in an ICU. The presumed cause is an amniotic fluid embolus.

There was only one baby, not two. That’s at the top of the long and horrifying list of mistakes. It is unheard of for a responsible practitioner to diagnose twins when only one baby is present on ultrasound, but Brandi assured Carri that one baby was “hiding” behind the other.

Even more appalling, if possible, is Brandi’s reaction when she heard only one heartbeat. According to Carri (posting on MotheringdotCommune):

One time the midwife gets two heart beats and the last time she just could not find the other and felt okay to let it be because there was active movement …

It would be laughable, were it not deadly. The homebirth midwife “diagnosed” twins, then clung to that delusion even though there was only one baby on ultrasound, and only one heartbeat.

Not surprisingly, someone deluded enough to believe that there were twins when only one baby could be seen was also deluded enough to believe that a clearly pathological pregnancy was normal. Carri measured much larger than expected even though there was only one baby. Almost certainly, there was a massive excess of amniotic fluid (polyhydramnios), both a sign of problems, and a risk factor for future complications (including amniotic fluid embolus). Carri’s abnormally elevated blood pressure was untreated by the quack remedy that was “prescribed.” Pregnancies over 2 weeks past the due date have a dramatically increased risk of stillbirth, as well as life threatening birth complications. The midwife pretended that this was not so.

So now Carri’s baby is dead, and Carri is fighting for her life.

People need to understand American homebirth midwives are a second class of midwives with less education and training than other American and European midwives. The standards for direct entry midwives, in terms of educational requirements and clinical training, are far below those of any other midwives in the industrialized world. American homebirth midwives are, by and large, quacks, and babies are dying as a result.

Addendum: One of the things I find most interesting is how everyone involved understands that the refusal to seek real medical care led to this tragedy. Carri’s family has removed the posts detailing her actions in the weeks leading up to the catastrophe, and MotheringdotCommune has removed the posts by Carri and those responding to her. The baby died possibly because of unassisted birth/homebirth, and now supporters and the family want to remove the evidence.

  • Gibran Ramos

    Here is the latest article series from the Lancet Medical Journal for Dr. Tuteur’s review: More midwives….”a simple way to halve deaths in childbirth” http://www.yorkshirepost.co.uk/news/main-topics/general-news/more-midwives-a-simple-way-to-halve-deaths-in-childbirth-1-6688377

    • Young CC Prof

      If all pregnant women had access to real midwives, with proper training and at least minimal supplies and drugs, childbirth deaths would drop considerably.

      More midwives who have little or no training and like to stand around and watch as disasters happen, that will not help at all.

      As for the finding that midwife-led units have fewer interventions and equally good outcomes, that’s not surprising given that the high-risk women are all sent to the physician-led units.

      By the way, why is avoiding hormone treatment a goal? Caesarean birth has real disadvantages for the mother, but judicious use of pitocin reduces maternal blood loss and the need for caesarean delivery and has few to no down sides.

  • Lalique

    Wow, this snobby attitude and rise in csection sis the problem with doctors. Just remember and OB is pretty much just an “educated on woman anatomy” surgeon. Ask how many of them have seen a natural labor in their hospital. Education doesn’t top experience. These kind of doctors are why I would never step into another hospital even if I were dying!
    Been to plenty of both hospital and home births and have seen 100% vaginal births at home with no stress and wonderful labors versus nearly half in hospital ended in csection due to intervention and really unnecessary situations that could be avoided with real education. Not some medical text book with BS in it!! I could so keep going as to the abuse and degrading attitudes. This article sickens me and saddens me. I love my home births and my midwife has better educated answers then any OB I have seen before with their “I am educated and know more than you attitude”. I have five kids and am doing my second home birth in August!

    • Young CC Prof

      Did you know that among women who have given birth before and have no prior c-sections or major pregnancy complications, the cesarean rate in hospitals is less than 3%?

  • Siri Dennis

    How do you spot a shoulder dystocia before it happens? How do you hand over to an expert if you are in someone’s home?

  • Audrey Yarper

    She also has a better record than just about any OBGYN in the US. I’ll provide the farm study if you don’t want to look it up yourself.

  • PJ

    Apprentice Midwife, we don’t know exactly what the safety outcomes of CPMs are, because they refuse to release their data (which because it is collected voluntarily is probably a load of trash anyway). In those few states where they have been required to do so, the statistics are appalling.

    Those are the facts. I would never use a CPM. I can’t believe this ‘qualification’ is even legal in a developed country.

  • Audrey Yarper

    Where are you getting this info? The peer reviewed studies on this matter have proven that home birth is a safe or safer than hospital birth.

    • Lizzie Dee

      have proven that home birth is a safe or safer than hospital birth….
      t….when you do a lot of risking out , exclude first time mothers, and nothing goes wrong.

      • PJ

        And you are examining a country where midwives are properly trained, regulated and integrated into the healthcare system–ie NOT the USA.

        • Audrey Yarper

          The studies are USA based although there are many similar studies done elsewhere. They include US midwives who are properly trained and regulated and would love to be integrated into mainstream health care if the OBGYN organizations, would quit being so frightened of loosing their monopolistic profits.
          The studies are cited above and I have more if you’d like. Read them please.

      • Audrey Yarper

        Nope. As you can see above, none of the studies exclude first time mothers and one of them even includes high risk women in the home birth sample and yet still has lower mortality rates along with much lower Csection and perrinal trauma rates. It’s funny how prejudiced people can be. Please cite your sources.

    • Amy Tuteur, MD

      Really? Which ones have you read in full? Let me guess: none of them.

      • Audrey Yarper

        I’ve cited 4 of them as you can see above. I’d be happy to provide more. There is no shortage of them.

  • Audrey Yarper

    I’m training to be a CPM at a fully accredited Midwifery college. I had to attend a university for 2 years, doing pre-reqs, just to get in. The program is a 5 year program, which includes extensive course work in addition to the clinical fieldwork, with approved, accredited and experienced midwives. So thats 7 years of intense study, which will not only leave me with CPM certification, but with a fully recognized and accredied Bachelors in Midwifery. The obstretic specific training I’ll have by the time I graduate,will far exceed that of an OBGYN.

    BTW, the reaon that homebirth is legal despite the efforts of OBGYNs, who fight for profit and power, not women, is that numerous peer-reviewed studies from all over the world, have proven without a doubt that homebirth is as safe or safer than hospital birth.

    A great book is “Born in the USA” written by an OBGYN/ clinical scientist, wistle blower, turned homebirth and midwife advocate,due to the hard data he found proving that OBGYNs often kill mothers and babies becuase of practices not based on science but self interest, (like the long use of Cytotec, despite FDA warnings against its use on pregnant women). For many its all about convienience for the doctor rather than saftey for the mother and child.

    • Lizzie Dee

      Do you have facts and figures, case studies, anecdotes, newspaper reports, inquests that show that women and or babies are killed by interventions? After all, if it is happening “often” you should have.

      In my fantasy world, I would like the death of any woman or baby to be closely examined, and for it to be easy to ascertain WHY it happened. How often was it inevitable, how often was it a cock-up? What kind of cock-up? Is it because birth can be inherently unpredictable and lethal? From my amateurish, sporadic and ineffective perusal of these things, some hospital disasters, like homebirth disasters, could and should have been avoided – with more and better medicine, more and better interventions.

      I would be quite happy to be proved wrong.

    • PJ

      “The obstretic specific training I’ll have by the time I graduate,will far exceed that of an OBGYN”

      Can such naivete really exist?

      • Amy Tuteur, MD

        Not naivite, “stupidite”!

        • Audrey Yarper

          Read the peer reviewed articles I cited above, and call these scientist stupid if you will. Name calling is easy. I don’t resort to that, but back up what I say with hard facts.

          • KarenJJ

            You think she hasn’t read them? And commented on them, with even perhaps less then glowing terms. As suggested you can use the search function to find out more or Dr Amy’s thoughts on these papers.

      • Audrey Yarper

        This is actually straight from “Born in the USA” a book by an OBGYN. He went through medical school and he said, “My first two years in medical school at UClLA, I was not required to attend classes; I just had to show up for and pass examinations. The next two years in medical school, I was rotating on various hospital wards and clinics where my teaching was “bedside” teaching, that is an apprenticeship. My internship was pure apprenticeship-there was no classroom teaching and there weren’t even examinations to pass. And my specialty training in paleontology and obstetrics was an apprenticeship with no classes, as all I had to do was pass the final specialty examination. So I pointed out that my training as a physician was also by apprenticeship and examination, just like the midwife’s.” OBGYN’s do a 4 year apprenticeship I will do at least 5 years of such training, and all of my course work is related to the birthing process. I am also trained in many areas in which an OBGYN is not trained, for example in how deal with the physiological health of a woman before, during and after birth as it relates directly to the outcome of her birth. This is something and OBGYN is not trained in. OBGYN’s are certainly needed in high risk women, but they often do much damage to low risk women and their babies. Apples and oranges.

        • Trixie

          Paleontology? This actually explains a lot. Perhaps he’s an expert in normal dinosaur birth?

        • Happy Sheep

          Marsden Wagner is NOT an OB

    • Captain Obvious

      So you spent 7 years of intense training to ONLY be able to deliver babies? OB/GYNs can perform primary care for women throughout all ages, perform office procedures, care for pregnant women, perform surgery, and care for post menopausal women. And an OB/GYN makes much more money than a CPM. I do not at all believe you received more obstetrics training than an OB/GYN, in residency, they will deliver 5-10 babies a day. And no study really shows Homebirth to be safer. It may show less interventions and less epidurals at the expense of deaths, seizures, and lower APGARS. And any study that uses university trained midwives from other countries who are licensed, carry malpractice, risk out FTM, breeches, twins, previous c/s, AMA, and such and try to compare to hospital birth CANNOT be extrapolated to American Homebirth who take on all risk moms, with no backup OB or hospital, often don’t carry meds like pitocin for PPH, and often don’t have a very long education and training.
      So again, you are either trolling about your length of training or stupid for doing so to achieve a lower paying CPM job after spend more time training than an OB/GYN.

      • Audrey Yarper

        In nearly all of the 49 (yes 49) countries which have lower rates of infant maternal mortality than us, the Midwifery Model of care is the standard. Midwifes are primary care providers and OBGYN’s are specialists. In many of these countries such as Britain and the Netherlands, OBGYN’s are required to attend home births as part of their clinical training. OBGYN’s and Midwives are partners and the results are fewer deaths. Many OBGYN’s in this country are more concerned about money than the health of women so are trying to maintain their monopoly on birth. Marsden Wagner and OBGYN/ clinical scientist who is a home birth advocate, says that OBGYN’s should only deal with high risk women, because they are trained to view birth as a medical procedure and have a tendency to prescribe unnecessary interventions to low risk women,which increase their risk. OBGYN’s do save lives of the very few women who are truly high risk. Unfortunately their medicalized view of birth, unnecessarily kills many low risk women and babies every year. (I’ll happily provide references if you’d like) Midwives and OBGYN’s are both needed and both have their areas of expertise. Would you want your family doctor operating on you if you got cancer, or would you want a surgeon doing your general check up?

        • I don’t have a creative name

          n nearly all of the 49 (yes 49) countries which have lower rates of
          infant maternal mortality than us, the Midwifery Model of care is the
          standard.

          Something akin to a CNM. NOT CPM. Your notion that you’ll know more than an ob/gyn when you’re done is laughable. If you want to help women and babies, get a real degree.

        • Susan

          You do know that infant mortality includes death up to one year and doesn’t compare stillbirth don’t you. It’s perinatal mortality that matters when looking at obstetric care not infant mortality. US perinatal mortality is better than lots of Western European countries that use midwives.

        • Susan

          “Unfortunately their medicalized view of birth, unnecessarily kills many low risk women and babies every year”

          Prove that gem please. You sound like you drank the homebirth Koolaid to me.

        • Young CC Prof

          I explained above that Netherlands and UK have HIGHER perinatal mortality rates than we do. Go do some research on the difference between infant mortality and perinatal mortality, including the most common causes of each one in first-world and third-world countries. Write at least 500 words about it, cite all sources, preferably to the WHO. Then come back and lecture us about obstetrical care.

      • Audrey Yarper

        The studies cited are American. And yes they do prove home birth to be safer. You are free to read them and I have more American based studies. But all first world countries which have much higher rates of home births and Midwife attended births do have much lower infant maternal mortality than us, and no in those countries Midwives are not able to perform surgical interventions. Their scope of practice is nearly identical to that of Certified Professional Midwives in the US. IN this countries Certified professional Midwives can and do use pitocin to stop hemorrhaging along with other proven methods. Hemorrhaging also occurs much less often in home births for many reasons, including not using pitocin to induce labor, which then inhibits the bodies ability to produce oxytocin and damages the oxytocin receptors in the uterus, leading to greatly increased chances oh hemorrhaging in the first place. (I’ll be happy to cite studies if you’d like.)

    • KarenJJ

      Care to cite a peer-reviewed article that shows that homebirth is as safe as hospital birth? Most of the articles are discussed regularly on here and people will happily discuss those you’ve found.

      • Audrey Yarper

        I would love to,

        Janssen, P., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Shoo, L. K. (2009).” Outcomes of planned home birth with a certified midwife versus planned hospital birth with midwife or physician.” CMAJ, 181(6-7), 377-383.

        Large scale study comparing planned home births vs. planned hospital births. perinatal death was nearly half for planned home births with Midwive (.35 per 1000) than planned hospital birth with OBGYNs (.64 per 1000) it was also lower than planned hospital birth with CNM’s (.56 per 1000)
        Intervention rates among planned home births were much lower. Rates or perennial trauma were much lower and C section rates were all much lower among the planned home birth group.

        Johnson K.C., Daviss B(2000) “Outcomes of planned home births with certifies professional midwives: large prospective study in North America.” BMJ

        This study including nearly 6000 home births which did not factor our high risk woman, found that home births had as low or lower infant and maternal deaths than hospital births, and home births had far fewer interventions.

        K. Johnson and B. Dvaiss, “A Prospective Study of Planned Home Births by Certifies Professional Midwives in America,”british Medical Journal 330, no. 7505 (2005) 1416

        This is largest scientifically valid study comparing planned home births with hospital births and the results were that the intervention rates were much lower among low risk home birth, than low risk hospital births. The intrapartum/neonatal death rate was a low or lower than the rates reported for low-risk hospital births. (most hospital under-report too and most states don’t even require hospital to report such deaths. I can provide references for that statement too)

        M. MacDorman and G. Singh, “midwifery CAre, Social and Medical Rish Factors, and Birth Outcomes in the USA,” Journal of Epidemiology and Community Health 52, no. 5 (1998): 310-17.

        A very large study which looked at all birth in the United States in one year- more than 4 million births, comparing low-risk planned home births, with low-risk planned hospital births, found that midwife-attended low-risk birth have 33 percent fewer newborn infant deaths, 31 percent fewer underweight babies, which means fewer brain damaged babies.

        I have more.

        I would recommend reading “Born in the USA” by Marsden Wagner, M.D. M.S (Obgyn and clinical scientist, who is a huge advocate of midwifery and homebirth) This book is full to the brim with such studies and he completely tears to pieces the studies the ACOG has used to demonize home birth. In one study they use to “prove” that home birth is safer they compare all births at home with hospital birth, including unintentional home-births (many of which are high risk women) aka taxi cab births and unassisted home births in the “home birth” sampling. Any studies that compare PLANNED home births, with certified Midwives in attendance find that home births are as safe or safer than hospital births for low risk women.

        I’ve got way more references. Let me know if you’d like them. I can back up what I say with hard evidence, unlike our hate spouting author who takes a bad case here and there and uses to spread fear, hate and ignorance without backing up a single statement with hard evidence.

        • KarenJJ

          Fantastic. Then you’ve read them and I assume are happy to discuss them further on here. What do you think of the Johnson and Davis paper where they compared home birth statistics with statistics from hospitals for several decades prior? Do you think that it was a deliberate misrepresentation to make homebirth look better or do you think they just got confused and/or were sloppy with their data?

        • Siri Dennis

          Is perennial trauma the kind that recurs once a year?

    • Something From Nothing

      Your training will far exceed that of an ob gyn? Seriously? So you’ll be better trained in emergency obstetrics, management of hemmorhage, Caesarean section, hysterectomy, etc? That’s very very impressive. Well, get through your fabulous extensive training, and show up all those poorly trained ob’s out there who are all lurking around looking for women to hurt. Go, Audrey!

      • Siri Dennis

        Now you’re just being HORRID and SNIDE! Audrey will be an expert in NORMAL birth, where all those stupid things won’t be needed. She has a little tiny bag of fairy dust instead.

  • Saddened Reader

    The whole hate filled tone of this article is appalling. It is sad that she says Dr’s refuse to attend homebirths because they are so dangerous. With all due respect, how would you know if you’ve never attended one? That’s just decent logic. The fact is that you actually know nothing of homebirth, midwives or the prenatal/postnatal care they give because you’ve never attended or supervised one. You have no experience or expertise on this topic. The hospital and Dr.’s close to Ina May Gaskin’s “Farm” are on fantastic terms with the local midwives and work with them/back them up to ensure a healthy, choice filled pregnancy and delivery. The Dr’s and the midwives work well together and all is peaceful. (The mortality rate and complications rate in this area of Tennessee is astoundingly low by the way). I don’t understand why this can’t be the norm. It makes sense in Tennessee, I guess they know something we don’t. I think Ms.Tuteur needs to go speak with and work with the OB’s in Tennessee (as well as watch The Business of Being Born). I challenge Ms. Tuteur to be kind and to try something new….try experiencing a few homebirths for yourself or talk with Ob’s who back up the midwives. Take a deep breath, it’s a better world when Ob’s and midwives work together!

    • KarenJJ

      “With all due respect, how would you know if you’ve never attended one? That’s just decent logic”

      Not really. I’ve never been in a war, but I know that they’re dangerous.

      • Susan

        I don’t know that she hasn’t attended a homebirth. She may have been present at one at some point. It really isn’t a magical spell; or at least one would hope not! My daughter was born at home with two CNM’s and she is healthy, and it was a lovely experience. But I still think now it was a less safe birth than it would have been in a hospital. I have been present at several homebirths as well and I was a Bradley teacher. I am not alone as a regular poster here who has been well immersed in the alternative birth. Some have had bad experiences but most like me just had more education and began to question the myths that home birth advocates cherish.

        • Audrey Yarper

          Please read the studies that I have cited. FACT home birth is as safe or safer than hospital birth. This is proven.

          • Karen in SC

            Where have you gotten your misinformation?

          • Amy Tuteur, MD

            I’ve debunked those studies in the past. Use the search function in the sidebar to look for the discussions.

          • Something From Nothing

            No, Audrey. You are simply wrong. Let’s see you analyze your ” solid science”. You sound like someone who says , FACT: the earth is 6000 years old. It says so in the bible.

          • Siri Dennis

            FACT: the Earth is flat. Don’t you think I’d know if I were standing on a great big ball?!

      • quadrophenic

        And it’s OBs, ER docs, and neonatologists who pick up the pieces after the homebirths that go wrong. Seems to me you don’t have to see the battle when you’re left to stitch up or bury the soldiers

    • Bombshellrisa

      ” I don’t understand why this can’t be the norm”
      Let’s start with the concept that not every woman of childbearing age is low risk, healthy, white and prefers to give birth without aid of trained staff, medicine and equipment.

      • KarenJJ

        I’ve got a program where I live where homebirth is provided for free by the government. Two university trained midwives are provided and they are backup by the main maternity hospital. There is strict risking out criteria and you need to live within a certain distance of the back up hospital.
        So even though it’s free:
        “approximately 200 women have a homebirth each year representing between 0.65 –0.80 per cent of all births.”

        Homebirth: You can’t even give it away.

    • it’s a better world when Ob’s and midwives work together

      Theoretically, quite true. The actual problem is that there are two versions of this “better world” – the one where homebirthing advocates will be happy, and one for the rest of those who prefer safe to nice, do not want to spend months into hypnotising themselves into believing pain doesn’t hurt, and have better ways of being empowered than having babies.

      If there are and have been occasions when pregnant women are treated disrespectfully perhaps it is caused (though not justified) by a minority behaving like idiots, and assuming that they and their concerns are the centre of the universe, and the world would be a better place if everyone else agreed with them.

      • KarenJJ

        “it’s a better world when Ob’s and midwives work together”

        They do where I live (mostly). Except these midwives are university educated and registered midwives. CPMs don’t exist.

    • The Bofa on the Sofa

      With all due respect, how would you know if you’ve never attended one?

      What do you think could be learned by attending one homebirth? Moreover, what couldn’t be learned by attending any birth anywhere?

      Wouldn’t it be more useful to do a thousand deliveries in the hospital and then ask the question, how often would have it been the same at home.

      Ms.Tuteur needs to … watch The Business of Being Born

      Good one.

    • Audrey Yarper

      We need to learn from Europe, where many countries (all with lower infant maternal mortality than us) require Ob-gyns to attend home births as part of their training. I think this a a major reason why home birth is very accepted in these countries.

      • Young CC Prof

        Infant mortality is the wrong number, it measures pediatric care, safety and even violence, but not obstetric care. Try comparing PERINATAL mortality rates internationally. Go look up the data and come back. Especially pay attention to the Netherlands, with its many home births.

        The US rate is 7 per 1,000, exactly the same as Japan and France. Netherlands and UK are both worse than us at 8, Ireland is 9. The Scandanavian countries have us beat, but I think that’s due to a better overall health system and fewer mothers in living in poverty.

        Statistics are complicated. The more you read, the more questions you have.

        • Warwick Dumas

          Caesarians kill mums rather than babies, usually. (Though they may also lead to forced preterm births later on.)

          http://www.theguardian.com/news/datablog/2010/apr/12/maternal-mortality-rates-millennium-development-goals

          • Young CC Prof

            Yes, that’s right. Cesarian delivery is harder on the mother, but actually safer the baby. (Except in things like placenta previa or cephalopelvic disproportion, where both would die without surgery.)

            Maternal mortality in the USA is higher than it should be, although that isn’t because we do too many c-sections. The excess c-sections and the excess maternal mortality are both caused by poverty, the problems of poverty and lack of access to primary care and prenatal care. More women with diabetes, heart disease and other chronic health problems are having babies. In fact, heart disease is the leading cause of maternal death in the USA!

            It’s a problem, but the solution isn’t to make births more “natural.” Natural births kill about 1% of mothers, that is, 1000 on the scale in the article. (The world’s poorest countries have numbers in that ballpark.) The solution is to make sure that every woman in the USA has access to good health care, even before she gets pregnant. (And, obviously, men and children as well.)

          • Warwick Dumas

            The reason is poverty? You are doing twice as badly as Albania.
            The reason is heart disease? Research in NY showed that 79% of maternal deaths were due to caesarian.
            No, the reason is unnecessary interventions. Having the option of home birth – with transfer when needed – has been shown to reduce the number of interventions while not affecting neonatal mortality.

            Yes caesarians are caused by a type of poverty, the poverty of the right to have a say, a right that exists with every other major operation. Yes it’s exacerbated by the private medical system – a system run for maximum profit and maximum interventions.

          • Happy Sheep

            79% due to c section? Citation needed. Your assertion that homebirth with transfer has better mortality is just plain wrong. With a properly screened low risk multip mother and a qualified attendant with risk is lowered, but it is still higher and infant morbidity hasn’t been studied properly either.

          • Happy Sheep

            have just asked you to inform me, that seems pretty willing no?
            I’m a happy sheep because I am educated enough to know what I don’t know and that Google u will not teach me about chemistry, biology physiology or even how to properly evaluate a study. I have looked into many NCB claims and I find them to be histrionic bunk, much like your 79% assertion. I call myself happy sheep because I am glad that I am called a sheeple for hospital birthing, vaccinating and generally going by medical recommendations made by people much more educated by actual schools then myself.
            If YOU make a claim, it is expected that YOU back it up, you clearly believe you are here to educate, so do it.
            The Dutch study is not indicative of American CPMs, they are college or university educated medical professionals with hospital priviledges. It has been shown that Dutch midwives have a worse mortality rate than Dutch OBs who only see high risk women.

          • Happy Sheep

            I had to reply to myself, discus is nutty on my tablet

          • Young CC Prof

            I believe I tracked down that 79% number. The article is here: http://www.nyc.gov/html/doh/downloads/pdf/ms/ms-report-online.pdf and it doesn’t say what you claim it does.

            It says that 79% of maternal deaths occurred after a c-section. Not “caused by,” occurred after. That’s like saying many hospital deaths occur after ambulance rides. Does the ambulance kill people? No, but the most seriously ill or injured are more likely to arrive that way.

            It also explains that half of maternal deaths occurred in obese women, and that black women were at much higher risk. Women with no health insurance were three and a half times as likely to die as women with health insurance.

            What all of this says is that it isn’t too much care killing women, it’s poverty, neglect and not enough care. These are problems we can and should solve, but natural childbirth isn’t the solution.

          • Warwick Dumas

            Referring to the uninsured cannot explain why the death rate would be several times greater than in other countries: they are simply too small a fraction of the population, even with an unexplained several-times-higher death rate themselves.

            The only risks that are really higher for obese women are those relating to interventions. People with contraindications for caesarian should be steered towards the best possible chance of success at vaginal birth. The best chance of success is usually a natural birth, if they are up for it, though not in every case.
            No, natural birth is not the solution for everyone. A free informed choice is the solution – if someone feels more relaxed with machines that go bing and a scalpel close by, they will labour best that way; if someone feels more relaxed at home, they will labour best that way.

            Now ask, why would black women be at higher risk? Not big on racial stereotypes but I was speaking to a midwife who had experience with various races and she said it’s as you might think, having bigger hips tends to lead to easier birth; it’s Asians that have the most difficulties; black women should find it easiest if anything.
            So what you are seeing here is not a genetic thing, but a cultural thing. It’s racism. Being black isn’t a factor for being bad at giving birth, but apparently, it is probably a factor for being ill-treated and not listened to.

          • Young CC Prof

            Yes, we are all well aware that the obstetrical risks for black women are not primarily genetic. Black mothers are less likely to have access to the best doctors, less likely to be listened to when they do get care, and more likely to suffer from chronic health problems before pregnancy begins. They are also more likely to give birth as teens, and childbearing is much riskier for young teens than for women in their twenties and thirties. It’s a national shame, but most of it has nothing to do with obstetrical policies.

            Please provide evidence your assertion that interventions cause the higher death rate in obese women. I claim the opposite, as obese women are more likely to have gestational diabetes, more likely to produce overly large babies who can’t fit through the pelvis, and more likely to develop pregnancy-induced high blood pressure, which can be very dangerous.

            1/5 of Americans are without health insurance. Assuming that the 3.5 times higher risk can be extrapolated to the entire country (it was based only on NYC data), then almost half of our maternal deaths occur in women without insurance! If all women had insurance, I extrapolate that the maternal death rate would be 11.1 rather than 16.7, maybe even lower if they had access to good care all their lives.

            Right now, you are starting with the assumption that interventions are unnecessary and cause problems, and twisting all evidence into that theory. Try taking a step back and examining the evidence without that assumption.

          • Warwick Dumas

            http://thelawdictionary.org/article/how-many-americans-really-do-not-have-health-insurance/
            claims 1 in 7 does not have it.
            Compare to Sweden and its 4.6 maternal mortality, the US is about 3.5 times greater maternal mortality overall. So at most, a 3.5 times greater risk of death for 1 in 7 of the population, for whatever reason, could explain only 1/7 of that. If you like, call it 1/5; I don’t claim to know the ins and outs of the US health insurance system.

            Sure, you are correct on the gestational diabetes, macrosomnia, high blood pressure. We dodged the bullets of them trying to tell us we were going to have each of these when we did not, and start a cascade of interventions we did not need. NHS are not motivated by profit but they are motivated by protocol and hyper-caution. So for us, interventions were the only thing where the risks were increased by obesity, but okay, my statement was incorrect – it could well be that gestational diabetes etc are at a higher rate in US.
            In that NYC report, many died from haemorrhaging on the operating table – that is not caused by diabetes. If you create a more enormous wound by having to cut through a lot of fatty tissue, this increases the risk of death, so more should be done to avoid it.

            No, I am not saying that interventions are unnecessary, not at all. I do say that the large disparity in death rates is likely due to unnecessary interventions. Sure you can say, the populations are a bit different and so on. It’s clear beyond a doubt, though, that there ARE many unnecessary interventions — the caesarian rate in Sweden is 14% — and that a decent number of the deaths are happening on the operating table.

            You are correct, it’s a miswording for me to say that all 79% were _due_ to the caesarian. However, when you are at 2 or 3 times the death rate of other countries, you know that inevitably, most of those 79% of deaths are avoidable; therefore it is not unreasonable to associate them with the treatment that was given.

            Difficult to understand why someone would oppose something that would help bring the intervention rate down. Unnecessary interventions have a long-term impact even if everyone survives.
            Am I twisting the data really? More just looking from a brass-tacks point of view. The US has the reputation of being the least libertarian birth system (except maybe China or somewhere). It also has a remarkably high maternal death rate. Coincidence, you say?

          • Amy Tuteur, MD

            I know you think you are demonstrating your knowledge but you are actually demonstrating your ignorance:

            http://www.skepticalob.com/2011/04/death-by-confounding.html

          • Warwick Dumas

            On the contrary, I have no interest in demonstrating knowledge – that is sheer projection. In fact I would be most interested to broaden my knowledge about different countries.

            Reputation says that in the US, you will be forced into hospital, you may be forced to have an episiotomy, amniotomy, syntocin, epidural (not the mobile one, and not one where you get to control the dosage), EFM, lie on your back, stirrups, possibly caesarian – with physicians pretty much calling the shots and a whole team of people present to conduct all their different examinations.

            How much of this rumour is broadly true? Am I barking up the wrong tree in saying that this is the type of place, that is doing so badly? Or is it really that it has just as much freedom for women as elsewhere, just that there are some poverty-stricken people that eat at Maccy D’s?
            I am asking genuinely, your opinion.

            I never said that a high death rate after caesarian in general proved anything. There are countries such as Italy with a caesarian rate at 22.4%
            http://www.bmj.com/content/310/6978/487.1
            (or 40% if you believe wikipedia) and yet with a low maternal death rate. Obviously that would be in a country with one of the premier publicly funded healthcare systems in the world, but so patient-focused that doctors make housecalls — there are multiple factors involved here. I never said otherwise.

          • Young CC Prof

            Reputation is wrong. No one forces women into hospitals to give birth. It’s strongly encouraged, but home births are NOT illegal, and in many parts of the USA, you can go to a freestanding birthing center.

            You aren’t forced to have an epidural. The only time a doctor would push for an epidural is in a particularly high-risk delivery where the doctor is worried about needing to do an emergency c-section. Nowadays, lower-dose “walking” epidurals are the norm in most hospitals. Low risk women are encouraged to walk around through the early stages of labor and choose a comfortable position, though of course doctors and nurses monitor them.

            What you’ve heard is natural-childbirth propaganda, partly based on standard practices of the mid 20th century which have largely been phased out. It’s a widespread myth, but it’s just not true. Most American women do not have that type of birthing experience today.

            I was outraged when I learned the truth! For years, I’d believed that the natural of giving birth was best and all those unnatural hospital interventions caused more problems than they solved. Once I started reading, the myth cracked, and I realized just how silly it really was. I’m so glad I learned the truth before my due date!

          • Warwick Dumas

            I suggested we go to a freestanding birthing center here and was told “nah, you don’t want to do that .. it’s further from the hospital than your house .. if you need to transfer, you’ll be better off at 3 minutes distance from the hospital”.

            When you say they monitor them, EFM is highly preferred though right? So that does restrict their movement rather a lot. And vaginals every 30 minutes? …
            Suppose labour stalls for an hour, the pressure to go to amniotomy and augmentation is probably going to grow pretty fast?
            What is your own background as regards this, you don’t mind me asking?

            Also is it standard, as I heard one firsthand anecdote, to cut the cord in under a minute and take the baby away from the mother for half an hour after birth?
            Apprehension of that could certainly be a reason for labour to get into difficulties. Psychologically, it’s a crocodile lurking in the back of the cave.

          • Young CC Prof

            Many hospitals do wireless EFM, which allows the mother to get up and walk around. And in fact, EFM makes doctors more patient sometimes. If labor is progressing slowly, but progressing, and the mother and baby are OK, they’re more likely to wait and see.

            Most hospitals now allow delayed cord cutting, unless the child requires immediate care (most do not.) They do not separate mother and baby unless the baby requires care. Also, I’ve never seen any evidence that anxiety delays labor. The cervix isn’t a muscle, it doesn’t relax, when it dilates, it’s because the tight connective tissue in it basically disintegrates.

          • Warwick Dumas

            “Also, I’ve never seen any evidence that anxiety delays labor. The cervix isn’t a muscle, it doesn’t relax”
            Hmm. If oxytocin is not relevant to labour, how come augmentation with syntocin does anything?

            Anyway, that is certainly relevant information. Which state is it that you are familiar with? You say you have not seen evidence – do I take it from your username that you work at a university?

          • Vyx

            It wasn’t stated that oxytocin wasn’t relavant, only that the cervix is not a muscle. The cervix doesn’t contract and relax like a muscle during labor, you’re thinking of the smooth muscle of the uterus.

          • AmyP

            “And vaginals every 30 minutes? …
            Suppose labour stalls for an hour, the pressure to go to amniotomy and augmentation is probably going to grow pretty fast?”

            Nope–those times are ridiculous. I’ve had three babies at three different US hospitals over the past 11 years, and there was never that kind of time table. I was annoyed by my first OB cranking up the pitocin for my first labor without explaining what she was doing, but by that time I had been in the hospital for some hours with both Group B strep and broken waters, so (as I’ve since learned) there was actually excellent reason to get things moving.

            Also, for my last baby (last year) I had the kind of epidural you can adjust as a patient.

            It’s not uncommon for Europeans to have absolutely ridiculous notions of life in the US (and vice versa, of course).

          • Sullivan ThePoop

            As I have said before, they let me labor for 24 hours after induction before they broke my water. No one was rushing me or even mentioned a C-section.

          • Trixie

            With my vaginal birth, the cord was cut once it stopped pulsing, maybe 1-2 minutes. The baby stayed on me for over an hour, and I was the one to decide to hand her to the nurse, because I had to use the bathroom. Once I handed her over, she was weighed and measured and washed and dressed and whatever else they needed to do to her in the nursery. I took a shower and then they brought her back.

            With my cesarean, he was separated from me while I was in recovery, and this was very hard on me. They did not, however, give him a bottle, but rather waited for me to be out of recovery to nurse him. But since that time, the hospital has changed its policy and they now allow babies to stay with moms in recovery as long as both are medically stable.

          • Most of these are standard NCB propaganda tropes.

          • Elizabeth A

            Warwick, I’ve given birth in the U.S. twice, once in a normal situation and once in a high-grade emergency.

            The cord was cut immediately in both cases, for good cause, but my first child was never taken out of the room (and remained mostly in my sight). My second was taken to the NICU because she needed help breathing. It was clearly never anyone’s plan to separate me from my babies for anything other then dire need (my second baby was quite premature).

            I labored in hospital for about 15 hours, and can recall only 3 vaginal exams. (I’ve only been in labor once. My second was a pre-labor emergency c-section. No vaginal exams at all with her.) I had the inconvenient kind of EFM both times, but in both cases, I wasn’t getting out of bed anyway. First time, I had the non-walking kind of epidural and took a nap. Second, I was bleeding like crazy and keeping my feet up.

            In most cases, I agree that you don’t want to go to a freestanding birth center. Most of them are like having a home birth at someone else’s house, combining the disadvantages of having to travel in labor with the disadvantages of not having appropriate facilities, personnel or equipment for an emergency.

          • Warwick Dumas

            Thanks, and thanks to all that responded. I hope that both your babies were both OK.
            When you had the non-walking epidural and took a nap, was that the only option available, apart from doing without?

          • Box of Salt

            Warwick Dumas, “How much of this rumour is broadly true? Am I barking up the wrong tree in saying that this is the type of place, that is doing so badly?”

            Answer to first question: pretty much none of it.

            Answer to second question: Yes. You are barking up the wrong tree.

            “In fact I would be most interested to broaden my knowledge about different countries”

            Are you willing to admit your assumptions about the US are way off base?

          • Warwick Dumas

            Of course, go ahead and enlighten me.
            But I do need specifics and to know on what your information is based.

          • Box of Salt

            I missed this comment earlier, Warwick. My information is based on receiving maternity care in the US during the “ought” decade, and discussions with others (friends and family) plus/minus a decade either way.

            I am an older mom who talks with both older sisters and the moms of her kids’ friends who are still having younger siblings, as well as reltives in other countries.

          • Trixie

            I would say that EFM is mostly universal, but they do let you off unhook for 20 minutes or so at a time as long as everything looks good. Episiotomy rates in the US have dropped pretty significantly. I don’t know anyone in my age group who has ever seen stirrups during delivery. Pretty much everyone I know was offered a variety of positions and pain relief techniques during labor. And pretty much everyone I know who chose an epidural was pretty happy with it, and got to control the dosage themselves with a little clicker.

          • Warwick Dumas

            Well, I am learning here.

            Here is one thing though. You mention that episiotomy rates have fallen. It seems to be acknowledged that they are still several times what they would ever need to be:
            http://www.webmd.com/baby/news/20050826/episiotomy-rates-too-high-say-experts

            I just don’t understand how that can happen, except as a result of a culture that does promote routine interventions, perhaps loath to abandon a traditional protocol from years past. (And if there is not any bullying involved, then it certainly seems that a lot of people must like to assume their physician is a god or infallible, or they would not go along with it.)

            In the UK the rate is now about 13% from what I gather, it is never done routinely. The NHS only changed their recommendations a few years back though.

          • Guest

            I guess the stereotype of the “ugly American” even extends to maternal/child health. I’m an ob/gyn in private practice at a community hospital in the US. I trained in a large, academic setting. Your claims are absurd. Routine vaginal exams every 30 minutes are unheard of, the expectation of active labor is cervical change every 2 hours, latent labor has no “time table”, and your much-lauded UK episiotomy rate of 13% seems rather high to me. My rate is less than 5%, although admittedly my vaginal laceration rate is higher. Epidurals are offered and easily available but never required and amniotomy is often offered as a method of augmentation than can frequently allow my patient to avoid Pitocin. I have a 10-15% primary C-section rate (excluding breech and multiples), discourage elective induction of labor prior to 41 weeks, and care for women across the socioeconomic spectrum.

          • Warwick Dumas

            “I guess the stereotype of the “ugly American” even extends to maternal/child health.”
            It’s not me putting the mortality figures all down to the population, though I’m happy to assume it’s a factor. Still, fat not= ugly. My wife is American and she is not slim but she is very beautiful.

            It sounds that you maintain exemplary standards, and I’m certainly glad to be wrong as far as your practice goes. I agree with you, I can’t see why the NHS needs 13% when Sweden has 9%.
            Clearly though, someone out there has an episiotomy rate that is way higher than yours, to get 31% overall. What could be the explanation?

            I am interested, do you happen to know a study that says amniotomy without pitocin/syntocin really makes any difference to the length of first stage? You may be aware, there are recent claims that it does not:
            http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0013776/
            Not criticising the sincerity of your beliefs in any way. Just wondered what you think about that research.

            The 30 minutes once labour was meant to be established is actually what we had here at home. It became 5 minutes between, with six midwives and students present, once labour stalled and they all wanted they and their student to get a go (they’d decided to transfer us pretty early on I think). Then we got to hospital and there were only a few staff, and eventually just one senior midwife that really knew her stuff, so that was a relief. (The bloodcurdling screams weren’t a plus, of course. For some reason UK hospitals don’t even have draught excluder on the doors. Maybe they afford that in America.)

          • The term “Ugly American” has nothing to do with physical attractiveness.

            “Ugly American is a pejorative term used to refer to perceptions of loud, arrogant, demeaning, thoughtless, ignorant, and ethnocentric behavior of American citizens mainly abroad, but also at home”
            (http://en.wikipedia.org/wiki/Ugly_American_%28pejorative%29)

          • LibrarianSarah

            It is funny how people usually through out the “Ugly American” epithet shortly after making a bunch of crude generalizations and stereotyping both Americans and American culture.

            Frankly, as fun as this conversation is to read, it is pretty obvious that this guy is JAQing off and it would be best to let him do so in private.

          • Warwick Dumas

            Not everyone that disagrees with you in some way is a troll. hth

          • Amy Tuteur, MD
          • Warwick Dumas

            Amy Tuteur: You call it a “high” rate of maternal mortality in the Netherlands (7.6) – though it’s broadly similar to some other places – so presumably you agree that 16.7 is exceptionally high.
            What are your views on this – is the culture truly at all interventionist/pressuring in the US, or is that a groundless fiction, that cannot possibly be the problem because it is not real?

          • Young CC Prof

            That post doesn’t discuss maternal mortality, either in the Netherlands or anywhere else, it discusses perinatal mortality, that is, death of the baby before or shortly after birth.

            Neonatal mortality is far more common, ranging from 5-10 deaths per 1,000 births through the first world, much higher in the third world. Maternal mortality is measured per 100,000 pregnancies, so neonatal deaths are roughly 100 times as common as maternal deaths.

          • Warwick Dumas

            That post does say “It also has a high and rising rate of maternal mortality. ” Seems unambiguous to me.
            What are the figures that you would use for perinatal mortality, incidentally? I looked up neonatal mortality on WHO; it looks favourable to the Netherlands. Miscarriage in late pregnancy makes the difference?

          • Young CC Prof

            Ah, the neonatal vs perinatal mortality question! We’re in advanced medical statistics now, but hang on.

            You see, the USA has the most liberal definition of live birth. Babies born almost three months early with terrible defects who die that same day still count as live births and as infant deaths as long as they draw at least one breath without assistance. This means that our neonatal mortality rate can’t be directly compared to other countries.

            The perinatal mortality rate is all babies who die between 28 weeks of gestation and 1 month of life. It’s term stillbirths, deaths due to labor complications, and newborn deaths all mixed together, and, among first-world countries, it’s a very accurate measure for international comparison. The USA is 7 per 1,000, right in the middle of the first world, Britain and the Netherlands are both 8. Sweden and Norway are outstanding at a mere 5 deaths per 1,000.

            But if you look at the numbers, you see an interesting pattern. Other first-world countries have a higher stillbirth rate and a lower neonatal death rate than the USA, supporting what I explained in the second paragraph, that we’ve got a reporting issue.

            This reporting issue might also apply to maternal mortality, believe it or not. In the early 1990’s, US health authorities changed the way they collected data on maternal mortality. Immediately, the number of reported maternal deaths went way up, because instead of just counting deaths that were directly caused by pregnancy or childbirth, they counted all medical deaths in which pregnancy may have been a factor. If you look at the NYC report, a bunch of those “maternal” deaths were actually caused by flu or pneumonia. Do other countries count their maternal deaths as thoroughly as we do? I don’t know.

          • Trixie

            You have to remember how vast the United States is, and how big our population is, and how decentralized our health care is compared to your little island nation with nationalized health care. I’d venture that many of the visitors on this page are relatively “educated elite” and skew towards urban centers along the east or west coasts, or maybe Chicagoland. So our anecdotes may not reflect the experience that a poorer, ethnic minority, underserved woman may have.

            That being said, I know only two women with small children personally who had an episiotomy, and one of them at least was very necessary (nuchal hand). In my local area the local hospitals have episiotomy rates that are around 12%, from my understanding.

          • MaineJen

            No forced hospital (although it’s a good idea and most of us do choose this), no episiotomy unless the dr feels it’s warranted and discusses it with you and gets your consent (and it’s very unusual), amniotomy only if labor is stalled, pitocin if you need induction or augmentation, epidural on request only (and very thankful for it!!), EFM usually, you can be in any position you want for labor (I was on hands and knees for most of it), no stirrups, CS only if baby is in distress. That was my experience, for what it’s worth. A lot of your information is just outdated…

          • Young CC Prof

            You’re still stuck confusing correlation with causation. You say, “Sweden has great outcomes, Sweden has a low rate of c-section.” Absolutely right. Then you say, “The USA has more c-sections and much poorer outcomes.” Also true.

            From this, you conclude that if there were fewer c-sections in the USA, there would be better outcomes. That is the point at which we fundamentally disagree. I believe that the USA has more c-sections AND more deaths because the average pregnant woman in the USA is in poorer health than the average pregnant woman in Sweden. The reasons include access to medical care, obesity, diet, possibly ages of pregnancies, and poverty. (These factors overlap.)

            Just consider that, please.

            And yes, I do think it’s a bad idea to make a goal of reducing interventions which are at least sometimes medically necessary. I’d be happy if we could bring down the c-section rate without compromising the safety of mothers and babies, but I’m not sure it’s possible. I’d hate to see women or babies die because the obstetrician waited too long, trying to avoid surgery.

            A grand total of 20 deaths out of 161 were hemorrhage with caesarian delivery. It doesn’t say they occurred on the operating table, nor does it say how many of those women were already bleeding badly when the surgery began. Those 20 deaths could just as easily be an indictment of poor nursing care after necessary surgery, or an indication that the mother should have been taken to surgery sooner. I have no way to know, neither do you.

            I have no idea what this means: “The US has the reputation of being the least libertarian birth system.” Most American women have lots of choices in childbirth, they can choose from multiple doctors and hospitals or freestanding birth centers. A few choose home birth. The only ones with no choices are the poorest, and those are the ones who disproportionately die.

          • Siri Dennis

            Look up different pelvic shapes and how they are distributed among women of different ethnic origin. And having big hips does NOT mean childbirth will be easier; for every skinny Minnie who pushes out a 10lb baby, there’ll be a hefty-hipped woman needing forceps to be delivered of a 5lb tiddler. Go find a good midwifery textbook and have a read.

          • Bombshellrisa

            Big hips=easier birth. Nope.
            Being relaxed with candles lit and a tub at home has nothing to do with how well someone will labor. ((Yes, I have seen, assisted with and been a primary caregiver at home births))

          • The Computer Ate My Nym

            Referring to the uninsured cannot explain why the death rate would be
            several times greater than in other countries: they are simply too small
            a fraction of the population

            About 20% of the overall population in the US under age 65 is uninsured. The rate of uninsured people peaks at around age 18-30, i.e. the “best” years for childbearing. A 3x higher death rate in about 20-30%* of the population is going to make an impact on the overall death rate.

            *It’s been fluctuating quite a lot in the past 5 years or so.

          • The uninsured population in the US fell to just over 15% in 2012. That is not a small fraction of the population.

            Note that since the elderly are generally insured through Medicare, and children are sometimes covered through CHIP and Medicaid when their parents aren’t, more than 15% of potentially fertile women in the US are uninsured.

          • The Computer Ate My Nym

            Just to note: the 15% number is all people in the US, including those over 65 who are nearly 100% covered by medicare, and under 18 who are often (but not always) covered by SCHIP. The number for adults age 18-64 is higher.

          • Indeed.

          • Something From Nothing

            Fail. Take a logic course and a statistics course while you are at it.

          • Trixie

            Are you implying that cesarean section is routinely performed without consent?

          • Warwick Dumas

            That was my understanding, though it could be false: I have no idea how many refused consent.

            http://www.childbirthconnection.org/pdfs/LTMCesareanData.pdf

            That link claims that truly elective caesarians – in the sense that the mother planned it in advance – are very rare.
            Now let’s imagine that mothers are voluntarily accepting physician decisions to go to caesarian, and that those decisions are motivated by what they see as the best interests of mother and baby at the time. Suppose we leave the perverse incentives and sinister systemic reasons aside.
            Suppose it is really true that say, 40% of Indiana births, 32% of US births, end up actually needing a caesarian, vs. say 14% of births in more successful environments.
            Under these assumptions the question becomes, Why is it that labour tends to fail so frequently, over there? Really, 40% of the time – there must be pretty big reasons.

          • Bombshellrisa

            “Perverse incentives”? What would those be? Right now, doctors in WA state who accept Medicaid get an incentive to LIMIT c-sections, not the other way around.

          • Young CC Prof

            Maternal request caesarians are rare, that is, surgical deliveries scheduled in advance simply because the mother asks, with no special risk factors requiring it.

            The biggest group of caesarians are medically necessary, but scheduled in advance. Sometimes it’s because an ultrasound reveals problems with the cord or placenta that make labor particularly dangerous for the baby, or because the baby is in a dangerous position and refuses to turn. Generally this is planned out well in advance, and the mother has plenty of time to ask questions and determine if safe natural labor is possible.

            Finally, you have women who start to labor naturally, but are sent for a c-section later on when problems crop up. This can be either a desperate-emergency situation or a calmer situation, and the desperate-emergency c-sections tend to have the worst outcomes. (Hence, good obstetricians act when things FIRST start to go wrong, rather than waiting for true emergencies.)

            “Why is it that labour tends to fail so frequently, over there?” Excellent job, you have asked the right question. I’ve already given you part of the answer: More health problems in the population, poorer prenatal care, etc. Keep researching and find more answers, it’s a really important question.

          • Warwick Dumas

            In your view, that fully accounts for it? How large a proportion are you assuming are obese? This claims 1/3, on what criterion I do not know:
            http://www.ncbi.nlm.nih.gov/pubmed/16704347

            Meanwhile, this says in England it’s 15-20%, using BMI 30 as the criterion:
            http://www.nhs.uk/conditions/pregnancy-and-baby/pages/overweight-pregnant.aspx#close

            Caesarian rate here is 25%, but note also:
            http://www.institute.nhs.uk/quality_and_value/high_volume_care/focus_on%3A_caesarean_section.html
            “the rate has increased from 12% with no improvement in outcomes for the baby”

            Given that, can obesity and related factors really be the full explanation?

            How would you describe the most usual course of events at an uncomplicated US birth, as regards all interventions?

          • Box of Salt

            Warwick Dumas “How would you describe the most usual course of events at an uncomplicated US birth, as regards all interventions?”

            Could you describe what you thtink that is, just to clarify what we are discussing now?

            “an uncomplicated US birth.”

          • Warwick Dumas

            one where there is not an obvious emerging reason to do other than the standard procedure…

          • Box of Salt

            Warwick Dumas, “one where there is not an obvious emerging reason to do other than the standard procedure”

            huh?

            Could you answer the question? What exactly do you think is going on?

          • Bombshellrisa

            Do you mean that when all is said and done that the baby delivered doesn’t seem to be in any kind of distress? It’s sad we don’t have a retroscope to be able to know when there are signs of distress which babies will be ok and which ones need to be taken C-section.

          • Warwick Dumas

            No. By a complication I mean something like a breech position, or that the waters have broken the previous day or with murky brown meconium, and so on. Once you get into all the possibilities, the ways that different medical systems will treat all the different cases becomes an endless subject.
            That is why I ask about, for an uncomplicated case, one without any particular visible reasons for intervention or special concern, what is the experience. (For sure, this kind of ‘uncomplicated’ case may not even be all that common, but hey.)

          • Bombshellrisa

            A baby in breech presentation or thick meconium ARE reasons for an intervention. Those are not merely variations of normal

          • Warwick Dumas

            To _some_ people, any type of breech is sufficient reason for intervention, though not to all. Hopefully it is clear now what I am calling ‘complications’ and what I am asking for. If not, don’t worry about it.

          • Bombshellrisa

            No, what you are trying to get across isn’t clear at all. The problem with a wait and see attitude in regards to a baby in a breech position is that you won’t know until it’s too late if an intervention is needed. There have been footling breech babies born at home to less than competent midwives in a rural setting without incident. That doesn’t mean that it should be the standard of practice to see what presents before choosing a course of action. Plans of care and protocols are developed for a reason.

          • theNormalDistribution

            Are you familiar with the term “prophylactic”? Just curious.

          • AmyP

            “the rate has increased from 12% with no improvement in outcomes for the baby”

            “Given that, can obesity and related factors really be the full explanation?”

            Of course–UK women have gotten fatter, too. The medical system may have to work much harder to achieve the same results as before.

            “UK women are fattest in Europe.”

            http://www.bbc.co.uk/news/health-15901351

            Also, the average age at first childbirth has gone up.

            “Nearly half of births in England and Wales are to mothers over 30”

            http://www.theguardian.com/uk/2013/jan/24/half-births-mothers-over-30

          • Lizzie Dee

            “the rate has increased from 12% with no improvement in outcomes for the baby”

            Statistically illiterate, I don’t really get how a statement like that makes any sense. Far as I know, the stillbirth and perinatal mortality rates in the UK have been dropping steadily since the early 80s – round about the time that epis started to be used instead of GA, and the CS rate started to increase. Can anyone better informed than me explain what it means? If CS was such a big problem wouldn’t the outcomes be worse?

          • Warwick Dumas

            Far as I can tell, you are correct to guess that the perinatal mortality rate has slightly dropped over the period.
            http://www.ons.gov.uk/ons/rel/vsob1/child-mortality-statistics–childhood–infant-and-perinatal/2010/stb-cms-2010.html#tab–Infant-and-Perinatal-Mortality-Rates

            However there is probably some genuine reason for an NHS website to be describing things the way it does. They are saying that if there are more caesarians, it might be justified by having fewer infant deaths, but they claim that is not how it happened. They may be looking at the mortality broken down by subsets.

            Perinatal mortality at that birth isn’t the only thing to worry about. If there were nothing else disturbing about it and no risk of haemorrhage, the CS could be a concern for the impact on future births. People on this page may be gung-ho about it compared to most, but on a blog called Sceptical Obgyn that is probably to be expected.

          • Young CC Prof

            Well, I wouldn’t call cutting the perinatal mortality rate in half a “slight” fall, I’d call it dramatic. (Of course, there may be factors other than c-sections involved, like better neonatal care) I’d also want to look at the incidence of palsy from shoulder dystocia and hypoxia-related brain damage, as well as severe tears or other birth injuries to mothers.

            Of course, the population is changing at the same time. All of the Western world has more older first-time mothers, more overweight mothers. The average sizes of newborns have gone up along with the obesity epidemic. If you tried to impose a 12% caesarian rate on the British mothers of today, it’s possible you’d see a much higher perinatal and even maternal mortality rate.

            Yes, a c-section is a risk factor in future pregnancies. If you’re carrying baby #2 after one c-section, the risk is pretty small, if you’re carrying baby #4 after 3 c-sections, it starts to get significant. Still, not too many women HAVE that many children. Which, believe it or not, may be a factor in the c-section rate: Falling birth rates. If the OB knows that a first time mother wants lots of kids, it’s a reason to try just a bit harder to avoid a section. But if the mother is planning on only having one or two children, it’s not such an issue.

            One last thought: Ultimately, a good doctor does a c-section, or any surgery, when he or she believes that the risks of the surgery are smaller than the risks of NOT doing it. Over the past few decades, c-sections have gotten safer and safer, so obstetricians’ idea of acceptable risk in a vaginal delivery has decreased accordingly.

            In the New York data set, there were a total of 33 deaths from hemorrhage or infection associated with a c-section, out of over 600,000 births in the city during the study period. That’s a 1 in 20,000 risk right there, or 0.005%. Now, let’s say you’re the obstetrician, watching over a woman in labor, and a complication comes up. Most of the time, vaginal birth with this complication works out OK, but about 5% of the time, the baby dies. What do you do?

          • Wren

            Are the outcomes for women considered as well? I know 3 women who had their first child within a month of mine who have required extensive reconstructive surgery after their “natural” deliveries, here in the UK. All three requested C-sections for their second child, and were given them.
            For the record, not one was obese or had other health issues that would indicate a problem prior to the birth. One is very tiny, especially in comparison to her much larger husband.

          • Warwick Dumas

            As noted previously, electives are not the reason for differences in caesarian rates.

            Regarding those few mothers that do consider an elective, for whatever reasons of their own which could be perfectly valid, they should certainly be given information such as this:
            http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110651/
            Caesarian-delivered children will suffer more from gastroenteritis, diabetes mellitus, and other problems because of their poorer immune systems.
            “Babies born vaginally were colonized predominantly by Lactobacillus, whereas cesarean delivery babies were colonized by a mixture of potentially pathogenic bacteria typically found on the skin and in hospitals, such as Staphylococcus and Acinetobacter”

            Nice.

          • Young CC Prof

            As noted previously, maternal request c-sections with no medical indication are rare. History of major tearing after a previous delivery is a medical indication.

            That article isn’t terribly conclusive, you realize, and it’s a literature review rather than an experiment. So, another statistics lesson?

            First, look at the table. See how most of the odds ratios were just a bit higher than 1. 1 means no difference, 1.37 means just a bit more likely. That means we can explain only a fairly small part of the rise in childhood asthma through the rise in c-sections. All odds ratios were smaller than 2, meaning the disease was less than twice as common in the c-section group.

            Also, the confidence intervals for the odds ratios of some of those outcomes were extremely wide, showing that they were based on small samples, and some narrowly missed 1. If the CI contained 1, that would mean that the study could not prove a difference at all!

            A separate problem is that it’s based on observational studies. No one randomly assigned babies to section or vaginal and followed them for 10 years to see what would happen! You can’t reasonably do a study like that, but it would be the easiest way to find out for sure. As it is, we can only observe after the fact. It’s tough to fully control for the reasons for c-section delivery. One question I’d like answered is this: Are pregnant women with asthma more likely to deliver by c-section? Because we know asthma is partly genetic.

            Autoimmune disease is a really complex problem, and there are so many aspects of it that aren’t well understood yet. This study is interesting, and I definitely think we should study the matter further, but it doesn’t prove anything.

            Heck, maybe c-section babies just need their lips rubbed with lactobacillus. It’s possible.

          • Warwick Dumas

            The following isn’t relevant to the link since you admit it does “prove” a result.
            This is OT and if it gets deleted, so be it, but it’s a point that I have always been at pains to labour with students and colleagues.
            Suppose you were doing a simple regression – let’s say you are trying to estimate a continuous variable and you find that it has a confidence interval between -0.5 and + 2.5, with the estimator coming out at 1. The most correct thing is to say that the effect is 1. Not that it is zero – that is no more correct than saying it is 2. Of course, you could choose to favour the idea that it is zero, and require strong evidence to shift you from your initial assumptions. Equally, you could choose to favour the idea that it is 2, and require strong evidence before you believe it is any less.
            Inference requires a certain degree of rationalism. Data mining does not produce reliable conclusions. Now here we are afforded a good example: we know that CD babies are colonised by staph and not by lactobacillus. It is therefore not that surprising when we observe some consequences of it. Rather than speaking about proof, which will never be available, it makes more sense to say that there is a credible interpretation of these combined facts.

            Of course if you are determined to believe something, such as that CD babies must be equally healthy, then there will always be a way to keep on believing it. The question is, at what point does it stretch credibility, with so many of these additional “explaining away” hypotheses, that Occam’s razor comes out and says “no, it’s because they were colonised by staph”. That is subjective for the individual – some are more resistant to evidence than others.

          • The Computer Ate My Nym

            We have a running joke about “Occam’s razor”: Occam never makes his clinic appointments and when he does show he’s always got a beard. Occam’s razor just doesn’t work in medicine. Too many variables. People are an outcrossed population and it’s very difficult to say that variable A causes outcome B, even when they appear closely associated.

          • Not to mention how disingenuous it is to look for THE ONE TRUE CAUSE in healthcare. Human bodies are insanely complex and there are almost always confounding factors of some kind. It’s one of the greatest challenges in medicine, isn’t it?

          • The Computer Ate My Nym

            The one true cause of health care issues is life. Dead people rarely have (further) issues with their health.

          • Young CC Prof

            The article you found claims that studies show a small but statistically significant increase in certain medical problems among c-section babies. Let’s assume that’s accurate, I’m not motivated enough to track the references today.

            You’re drawing a connection between an event at birth and a complicated multifactorial medical problem that shows up years later. No one has demonstrated at a biochemical level why inadequate lactobacillus exposure at birth would lead to asthma later on, it’s just an association, and confounding variables including genetic, socioeconomic, and even geographic factors have not been ruled out.

            What I say about that study is that it’s interesting and worth considering. It’s not conclusive proof.

          • The Computer Ate My Nym

            The numbers in questions are relative risk ratios. I don’t think a relative risk of -0.5 makes any sense. A risk of, say, 0.01 might indicate that something virtually never happens in the experimental group (i.e. perhaps the control group is smokers and the calculation is relative risk of lung cancer), but I don’t know how one can get a relative risk of less than zero.

          • The Computer Ate My Nym

            Thank you for including the link. That makes it much easier to discuss the content. And the content does have some issues.

            First, the differences observed aren’t that large. They show statistical significance, but a fair number of small, statistically significant differences are in fact due to chance. People are extremely diverse and controlling for all variables is difficult.

            Second, correlation =/= causation. For example, there are probable genetic elements to diabetes and other autoimmune diseases. So women who are diabetic are more likely to have children who are diabetic. They are also more likely to need c-sections. And women with SLE, for example, are more likely to have complicated pregnancies which may require c-sections. Likewise, asthma and decompensation during labor could easily lead to c-section.

            Third, buried in the text is the admission that a number of autoimmune diseases were not correlated with c-section. This makes the chances of it being, well, chance, higher. Remember, a 95% confidence interval means that the “true” number will be within those boundries about 95% of the time. If you look at 20 values, there is a good chance that one of them will be outside the “normal” simply by chance.

            In short, it’s an intriguing hypothesis, but hardly data that should be practice changing.

          • I. Call. Bullshit. I am so sick of this paternalistic crap that women just can’t WANT a C-section, they have to be counseled over and over. Yet a woman going against EVERY piece of medical advice from multiple providers is an Educated Mama.

          • Dr Kitty

            Or, Warwick, they could be given the accurate information as recommended by NICE.

            http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf

          • Box of Salt

            Warwick Dumas “That was my understanding, though it could be false: I have no idea how many refused consent.”
            in reply to “Are you implying that cesarean section is routinely performed without consent? ”

            No. You are flat out wrong. Drop the shovel, Warwick.

            Your link does not back you up, either.

            Please correct if I am wrong. I have inferred from your comments and screen name that you are a man who lives outside of the United States, and doesn’t know much about maternity care anywhere.

            Get back to me when you can prove otherwise.

          • Warwick Dumas

            Inviting as it sounds, I don’t think I shall.

          • Box of Salt

            Warwick Dumas “Inviting as it sounds, I don’t think I shall.”

            I didn’t think you could.

          • In as litigious a society as the USA, you honestly believe doctors could carry out surgery WITHOUT consent and not face endless lawsuits?!

          • Trixie

            Yeah, you’re just wrong. Except in cases where the mother is unconscious and there’s an emergency, the hospital needs to obtain consent before performing surgery. Any doctor or hospital who performed cesareans outside of those parameters would quickly be sued out of existence. I had to sign a very detailed consent form, which was also explained to me, and my husband, in detail, in plain English, before my medically necessary cesarean could be performed.

            You could make a nuanced argument that low-risk women who would like a trial of labor after cesarean (TOLAC) are having trouble accessing them in hospitals in some areas of the country, and this is probably not a good thing. But, you’re not making any nuanced arguments.

          • moto_librarian

            Do you know the difference between the primary c-section rate and the overall rate? Here’s a little clue for you: the primary rate for primips is around 15-20%. The 40% number that is always bandied around by NCBers is for ALL c-sections, including repeat sections. Not every woman wants to have a VBAC, nor is every woman a good candidate for one.

          • Warwick Dumas

            No, I don’t know what you are saying. What does “the primary rate for primips” mean, in everyday language?

          • PrimaryCareDoc

            If you don’t know what she’s saying, you don’t know enough to be making your assertions.

          • Warwick Dumas

            That is one point of view. You probably would apply the same attitude to your patients, it’s fair to say, PrimaryCareDoc? You wouldn’t want to assume you know best and unilaterally take their decisions for them – only if you can think of a jargon word they do not know, perhaps one not common in their community. Is that about right?
            In your world, being right is about being in authority or having rote-learned some obscure jargon. In my world, it is different. It is about the argument, not who is saying it. Even when it is a subject as familiar to me as some part of your job is to you, I only expect my claims to be taken seriously as far as justification can be provided for them. That is how the rest of us work, that are not in medicine.

          • Wait, what? You’re deeming a rate *you* brought up to be “obscure jargon”?

          • moto_librarian

            Did you know that I am NOT a doctor, yet I know this supposedly “obscure” bit of terminology? I suppose I should have said “first-time mothers” rather than primip, but the overall point is the same. If you are a first-time mother, your “risk” of having a c-section is NOT 40%, but 15-20%. That 40% figure is ALWAYS cited by natural childbirth advocates, when the reality is actually much more nuanced.

            BTW, you have the internet at your fingertips. Not that hard to look up what primip means, now is it?

          • Sullivan ThePoop

            I am a doctor, but not of medicine and I know all of this “obscure” bit of terminology.

          • PrimaryCareDoc

            Er, no. But my patients also don’t pretend to be an authority on things that they know nothing about.

            In my world, being right is about being right. It has nothing to do with authority or jargon or rote memorization. It has to do with facts.

          • Warwick Dumas

            I never claimed to be an ‘authority’ either. If anyone claimed to be an ‘authority’, I would ignore it; only an actual argument amounts to anything. You are just assuming that someone would have to be some kind of an ‘authority’ to make some assertion that I made.
            Let’s be honest, you and some others here have been sending some quite aggressive messages, and there must be some reason for that.
            I put it to you that the mark of a fanatic is that they hate an agnostic fully as much as they do any other brand of infidel.
            Meanwhile I am grateful to those who have given serious and non-aggressive responses to my questions, whether based on their own experiences or anything else.

          • KarenJJ

            Don’t know what sort of doctors you’ve come across, but my doctors have all been at great pains to try and explain things to me such that I might understand. One even had a go at explaining the immune system in terms from electrical engineering. If I don’t understand something I ask them. The show-off-y, jargon-y doctors on TV, like Dr House, I’ve never come across in real life thankfully.

          • Warwick Dumas

            True, I haven’t met a lot like that either, and I have a GP that is a very decent chap.
            House was written by a corporate lawyer btw.

          • Box of Salt

            Warwick Dumas “No, I don’t know what you are saying. What does “the primary rate for primips” mean, in everyday language?”

            Thank you for confirming that you have no clue about anything you’ve been discussing over the last couple of days.

          • Primip = first birth

            Ergo, the FIRST CS on the FIRST birth is a different rate (15-20%) vs the OVERALL rate (subsequent CS on subsequent pregnancies, CS in a subsequent pregnancies when a VB happened in the first one)

            Primary-level understanding of statistics required.

          • Poogles

            “What does “the primary rate for primips” mean, in everyday language?”

            The rate of first-time moms that will have a CS, versus the rate of ALL women which includes those who had previous CS and choose to have a repeat instead of a VBAC, are not candidates for VBAC or do not have access to VBAC.

          • Lalique

            Being bullied into a csection and refused. Medical attention unless you do is not a necessary csection. Then to see that they write down routine csection on papers. That is who OBs are. Happened to me!! On my second home birth!

          • Young CC Prof

            And you transferred to the hospital because everything was going perfectly?

          • The Computer Ate My Nym

            The reason is poverty? You are doing twice as badly as Albania.

            This is not necessarily inconsistent. The US is wealthier than Albania, but has a higher GINI coefficient.

          • Sullivan ThePoop

            Provide the research from NY because that does not fit with anything we know about C-sections from research or even history.

      • Busbus

        Sorry to be posting on this very old thread, but I’m from Europe, and I frequently see posts containing blanket statements about Europe that are simply not true. I don’t know of a single country in Europe that requires OB-GYNs to attend a home birth during their training. Certainly not in France or Germany, where the vast majority of obstetricians will strongly advise against home births. To my knowledge, the only country where this might be true would be the Netherlands, but that’s just a guess on my part—I know next to nothing about obstetric training there.

    • “With all due respect, how would you know if you’ve never attended one?”

      This is the most inane thing I’ve read yet today. No wonder (non CNM) midwives think things like placental abruption, macrosomic babies and uterine rupture never happen – if you don’t witness it in person then it simply CANNOT BE!!

      • The Computer Ate My Nym

        I’ve never jumped out of an airplane without a parachute, therefore I can’t possibly know that it’s dangerous.

    • moto_librarian

      I live in Tennessee. Why in the hell would I go to The Farm to have my baby when Vanderbilt University has an amazing team of CNMs, OBs, and L&D nurses? I was able to have my “natural” childbirth in the hospital. The only difference between doing it in the hospital vs at home is that I survived it. You see, my son tore my cervix when he was being born, and I began hemorrhaging as soon as the placenta delivered. Prompt care in the OR saved my life, and I was able to avoid a blood transfusion. This was a relatively rare complication that occurred during a birth that my midwife described as “textbook” up to that point. Maybe you should speak to the CNMs that deliver at Vanderbilt…

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