Thank you, ACOG!

ACOG district meeting

Thank you to the folks at ACOG for inviting me to address the district meeting in Maui.

It was a privilege and a pleasure to speak to nearly 300 obstetricians, medical students and CNMs, all of whom were eager to learn what they could do to prevent homebirth tragedies. As I told the group, I wish I could have taken a picture from the podium. I think many homebirth advocates would be surprised. They’d be surprised that the group was 50% women; they’d be surprised that the group was anxious to learn all they could; and they’d especially be surprised that the question I heard repeatedly, both during my talk and afterward was: “How can we convince homebirth midwives to transfer a higher proportion of their patients, earlier in labor, before it is too late to save the baby?”

Homebirth advocates also would have been surprised by the straightforward nature of my talk. All I did was tell the truth: the truth is ugly enough, and there was hardly a soul in the room who was not aware that homebirth leads to preventable deaths, because they had seen if for themselves.

The talk was not recorded, but I have posted my Powerpoint slides:

You can read my notes for the talk (complete with typos) here:

Dr. Amy’s ACOG talk

The talk took over an hour plus time for questions from the audience.

My questions to the audience were these:

How many babies have to die preventable deaths before we address the misinformation spread homebirth advocates and homebirth midwives? How many babies have to die before we abolish the pathetically inadequate CPM credential?

I don’t know, but every death is a tragedy too many.

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  • Felicitasz

    I read your notes, THANK YOU VERY MUCH for publishing them here.

  • areawomanpdx

    I don’t think CPMs will start transferring sooner until the demonization of the hospital and the cries of “unnecessarian” stop, which is never (when it comes to the homebirth community). The midwives won’t transfer because they won’t get paid, and the mother will resist transfer because she’ll be painted as a failure and she sees the beautiful birth she’s built up in her mind slipping from her fingers. Until the scientists out-shout the woosters, babies will continue to die. You only have to look at what is happening with vaccination — the loudest, most obnoxious voices win, no matter who is actually right.

  • guest

    Bummed we couldn’t watch a recorded version! Looks like it was a great talk Dr. Amy!

  • DaisyGrrl

    Wonderful presentation! I’ve been mulling the question of how to get CPMs to transfer sooner, and I don’t think there’s an easy answer for that. In the countries where homebirth is less dangerous, there is better screening and much better integration into the existing health system. A transfer won’t automatically mean that you’re sent into the care of strangers where your midwife no longer has any say in your care. Qualified midwives keep proper records and are more likely to have a working relationship with the L&D people at the local hospitals so continuity of care is possible. CPMs have set up an adversarial relationship with OBs and hospitals, and we’ve all heard of the dump and runs that happen when homebirth goes very wrong. And of course, finances play a large part in this. Where I live, you don’t pay out of pocket for care provided by midwives or doctors/hospitals. There’s no financial disincentive to transfer – I don’t see how this will change in the US anytime soon.

    Short term, I think ACOG and the CNMs should work on a public education campaign aimed at women considering homebirth. Since CPMs are so big on self-education and taking charge of your own health, health officials should arm prospective clients with information. Publicize the 40% transfer rate of good HB midwives far and wide. Scream the difference between CPMs and CNMs from the rooftops (CNMs, I’m looking at you). Let women know what signs are clear indications to transfer care. Write articles for prominent women’s/parenting magazines and websites that provide this info in as non-judgmental a way as possible. Get testimonials from women who transferred and were surprised at how nice the hospital was. Use the testimonials of families hurt by homebirth as cautionary tales to demonstrate that birth is still dangerous. It will be much harder for CPMs to attend dangerous homebirths and/or delay transfer if the parents are armed with knowledge about safer practices. I wonder if baby Natalie’s parents would have continued at home if they knew that meconium was an indicator that transfer needed to happen immediately. If they had a list of deal-breakers that was predetermined, would they have felt differently about the “care” being provided by the midwife once it was clear things were going wrong? Would they have hired a CPM if they knew how little training and oversight these women have?

    Other places where a little education can go a long way would be for OB/GYNs and GPs to be able to have a handout with links to good info sources for women considering homebirth (birth classes too, but good luck with that). Basically a summary of the above, but a bit more official-looking. If you get a woman early in her pregnancy with good info, there’s a chance that you can plant ideas to counter the woo of the NCB movement.

    While I firmly believe that health care providers are responsible for acquiring the knowledge necessary for providing optimal care, CPMs have proven that they are not capable of this. So this information needs to get directly to the mothers in as positive manner as possible. OBs could also try to reach out to CPMs to let them know that they’d much rather see women earlier in labor, but I don’t think they’ll get too far with that.

    Long term, the goal is complete abolition of the CPM credential. They are a danger to the women and babies they claim to serve. And should MANA ever release their death stats, the evidence will be there in the form of numbers of dead babies and devastated families.

    TL;DR – educate women about CNM vs CPM, ideal 40% transfer rate, indicators for transfer.

    • Karen in SC

      Agreed! I would like to see articles in Good Housekeeping, Family Circle, and others on an annual or biannual basis (much like the October Breast Cancer features). Online sites like ivillage, too. Where do most women of childbearing age get their information?

      There are also local monthlies that love to write exposes….why haven’t any of their freelancers discovered this issue?

      • DaisyGrrl

        I think with the Gruenenbaum (sp?) study the issue will have a higher profile and it’s a good time for the press to get involved.
        I have no idea where women of childbearing age get their info (despite being one myself…I’m in Canada so my first thoughts are Canadian Living and Chatelaine). Aside from the ones you mention, maybe Real Simple?

        American maternity wards sound heavenly compared to what’s available here (ours are adequate, but definitely more utilitarian since it’s paid by public funds). I don’t understand why women wouldn’t want to give birth in a private American hospital.

        Could MDC be convinced to run a blog post on when to transfer care? I know it’s crunch central over there, but maybe something along the lines of “while homebirth is lovely, a hospital/OB is better when you encounter these situations…”

    • Lisa from NY

      It’s not always realistic to expect hospitals to be nice to transfers.
      When a woman goes into labor and is being monitored, there is plenty of time to see how things are doing.
      When a woman is transferred, it’s because of a life-threatening emergency and other staff members are pulled from their duties to attend to this one patient. At least, that’s how it was when my friend had her PPH following her hbac.

      • DaisyGrrl

        I agree, but we’ve seen several times women who have transferred to hospitals during homebirth disasters commenting on how surprisingly nice the staff were. It won’t always be that way (nor should it be), but if you’re scared of the hospital it can be very reassuring to learn that the folk at the hospital can be nice.
        My point was responding more to the question of how to get transfers to happen before it’s at the immediately life-threatening stage. It’s hard to be nice to a woman who is at imminent risk of death. It’s more important to have her survive. And yes, I’d resent the hell out of an emergency dumped without warning on my doorstep and being expected to work miracles when a little bit of forethought would have prevented the whole mess in the first place. I have nothing but the utmost respect for the professionals who have to clean up homebirth messes, regardless of their attitude.

  • Guest

    Very interesting presentation! I’m sure it was a hit, and so glad you hit these crucial major points. I was hoping to see the CO stats included as well, and was wondering if they came up at all?

  • KarenJJ

    That was a great summary of all the main points you’ve spoken about on this blog. I really enjoyed reading the notes.

  • Well done.

  • Kelly P

    As a final year medical student, I wished I could have gone to the conference, but Hawaii is way out of my budget.

  • Amy M

    Had the audience heard of the crazy practices you mentioned at the end, like placentaphagy for PPH and PPD, and garlic for GBS, and hatting? What did they think of the really out there stuff? Were there any CNMs (or OBs for that matter) who were on the fence or leaning in the woo direction that you convinced back to the reality side?

    • Amy Tuteur, MD

      When I showed the slide about learning objectives, I told the audience that I had an additional objective: that every person in the room should say to him/herself at least once, “really??!!” By that point in the talk, there were gasps and laughter and people looked like they were saying to themselves, “really??!!”

      • Susan

        Really? (Nah I am sure most people are too busyworking to know about the Lotus birth crowd)

  • Susan

    Read Dr. Amy’s notes! I would love to hear more about the questions and comments you received. It sounds like I great ( and needed ) lecture! Did you play “Wren’s Breathing” as part of the presentation? Very compelling ending!

    • anion

      Every time I hear that, or see it mentioned, I think of that baby and how amazing his parents are to share their story in hopes of helping others.

      • Amy Tuteur, MD

        I’m sure you can easily imagine the comments that agreed, but there were several that questioned me on whether we could do more to improve obstetric care so that no one would choose homebirth (I doubt it, although we should improve obstetric care regardless) and one took me to talk for implying that the “experience” was unimportant. i said that I truly thought that most women place such importance on the experience because they think a healthy baby is guaranteed. If they truly understood the risks, their experience would drop dramatically in importance.

        • AmyP

          And some of the poor silly geese think that home is safer. They really do.

        • Amy M

          Well this has come up on this blog many times, that most people here feel the experience was dependent on having a healthy baby and could only be determined in retrospect. The homebirthers seem to view it in the opposite direction, that they can determine beforehand what a good experience will be and how to make it so. Of course, when things don’t go exactly as planned, they are “traumatized.” Expectations vs. reality, the illusion of control where none can be had.

          Perhaps a way to improve obstetric care with this in mind (and I see the obstacles here, this is just “in an ideal world”) would be to improve patient-doctor communication. Many pregnant women are scared, most don’t understand medical terms, some don’t trust doctors/medicine already….fear breeds hatred and mistrust and leads people to do stupid things. Homebirth midwives go too far in the other direction…allaying fears by telling pretty lies that soothe the terrified women. How can OBs and CNMs find a way to address fear in a way that calms the scared women down, yet doesn’t mislead them into ignoring important advice or warning signs?

          I don’t have an answer here. I am one of those that prefers to have all of the information, not stick my head in the sand. I’m a worrier, and I always like to feel like I am doing/have done all I can to prevent or deal with a bad situation. Clearly not everyone is like me, and lots would rather ignore bad things and/or pretend they don’t exist. Those are the ones who need to be reached here, and I don’t know how. But yeah, I think this is more a psychological issue than a technological one.

          • Jennifer2

            I think the problem is that there are two different definitions of “good birth experience” and two different definitions of “traumatic.” There is ABSOLUTELY room for improvement in obstetric care if even one mother is yelled at, berated by, or treated with derision by her doctor or nurse. There is absolutely room for improvement if doctors and nurses are unwilling or unable to answer basic questions about what they are doing and why. There is absolutely room for improvement if medical personnel deny a woman pain relief, make decisions about her care based on their convenience, or bully her regarding her decisions. Most doctors and nurses are kind, compassionate people who will sit down and talk to a worried patient. Some are perhaps lacking in the bedside manner department and could use some guidance on improvement. And a handful of bad apples probably need to be formally disciplined or have their licenses suspended.

          • Jennifer2

            However, I don’t think the medical establishment needs to buy into the woo stuff. It gives the pseudo-science credibility. Sure, make your birthing suites more homey. But make all patient rooms more homey (it really does improve recovery). But don’t start offering belly casting and henna tattoo classes for expecting moms to try to attract them to your hospital. Don’t let your childbirth class instructors get away with skipping over pain relief because everyone in the class is sure they won’t need an epidural. Don’t agree that your patient can try moxibustion to get the baby to turn even though you know it won’t work. Gently oh so gently, shoot the wooiest ideas down. It’s the inflated expectations that can turn a perfectly lovely birth experience with a healthy mother and baby into a traumatic experience because the lights were too bright, the vitamin K shot wasn’t explained, the baby was hatted too soon, or a c-section was necessary (was it really?) because baby was in distress.

          • Mishimoo

            “C-section was necessary (was it really?) because baby was in distress.”
            I actually had to clear this up for my dad recently. Thanks to my mother’s woo stage, he’d been questioning for years whether the c-section to deliver me was necessary. He told me of how the OB/GYN couldn’t sleep the night before and basically begged my parents to have a c-section because he was that worried. Dad explained what the doctors had said to him, because he’d felt guilty for quite rightly talking my mother into a c-section, and I explained just how lucky they were. (Post dates, android pelvis, 9lb 15oz baby + placental abruption.) Dad honestly thought they’d punched a hole in the placenta while delivering it to justify the c-section, because my mother insisted “that’s what they do!”. Never mind the strong contractions that suddenly stopped 3 days prior to the c-section or the difficulty finding the heartbeat. Those aren’t indicators of a problem, they’re just variations of normal! 😉

          • KarenJJ

            My mother shares similar thoughts and my Dad shares similar guilt over the c-section of my birth. It gives a unique perspective on NCB.

          • AmyP

            You are so lucky to be here! Wow!

          • Amy M

            Oh I agree absolutely, I was trying to address one of the issues the homebirthers often bring up which is “if OBs didn’t bring up the dead baby card/if we didn’t fear and loathe the hospital/if we felt listened to and respected….maybe we’d consider going to the hospital. To me, those are all basically “we are scared and no one is making us feel safe.”

          • KarenJJ

            “To me, those are all basically “we are scared and no one is making us feel safe.””

            I think this is one area where obstetrics could improve independently of trying to counter anything from homebirth advocates. I didn’t trust that doctors would listen to me and look out for me. My background was as someone who was treated like a hypochondriac by various doctors and when I was a teenager my specialist thought I was most likely attention seeking. I was worried about how I would be treated in hospital.

            And of course I didn’t bring any of this up with my doctor or obgyn because I saw anything they said as being false assurances to try and keep me happy and compliant. I just sat and boiled away in my own anxieties.

            In my experience it is not uncommon for people with rare and undiagnosed diseases to feel negatively about doctors and medicine. Even with common things that are hard to treat, like severe period pain, teenage girls most often get the short shrift from doctors.

            I do understand the time constraints from doctor point of view but wish there was a better way to build better relationships with some of these types of patients.

            Not that this lets NCB off the hook. They play right into these fears and anxieties and feed them.

          • Guesteleh

            I switched OBs halfway through my pregnancy because my first OB kept scaring the shit out of me and it was making my pregnancy an emotional rollercoaster. My second OB communicated the same info to me but she was so supportive and kind and reassuring that it made all the difference. But to be fair to the first OB, he had a bad experience with being on call when a patient showed up with a footling breech and adamantly refused a CS. He delivered the baby, it survived but wound up in the NICU for six weeks. The capper is the parents wanted him to deliver their second kid (he said fuck no). So while I didn’t enjoy having him care for me and I’m glad I switched doctors, I get where he’s coming from.

          • Laura Thomas

            I think I know your OB! He did have some scare tactics and seemed really, really damaged by having “nice, normal-seeming” people turn on him. He did seem traumatized by the baby’s six-week stay in the NICU that was entirely preventable. Interesting that doctors can be traumatized by their patients, huh? I hope that he can find some balance, though, and not just assume that every patient will be that determined to have a vaginal birth regardless of the risk factors.

          • Guesteleh

            He must tell that story to every patient he sees. Poor guy.

          • Laura Thomas

            I agree. I’m glad you found a better doctor! I’m so curious as to who you found, given that we probably live close to one another and he is known to be one of the most popular OB’s around. From hearing his patients talk about him, you’d think he walks on water! But I have met other women who have left his care very turned off by his anxiety, but they tend to be the quieter ones. Anyway, it sure is a small world!

          • Guesteleh

            Same office space, female doctor in practice with two other women. Sound familiar?

          • Laura Thomas

            Yes. In a big metropolitan city? Did you like the hospital, too? Funny, he used to be known as being very NCB-friendly, and his female colleagues not so much. Those bad experiences (he has another one he shares, too) have really changed that. Interesting how a doctor’s experiences really change his practice. Those group of women sound very balanced, though.

          • Susan

            I completely understand how an OB can be “traumatized” by a patient care experience but we all can expect some awful things and disturbing patients in our careers. It’s really too bad this guy brings up this case ( or cases?) to his patients on a regular basis. Does he do this with every patient or in response to NCB questions? I am a lot more careful than I was at the beginning of my career to not refer to specific examples that could be HIPPA violations as well. Somehow I just feel sorry for the doctor though having seen careers damaged by similar things. Sad. Hate to think of someone getting defined by something like that.

          • Laura Thomas

            I didn’t see a really clear HIPAA violation in the several stories he told. I think he was surprised by the patients whom he couldn’t influence to do the right thing and really upset that the baby fared so badly.He seemed to take the issue personally and feel too much responsibility. He tended to be fairly emotional about quite a few things. His patients and their husbands tend to adore him, though, because his emotional connection and his caring demeanor, along with a good sense of humor, make him very popular. He is quick and efficient, too, yet is very patient with questions and always returns phone calls. Still, though, his emotions about certain things were odd and not altogether healthy. It showed up in different areas and I left his care knowing I would never see him again or recommend anyone else to him, either. I wish him well and hope that he can get past these bad cases.

          • Guesteleh

            I didn’t think it was a HIPAA violation either since there was no PII revealed. I have no idea who those nutbags are, thankfully. I agree he needs to step back and get some emotional distance from his practice. I left 28 weeks in which is not ideal to say the least. I got lucky because it turned out to be a very easy transfer.

          • Laura Thomas

            I am glad you had an easy transfer – although I can only imagine how that conversation went when you told him. Did you ever explain to him why you were leaving? I can’t imagine, even remotely, that he was happy about that. He does take things very personally, although maybe he put on a good face. I wasn’t so lucky.

          • Guesteleh

            Oh God, it was pretty painful. After I made the decision to move, my new OB looked in my file and discovered there was a positive Hep B test result in there from the previous office but no one had contacted me to tell me (thankfully it turned out to be a false positive). After all that fear-mongering, his staff screwed up in a way that potentially could have seriously injured my baby.

            After I transferred I wrote him a letter expressing how unhappy I was with his care. To his credit, he called me personally to apologize but it was a lot of drama at a time when I really didn’t need the extra stress.

            What happened when you left his care? How did he react?

            As an aside, I was thinking some more about the whole footling breech thing and how the parents were all, wow, that birth was awesome! We want you to attend our next birth! Also, how he has this great NCB rep, I’m guessing precisely because he delivered a footling breech in the hospital which gives him like 10 million crunchy points or something. The whole thing is freakin’ nuts.

          • Laura Thomas

            “Freakin’ nuts” is rights! How long ago did you have your baby? Unfortunately, his office is known for serious incompetence. I see some of his staff as a liability, actually. It is very serious, imo. But I am soooo glad you wrote a letter and that he talked to you. Did he seem bothered that you left? Were you honest with him – as awkward as that must have been? In my situation, my delivery was horrible and there were a couple of people I held responsible – including him. I left abruptly and he knew that I was unhappy. He seemed very upset by all that happened, saying, “This has never happened before!” I have always wondered what impact my delivery – in all its awful sordidness – had on him. It was over 5 years ago and my daughter, thank God, was okay. My scars, although only emotional, have taken a lot longer to heal. When people talk about a healthy baby being the most important part of a woman’s childbirth experience, I don’t disagree. But, a woman’s childbirth experience is important, too. So much good has come from my last delivery, though. I am in nursing school and aiming to become a CNM in the next several years. Good things are ahead! And, by the way, congratulations on your baby!

          • Guesteleh

            Wow, that’s terrible. I’m sorry you went through that. My son is seven years old so it was a while ago. I was very straightforward with him about how I felt and he wasn’t very happy but I think he was probably also a little relieved because me and my husband are very assertive people in general.

            Re: experience, you know, I never expected unicorns and glitter but there is a baseline level of decent/adequate experience every woman should be getting.

            Glad you are getting your CNM, congratulations on that!

          • Susan

            And maybe this will be the last time I write HIPPA instead of HIPAA……I don’t know him I am sure because the description of where you live isn’t like where I am.

          • Laura Thomas

            You are so funny Susan! HIPAA is so commonly misspelled in health care settings! I am a spelling weirdo and very particular, so I try to get all my spellings right. It is hard! I’m sure you don’t know him and I would never, EVER want to reveal who it is because I do respect his professional life and would never want to publicly criticize him. Many, many patients love him and the nurses at his hospital routinely see him for the OB care, which says a lot. I think his traumatic story telling is only partly related to a knee-jerk “you can’t tell those people anything” response and also a need to process whatever it was that bothered him about those bad situations. Really and truly, though, I hope someone has the guts to say, “Move on, dude, and let it go! It’s not about you!”

          • Guesteleh

            Yes, big city. No, the hospital kind of sucked. Delivery room was fine but recovery floor was awful. Just a lot of balls dropped by the nurses in aftercare, unfortunately. Nothing life-threatening just stuff like not getting meals and not getting laxatives prescribed by the OB (that last bit felt life-threatening).

            Male Ob still has the NCB-friendly rep, weirdly enough. The women are great but they’re so popular it’s hard to get an appointment.

          • anion

            I had an awful experience with aftercare with my first, largely due to the forced rooming-in policy. (I didn’t even know about it and hadn’t thought to ask, because all the books etc. told me how hospitals refuse to “let” women keep their babies with them 24 hours a day.) I desperately needed sleep and was so terrified of something happening to my baby when it was just me and her in the room, and the nurses flat-out refused to take her for even an hour or two. Worse than that, they acted like I was a terrible person for asking them to do so.

            There was more to it–delays in pain meds, a seeming inability to remember that I’d had a c-section, stuff like that–but the big problem for me was the rooming-in and the fact that none of them cared that I was in tears from exhaustion and fear. It was the only time I ever saw any potential benefit in homebirth (not that I’d ever seriously consider it, but still): if I wasn’t going to get any help at all, I might as well be at home where at least it was quiet and my husband could be with me, and no one would berate me or act like I was crazy for asking if they could watch my baby for a bit. I had PPD after her birth and I still believe that contributed to it; I was made to feel like a failure right off the bat because I didn’t instinctively know all the right things to do to take care of her, and like a bad mother for wanting help.

            I picked a different hospital for my second–with a nursery–and had a completely different experience. Awesome nurses who actually helped me and cared about me and my baby, and were totally understanding and non-judgmental. It was amazing what a difference a little sleep and a few kind words made.

            I absolutely blame rooming-in for my bad experience with my first. “Family friendly,” my behind.

          • Laura Thomas

            Sorry, Guesteleh for your bad post-partum experience. That hospital is known to have a bad rep for their post-partum unit. I left so quickly that I was grateful to have at least one nurse who was caring on that unit. Among one of the most reputable childbirth educators in this area, that male OB is not recommended because he is hyper-vigilant with recommending inductions partly due to another bad experience he had years ago. He is VBAC-friendly and overall more NCB-friendly than most of his colleagues which I think is good for the most part. I still couldn’t recommend him, though. There are other doctors who I think deliver better care overall.

          • Renee Martin

            I think I have an answer for this problem.

            What if there was a business that offered OB offices secondary, social, support, so that their patients could have the community and attention people claim HB MWs give them, but without the woo? There would be a main HQ where content was written and people organized, plus the creation/moderation of a national forum like babycenter for participating patients. There would also one lead person per every area (based on size), and could offer this service to individual OB groups or a handful together. This lead would run a localFB group, offer evidence based groups/classes on all the things women ought to know (like what to expect, why interventions are done, how to BF or FF), and have meet and greets for patients to meet docs, as well as weekly support meet ups and other community needs based on the norms of the community. I call it OB+

            There is a VERY real need for community, and info, in this turbulent time, and this is where women are vulnerable. It’s totally possible, and very affordable, to offer this, all while using it as a way to head off the woo. OBs cannot do all this stuff themselves, but they can get a lot of benefit from hiring a company to do it for them. Also cheaper and more comprehensive than hiring someone, or getting an existing worker to do this stuff.

            I think it’s a good idea anyway.

          • Karen in SC

            That’s a fabulous idea!

            I think it would need to show a benefit to insurers so that there would be a billing code. Unfortunately, the economics of health care in the US means that if there is no billing code, it can’t happen.

          • Lizz

            I was actually thinking of a similar idea and I’m working on finding a way to teach childbirth education in the community from more of a public health standpoint. I even noticed that the library has free space and my doctor’s office has a downstairs room they rent out occasionally. It just seems really difficult to get started if your not a nurse or generally regarded as someone with experience.

          • Lisa from NY

            I was thinking of calling up the local high schools and offering to educate their students on the dangers of the Internet and false health claims.

            I would include the dangers of HB as well as the dangers of using alkaline water to treat cancer, not vaccinating, etc.

            I would give out examples of real information – like web MD – and false information – like blogs – and explain that anyone can post anything and there is no oversight.

            I would also include the dangers of FB, anyone can post as a 13 year old boy, in order to kidnap girls.

            I was going to charge for my service, but I think the local schools would be willing to pay.

            I don’t have powerpoint, but I suppose I could buy it to make my presentation.

          • Karen in SC

            I believe the presentation software in Libre Office would suit your purpose and Libre Office is free.

          • Lisa from NY

            THanks. I didn’t know that.

          • Anka

            I love this idea–this is exactly what was missing from my OB/hospital experience. I would never, ever choose midwife/homebirth instead, but the truth is that a) I had TWO dud OBs before getting an even remotely compassionate third one (the first one freaked out because of my fibroids and told me at week 12 that I might not be able to deliver vaginally OR via c-section and that I might need a hysterectomy during childbirth IF I made it that far–not true, by the way; the second one was a high-risk OB and I was not high-risk enough for him so he never came to my appointments and acted disgusted whenever I asked him questions, but did not refer me to a low-risk doctor); and

            b) we have no support system in this country, and for me it was either get info about pregnancy in general and my conditions specifically from indifferent OBs and their students (all of whom made disturbingly contradictory pronouncements) or read the standard outdated books that had nothing about fibroids in them other than that they cause miscarriage; take to the internet, which is an exercise in crippling anxiety; and

            c) I DID have a resident during L&D who pressured me to have a c-section *when there was no need,* apparently because he wanted the experience.(I would have been fine with a c-section if there had been a need, and the OB overseeing him overruled him and delivered my baby easily and quickly herself, via the standard way). I hate to admit that last part because I do NOT want to give credence to that “unnecessarian” bs, and I am *STILL* adamantly pro-c-section for anyone who wants them.

            But seriously–I know OBs are strapped for time, but pregnancy IS a difficult, complicated, sometimes scary thing, and pregnant women deserve at least the same amount of compassionate, explanatory time as someone going into surgery. Whereas instead, from my experience anyway, I would do that informed-patient-ask-questions thing (that they always say you should do if you want answers because otherwise you are being irresponsible you silly patient), and I’d usually be treated with contempt and disgust. And looking back with more knowledge, I can see that my questions were not even stupid. I DID have several not-so-common conditions. It’s like–of all people interacting with the medical establishment, pregnant women in particular are supposed to be not curious people but insensate cows or something. We’re not supposed to ask questions of our OBs, even when the OBs and their nurses tell us contradictory things that have an impact on what we do during our pregnancy, yet we’re also not supposed to look at the internet because only stupid uninformed women do that and we’ll freak ourselves out. Then what ARE we supposed to do? (One of my second OB’s students, when I asked him what contractions are supposed to feel like, told me to read a book, as if I hadn’t been doing that all along.) I’m sure that part of the reason pregnant women flock in such great numbers towards the woo is that that is the only place where they’ll get care that looks compassionate (I don’t want to say that it IS compassionate, because of course lying and endangering pregnant women’s health is not compassionate), at a time when they really need it. If your idea takes off (I could maybe see it happening here in Canada, if not in the US right now), it would be wonderful.

        • Kelly P

          I’m not sure if my views on experience is correct but I will just say it anyways. I feel like the NCB crowd experience views are absolutely unattainable by the average hospital birth. This is because they created it to be this way, They, specifically CPMs, undermined every hospital protocol and basically said if its a part of your birth experience then your experience was negative. Basically they created a scenario that only they could provide and no highly educated professional would. They are great at this because they use these women weaknesses in understanding basic peer reviewed studies and focus on the emotional aspect.

          I’m sorry but the NCB zealots have utilize the term experience to push their own agenda.

          • The Bofa on the Sofa

            Just another case of, “If the doctor does it, it’s a medical intervention. If the midwife does it, it’s natural”

          • Amy Tuteur, MD

            Exactly!!

          • Susan

            So true… exhibit A…. if you can’t find anything else to complain about… HATS!

        • Anonymous

          I’ve never really seen the issue with the “experience” of birth. I didn’t particularly care about the “experience” of having my torn ACL repaired.

    • Dr Kitty

      I agree, the notes are very, very good. I bet the Q&A was great.

    • Amy Tuteur, MD

      I didn’t have the audio file, but most people in the audience knew what the “cute noises” were before I explained that the baby was grunting.

  • Anj Fabian

    Ironically, if you go to various Midwifery organization websites (these are CPM, not CNM) and read the standards of care and scopes of practice laid out there, you might be greatly relieved.

    Those standards laid out seem like very good rules to follow. The only problem is that there is no way of knowing how many CPMs follow those rules and how faithfully.

    Most of the home birth tragedies often have care that does not fall into the standards or scope, or for the stories that leave out enough details, it’s plausible that standards or scope was violated.

    CPMs due have rules, but they don’t follow them.

    My biggest problems with CPM midwifery practice is too little education, training and experience.

    After those problems – my next issue is that you simply can’t trust a CPM because there’s no one and no organization holding them accountable.

    • The Bofa on the Sofa

      CPMs due have rules, but they don’t follow them.

      The word I’ve been using a lot lately is “denial.” You can have all the standards about only accepting low-risk patients you want, but if you insist that breech is merely a variation of normal, and deny that it is too risky, then what good are the guidelines?

    • PJ

      The most shocking thing to me is that most of them are practicing without oversight by a doctor. There should be mandatory guidelines governing when to consult a doctor as well as when to step away entirely. This is how the midwife model of care works in every other developed country. I realise this is difficult to achieve in the US’s privatised healthcare system and I wonder what a realistic solution could be. Would doctors be more willing to collaborate with homebirth midwives if they were better trained and more accountable?

    • Squillo

      Per NARM:

      The scope of practice of the CPM is derived from the NARM Job Analysis, state laws and regulations, and individual practice guidelines developed by each midwife according to her skills and knowledge.

      The Job Analysis is a requirement of the NCCA, who set standards for certifying bodies. It’s a survey of NARM members asking them to define the essential skills for their job. As NARM writes, “The list of tasks is not meant to limit the job performed by those professionals, but to identify the core skills needed for entry into the profession.”

      In other words, there is no meaningful, enforceable scope of practice, except where it is specifically defined in state regulations.

  • MrG

    We all need to understand that it’ s not the “trigger” to transfer patients faster to the hospital. A better trigger will not necessarily improve the horrendous mortality rates. You have less than 10-15 minutes in an emergency (abruptio, cord prolapse, ruptured uterus etc) to delivery the baby, never going to happen if labor starts at home. With shoulder dystocia you need a “village”, McRoberts, suprapubic pressure, gentle delivery, experience in posterior arm, pediatricians, etc. Never going to happen at home.
    Choosing the “right” low risk patients for homebirths. Never going to happen at home.
    Having an experienced person delivering you with backup 3 min away. Never going to happen at home.
    etc etc

    • Young CC Prof

      True, home birth is never going to be as safe as hospital birth. Crazy unexpected emergencies can always happen.

      However, quite a few of the tragedies described on this blog or at “hurt by homebirth” could have been prevented with faster transfer or better risking-out. NO VBAC, no twins, no great big postdate babies, proper testing for GBS and other infections. That would have saved quite a few. And some of the intrapartum deaths, there were signs of trouble hours in advance. A prompt transfer policy, and midwives who don’t view the hospital as the enemy, almost certainly would have saved them.

      Home birth is a dumb idea, but I don’t think we can stop it anytime soon. The trick is to reduce the body count.

      • The Bofa on the Sofa

        “faster” transfer does not mean “get to the hospital faster,” it means transfer away from the home sooner. Absolutely hospital monitoring is the safest approach, but a huge improvement in HB could be made by just having that itchy trigger finger, transferring at the FIRST sign of a problem, instead of waiting until it is an emergency. Yes, it would lead to a lot of “unnecessary” transfers, but that’s the secret – prevent emergencies, don’t try to save them.

        • Young CC Prof

          That’s exactly what I mean. Not driving to the hospital faster, transferring SOONER.

          • The Bofa on the Sofa

            Yeah, I just got the impression MrG is implying something else.

  • Anonymous

    Fantastic slides Amy. I really wish that you could speak at Emory down in GA.

  • Maria Miller

    Ironically many homebirth midwives pride themselves on their low transfer rates!

    • The Bofa on the Sofa

      Yep.

      This is absolutely the irony of it. If hb midwives were so much quicker to pull that trigger, we wouldn’t have the issues we have.

      Actually, if you think about it, “transfer” is actually the middle ground that midwives claim to be seeking. If the culture of hb midwives was “transfer early and often” this would be a completely different ballgame.

      • Young CC Prof

        Like I said, the new Oregon report found a 40% transfer rate in home births performed by CNMs. That’s probably high enough to minimize the deaths, and definitely high enough to prevent the “OMG so stupid” deaths, in which the problems were obvious hours before tragedy struck. The licensed direct-entry midwives had a transfer rate more like 10%, which is pretty freaking arrogant.

        • The Bofa on the Sofa

          Exactly.

          No one denies that, even among CNMs, there would be improvement by avoiding the homebirth altogether, but at least get the obvious ones going earlier.

          See the story of Natalie the other day. There were not so much warning signs as there were flashing lights and sirens, and still the midwife was reluctant. I mean, even a trigger as simple as “two hours of unproductive pushing” would have gotten her to the hospital more than 4 hours earlier.

          That’s a real difference.

          • Anj Fabian

            Using the medical model (partogram) at home? Never.

            We need to rename it to something like “The guide to the natural progress of normal labor”.

          • Captain Obvious

            But Marjie Hathaway coined the phrase “Natural Alignment Plateau”, or “NAP” as an answer to the dreaded “diagnosis”: “FTP”, or “Failure To Progress”. You can go on forever allowing the baby to align.

            http://www.sweetpeabirths.com/blog/2012/06/01/Failing-to-Progress-or-Naturally-Aligning.aspx

          • Jennifer2

            As someone who had a very long labor (induced, in hospital, with monitors) I don’t think there’s anything inherently wrong with allowing some time as long as 1) mom and baby are being monitored appropriately and 2) mom is comfortable and baby is not in distress. The problem is when junk like this is used to justify a 72 hour home birth with 6 hours of pushing and manual retraction of a lip of cervix while mom is sobbing and passing in and out of consciousness because she is so exhausted.

          • Captain Obvious

            I agree totally, doctors like to established thresholds as guidelines of safety. Homebirth quakes like to come up with excuses to go beyond those thresholds, even in extreme.

          • Jennifer2

            It’s a lot like speed limits. A few people like to go 55 in a 65 even on a beautiful day because they like to be overly cautious. Most people go 65. A few realize going to 70 in good conditions probably won’t kill anyone (but wouldn’t drive 70 in a blizzard). And the CPMs are the ones doing 95 in a blizzard, complaining about all the slow drivers and bragging about what good time they are making as they run other cars off the road.

          • Captain Obvious

            Nice

          • Young CC Prof

            Definitely. “Labor absolutely can’t go over 24 hours” might not be a rule that makes sense for every situation, which is why most hospitals don’t use it anymore. Maybe you’re at hour 25, but labor started slow, and now things are really moving along. However, if a woman has gone more than 2 hours of pushing, or more than some length of time at any active stage without progress, then you really want to pay close attention. And ask a doctor who’s delivered thousands of babies whether it’s time to intervene :).

          • The Bofa on the Sofa

            And I’m not even suggesting that 2 hrs is the end of labour. I am, however, saying that after 2 hours of unproductive labour, it is time to move away from “sit and do nothing at home” and move to an environment where you can monitor the situation much more detailedly.

          • Jessica

            JFC – surrendering to birth or making more colostrum? Really?

    • theadequatemother

      If you are an uneducated client wanting a homebirth, you think a lower transfer rate is an indication of more skill and success. If you go into it knowing you have a high transfer rate, like 40%, then many would probably just start off at the hospital (which IMO would be a good thing). Also, when the midwife has priv, transfers and easier and smoother, they they get to stay with the patient until delivery so there is continuity of care…those things help the threshold for transfer to be smoother…and no I’m not advocating that CPMs get hosp priv! Its also a shame that economics comes into it…when a family is paying out of pocket and transfers in a nonintegrated system now they have to pay twice…both the midwife and the hospital plus sometimes and extra fee just to transfer.

      That just creates more pressure NOT to transfer.

      • Guesteleh

        40% transfer rate under ideal conditions! Can you imagine? Even if everyone gets through the birth undamaged, who the hell wants to transfer while you’re in active labor? Plus if you’re a CNM and you know that nearly half your clients are going to end up in the hospital anyway, why are attending homebirths in the first place?

        • PJ

          I agree–for me personally this is one of the most potent arguments against homebirth. The niceness of a nice, cozy home environment pales against the hideousness of transferring while in active labour. (In my experience the location didn’t make the slightest bit of difference when I was in labour anyway–my mind was far away on other things.)p

          • KarenJJ

            I laboured at home until my waters broke. Geez it was a mess trying to get to the hospital then. And the hospital was literally a 1.5 minute drive with only one set of traffic lights.

            Once I was comfy in the hospital room with others to clean up and I could rest and read a book it was much more relaxing.

      • PrecipMom

        It’s not just a question of health in the US home birth community for transfer, though. It’s that you get no refund at all if you paid for a home birth midwife and then transfer to a hospital and have to pay their bills. So, you can get to pay full fees for both. You’re paying for a slot as your midwife’s client, not for birth attendance. But you’re supposed to lay out this money for this birth, because isn’t this once or twice in a lifetime experience worth investing in? There are economic pressures here too, not just ideological ones.