The AAP responds to obstetrician criticism of its homebirth position

Autonomy

You may recall that last fall the American Journal of Obstetrics and Gynecology published a position paper opposing homebirth and I savaged it (You heard it here first: new paper opposing homebirth is poorly researched, relies on bad studies and is woefully paternalistic).

The paper in question is The paper is Planned home birth: the professional responsibility response by Chervenak et al.

Chervenak is presenting a personal, religious philosophy on maternal autonomy and fetal beneficence and it would have been appropriate for him and his colleagues to acknowledge that their views are not supported by the mainstream medical ethics community. Simply put, in light of American law, and non-religious moral ethics, Chervenak et al. are wrong about the extent of women’s autonomy and women’s ethical obligations toward their unborn children.

And:

Women’s well established right to medical autonomy is not “rights-based reductionism”; it is a foundation of medical ethics. Professional responsibility never involves forcing patients into doing what you recommend or harranging them for failing to follow your recommendations. Professional responsibility requires informed consent, nothing less and most certainly, nothing more.

Chervenak et al. have now taken their incorrect and misguided argument to the journal Pediatrics. In a paper entitled Planned Home Birth: A Violation of the Best Interests of the Child Standard?, Chervenak actually has the temerity to accuses the AAP of violating ethical standards in their position statement on homebirth, published earlier this year.

The AAP statement correctly states that hospital birth is the safest form of birth. However, the effect of this statement is to sanction, and unintentionally enable, planned home birth if certain circumstances are met. However, meeting these circumstances does not eliminate the preventable, increased perinatal risks of planned home birth. The AAP should consider withdrawing
this sanction and replacing it with the professional responsibility of pediatricians to be strongly directive in recommending against planned home birth and recommending in favor of planned hospital birth. The AAP should also emphasize the professional responsibility of pediatricians not to participate in planned home birth, except in the very limited circumstances described in this article. Pediatricians should support creating settings that resemble home birth in the hospital and in birthing centers that are in or adjacent to hospitals.

Once again, Chervenak et al. are spectacularly wrong are wrong about the extent of women’s autonomy and women’s ethical obligations toward their unborn children.

Not surprisingly, the American Academy of Pediatrics (AAP) has responded sharply to the accusation, Policy Statement on Planned Home Birth: Upholding the Best Interests of Children and Families written by Kristi Watterberg on behalf of the Committee on Fetus and Newborn.

The arguments made by Chervenak et al regarding the “best interests of the child” have several notable flaws. First, before delivery, the fetus is not an independent being (child), but a fetus, and the authors inexplicably ignore both the ethical principle of autonomy for the expectant mother and the difficult balance of maternal and fetal benefits and harms. Previous commentary by these authors advocates overriding both maternal and fetal rights, arguing instead for the “professional responsibility model of obstetric ethics … In other words, it appears that physician beneficence is the dominant ethical principle, and that when a pregnant woman becomes an obstetric patient she gives up her autonomy and her decision-making capability to the physician…

Watterberg concludes:

…[W]e firmly believe that the policy statement on planned home birth follows the AAP mandate to promote the best interests of children and their families, by acknowledging maternal and family autonomy and the complexity of their decision-making, by setting rigorous standards for care of infants born in any setting, and by promoting increased professional collaboration and communication.

Watterberg is correct.

Chervenak et. al, in addition to being wrong about the ethical principles that govern a woman’s right to choose homebirth,  appear to believe that they speak for most obstetricians when the reality is the opposite. Most obstetricians recognize that both medical ethics and the law requires that a woman’s decision to choose homebirth must be respected.

Chervenak and colleagues are certainly entitled to their personal opinions, but that’s all they are, merely their personal opinions. It is deeply unfortunate that they have chosen to mistake their personal beliefs for the ethical principles that govern contemporary medical practice.

  • Liz

    hear hear. Chervenak and colleagues have a heavily paternalistic bent to their writings and take a very narrow, very strict view of only some of the research, apparently ignoring the studies showing no significant difference between perinatal and neonatal outcomes in planned home vs. planned hospital birth, not to mention the decreases in serious maternal morbidity associated with a less interventionist birth. This is not to say one set of research is better than the other, but more to point out that there is not yet consensus as to the safety of home birth attended by a midwife with a nationally recognized certification. To top it off, their discussion of maternal autonomy vs. beneficence to the fetus rings strongly of the anti-choice debate…

    • Amy Tuteur, MD

      Which studies are they ignoring? To my knowledge, there is not a single study of American homebirth that shows it to be as safe as hospital birth.

  • Mr.Smith

    Amy: This time you are spectacularly wrong.

    Chervenak said: “the professional responsibility of pediatricians to be strongly directive in recommending against planned home birth and recommending in favor of planned hospital birth.” That is exactly what you have been doing all along.

    Chervenak never ever suggested that women do not have the autonomy to decide where to deliver. All he said that doctors have the responsibility to counsel women against homebirth. Like they should counsel against smoking, drinking and for seat belts.
    You counsel a woman strongly against smoking and you take away her autonomy? Where are you getting this from?

  • Kiwi

    Off topic but has anyone else seen this: http://www.stuff.co.nz/national/health/9323430/Robot-mum-gives-birth

    The $70,000 hi-tech robot mum named Emily plays out real-life situations that can happen when a woman is in labour – even to the point of swearing.

    It can be programmed to have a breech birth or haemorrhage and in a worst-case scenario can even die.

    • wookie130

      I would love to see a video of how the SimMom works. Sounds like a great training tool, really.

      • Burgundy

        My school doesn’t have SimMom but has other dummies/robots from the same company. They are really amazing and are great training tool. (But really really expensive too).

  • Renee Martin

    Wait, Dr A criticizes an MD? And says women have a right to HB?
    I’m sure this will be ignored by the HBers, just like the last post was. They really have selective hearing (or reading in this case)

  • kari

    Maybe I’m reading it wrong or there’s more in the rest of the statement (which I haven’t read) but I don’t read this as Chervenak wanting to force women to birth in hospitals, but only to strongly recommend doing so based on the evidence. Isn’t there a difference between forcing someone and advising them?

    • NCBer No More

      My understanding is the AAP policy is to inform women of the risks of OOH birth, while Chervenak wants the AAP to outright recommend against it.

      • kari

        What’s wrong with recommending against it? A recommendation isn’t forcing someone’s hand. Don’t they recommend immunization and other practices that are proven safer for children? It doesn’t look like it’s calling for a ban on home birth, just simply a recommendation. How does that interfere with autonomy?

        • NCBer No More

          I refer you to what SarahSD said. “he doesn’t seem committed to allowing women to make a decision for themselves”

          I don’t know what is right/wrong from a medical ethics standpoint. But I can relate my personal experience. My daughter’s pediatrician was the only MD I spoke to during my pregnancy (cause OBs play the DEAD BABY card!!) My mind was made up to have an OOH birth, but I hadn’t really given informed consent (hard to do when you’re not informed). When I interviewed the ped, that was an opportunity for her to tell me the risks of OOH birth, which I didn’t know about. If she had just said she didn’t approve of my decision, that would have ended the conversation. But telling me about the risks and pointing me to this AAP policy statement with guidelines for a safe OOH birth, that would have planted a seed of doubt, because my birth center sure did not meet these guidelines.

          • kari

            So he’s saying to just oppose it without saying why? I guess I’d have to read his full statement. I am confused how it would be different to recommend hospital birth than it would be for them to recommend vaccinating children. Wouldn’t both of those be evidence based recommendations? Parents still can choose to go against the recommendation if they choose.

          • NCBer No More

            ” the effect of this statement is to sanction, and unintentionally enable, planned home birth if certain circumstances are met”

            He thinks there are no circumstances when HB should be condoned. It’s a very paternalistic attitude. Women should be informed of the risks and their decision respected, which is what the AAP recommends.

          • The Bofa on the Sofa

            Women should be informed of the risks and their decision respected, .

            What does that mean, “their decision respected”? So if a woman is informed of the risks and still chooses to have a HBA4CS, what does the doctor do to “respect” that decision? What would be considered “not respecting” that decision? It’s not like he can force her to have a c-section or even give birth in a hospital, so that’s not the issue.

            If she chooses to have a HBA4CS, what’s stopping her? That he refuses to come to her house to attend the delivery? Or what?

            I just don’t understand

          • NCBer No More

            All I mean by that is they should not repeatedly lecture her about it and continue to provide care if they can. For example, my dentist wants me to get my wisdom teeth out. He explained to me why they need to come out, and I told him I didn’t want to rush into the decision. Every visit after that, we only talk about my wisdom teeth if I bring it up. He still examines my other teeth.

            I think a pediatrician should give homebirthing women the AAP guidelines and talk about the risks. If she still chooses homebirth, then I would like to see that pediatrician stick with her and be her kid’s doctor. Indeed, when someone chooses not to vaccinate, I believe the AAP position is that peds should not turn away those children from their practice. Crunchy people I know (those who go to the doctor) all say their ped is pro-vax, but they had that conversation once in the beginning and don’t repeatedly lecture them about it.

            In the case of the OB it’s different because they are responsible for the safe passage of the baby. My statement was really not about OBs, but about pediatricians. But OK, in the case of a very high risk pregnancy where mom insists on OOH birth, what should an OB do?? I honestly don’t know. That’s why I read this blog. 😉

          • Guesteleh

            A couple of thoughts: an OB who provides prenatal care and refuses to attend the birth is opening him/herself up to a lawsuit. They basically have to completely remove themselves from the equation.

            Re: pediatricians and vax, in my major metropolitan area there are only two peds who see unvaxxed kids and they are notorious woo peddlers. Every other ped has a no vax/no service policy (and I’m all for that).

          • fiftyfifty1

            ” Every other ped has a no vax/no service policy (and I’m all for that).”
            Not me. Because kids without their shots need and deserve good doctors too. It just pushes these kids into the hands of chiropractors and naturopaths and woo-idiot MDs. A no vax/no service policy is too manipulative and in the end it backfires. Such a policy also can serve as a way for doctors to be lazy. Yes, woo-minded patients can waste a lot of your time with their demands for un-needed tests, their constant desire to “educate” you etc. Yes, it would feel rather freeing to just dump them all into the street. But that’s lame. Dumping woo-patients is a form of cherry-picking.

          • auntbea

            Interesting. Under what conditions would you fire a patient? Or would you not?

          • fiftyfifty1

            I’ve fired 2 patients. One grabbed my butt. The other was making physical threats. Both adults.

          • auntbea

            Oh dear.

          • fiftyfifty1

            The threatening patient was indeed an “oh dear” situation. The police got called. The butt grabbing was more of an “oh darn” situation. It was done by an actually pretty good patient, a nice guy. He had very bad bipolar and was pretty med non-adherent. I always had warned him “you’re going to end up doing something stupid if you don’t take your meds”. He was manic when he did it. Felt bad to have to fire him, but sheltering patients from the natural consequences of their choices isn’t the way to go either.

          • Lisa from NY

            Ok.

            Your name is Dr. Duke, and you have healthy newborns in your waiting room, along with a whole tribe of non-vaxers who are coughing… (all symptomatic of whooping cough)

            What will happen to those newborns?!?!?!

          • Guesteleh

            Exactly. By allowing unvaxxed kids into your office you’re putting all of your patients at risk.

          • Guesteleh

            Wanted to add that in my area this isn’t a hypothetical risk. There was a pertussis outbreak in my area a few years ago that killed 6 infants. This shit is no joke.

          • S

            Our peds group has a small, separate waiting room exclusively for well babies, though you do have to go through the same entrance as the rest of the waiting room. Also, there is an “infant nurse” who i think only does newborn checkups. I remember the pediatrician having only minimal contact with my son in that first visit.

          • DiomedesV

            Fine. But be honest. Tell your parents who vaccinate and have newborns that you see the unvaccinated. Give them the opportunity to vote with their feet. I would have, and I told my pediatrician so.

          • jenny

            When my oldest daughter was a baby, I asked about alternative vaccination schedules. I was a scared new parent who’d heard some scary things. Our pediatrician told us that they strongly recommended vaccination on the CDC schedule, and why. Then he said that ultimately it is the parents’ decision and that they would still see our child regardless. If I’d been told we’d need to find a different pediatrician, we might have gone for some woomeister. Instead, my boyfriend I mulled over what he said for a few weeks and then decided to vaccinate on the CDC schedule. I had mixed feelings for a while but don’t anymore. I think we could have swung the opposite direction in a practice that was more welcoming of non or selective vaccination.

            I feel comfortable taking my kids there, even though I know that not every family in their practice vaccinates or does it according to the schedule. But I wonder how many it could be – most of the non-vaccinating families I know would have a problem with going to a practice that “strongly recommends” vaccinating, heh. Anyhow, I definitely understand if others would not feel comfortable with that.

          • yentavegan

            The ob/gyn who delivered via c/sec my second child and who delivered via VBAC my third child wanted me to sign a document saying that I acknowledge his intent to resign as my health care provider up to and including during labour if I object/reject any of his professional medical recommendations.
            This document was handed to me during my first prenatal visit with my fourth child.
            That is how he avoided a lawsuit.
            It took me 2 decades to realise that he was right. He did have the autonomy to refuse my business.

          • NCBer No More

            Not vaccinating only affects the child’s welfare, whereas the choice of where and how to give birth involves mom and baby. It’s outside the purview of a ped to tell mom “you should not give birth that way” because that ignores her autonomy over her body. All they can ethically do is give information about the risks.

          • Tim

            Not vaccinating affects an entire societies welfare, tyvm.

          • NCBer No More

            True!

      • Mr.Smith

        Exactly. That is what he is saying. Nothing wrong with that.

    • SarahSD

      I think the issue is that the evidence that he uses is crummy and his concept of “autonomy” is that fetus trumps all. Both of these things undermine the principle of informed consent, from both directions (the “informed” direction, if the way he presents research is weak, and the “consent” direction, since he doesn’t seem committed to allowing women to make a decision for themselves).

  • SarahSD

    Wow. I know you don’t need my approval or admiration, but this post and the one from last fall (don’t know how I missed it) are so so great. They make plain your position on women’s autonomy as well as your commitment to good research. Using crappy research to justify forcing women to birth in hospitals is just as unconscionable as using crappy research to convince them to birth at home. I would expect better from a medical professional than to pretend that their personal ideologies can stand in for medical/professional ethics and solid data.

    • SarahSD

      I should say, using crappy research AND/OR using decent research crappily without appraising what it actually shows.

    • Ob in OZ

      Doctors produce and use crappy research all the time. An example is the term breech trial. It can take either very good editors or comments from others to crack holes in what appears to be very good research. Every time something sounds too good, or not quite right, studies are repeated to make sure the benefits are real. This can take years. The natural birth movement is able to publish crap articles in crap journals and then use that as evidence. Most of us can pick the articles apart very easily, but it can be more difficult when real Doctors are doing real research and getting it published in real journals. This is all part of our continuing education requirements that keep us up to date on what our national governing body feels is important to know to remain current with medical research and technology. Doctors can have an agenda too. The thing is they will get questioned rigorously to defend their work, which is what Dr Tuteur and others will do in this case.

  • yentavegan

    If you are a doctor and you want to make a stand, and take a public position against homebirth it must come from scientific data not from moral posturing.

  • Dr Kitty

    Well said.
    It is not, nor has it ever been about banning HB.
    Women have a right to birth at home, but they ought to be aware of the risks of that choice, and deserve to be attended by a properly trained, accountable professional (I.e, not a CPM).

    My position on HB is that some women will always choose HB, which is their right, and they should go in with their eyes open and a competent care provider at their side. As HB is less safe than hospital birth it should never be the default option you have to be risked out of to access hospital birth.
    The end.

    • The Bofa on the Sofa

      and deserve to be attended by a properly trained, accountable professional

      But what if no properly trained, accountable professional is willing to attend? Are you going to force one to do it, because the woman
      “deserves” it?

      This is the problem in the US. It’s not that women aren’t allowed to do a HB, just that, for the most part, no serious provider is willing to attend. You can say that they won’t “because the liability is too high” but that just highlights the whole point – it’s too risky for an accountable professional. Thus, the only way to do it is to resort to an incompetent, unaccountable non-professional.

      • Many doctors won’t perform an abortion – but they can’t stand in the way of one. Many hospitals won’t allow a VBAC – but again some will. The problem becomes an informational one – how do women know where to go to facilitate their well informed wishes for care? Mothers who want to deliver by way of cesarean w/o medical indication face the same challenge.

        • The Bofa on the Sofa

          Many doctors won’t perform an abortion – but they can’t stand in the way of one

          But there are plenty of doctors around who can do it for them. That’s not the same as HB, where there are very few providers who are willing.

          • Not everywhere, there aren’t. Lack of access to legal abortion (due to lack of providers/clinics) is a large and growing problem in huge swathes of the country.

          • The Bofa on the Sofa

            Because of legal control, yes.

      • Dr Kitty

        Then your choice is UC or hospital, or improving integration of care, logistics and infrastructure to allow the professionals to attend.

        I do not support an unregulated sub class of birth junkies masquerading as midwives giving a veneer of safety and accountability to risky HB.

        If the real professionals feel they cannot, in good conscious attend, well and good.

        You don’t invent a qualification to allow anyone who wants to attend high risk births carte blanche to do so as an acceptable alternative.

        • The Bofa on the Sofa

          But that doesn’t answer my question. Where are you going to get real professionals that you claim homebirthers “deserve”, since real professionals, far and large, choose not to?

          The reason women use incompetent hacks to do homebirths is because legitimate professionals won’t do them, so they have no other options for a homebirth.

          I don’t know how you get around that. You can’t force providers to do homebirths if they feel they are too risky, and you can’t waive liability for a provider who does a homebirth. So who are going to be those real professionals that are going to be doing homebirths? Those who are willing to pay the crazy high liability costs? Or those who don’t think it is too dangerous and are willing to take the risk.

          I just don’t see any way that homebirth can become part of the process. Because of the risks involved, you are not going to have most providers willing to do them, and those that are will have high liability costs, since a) it is risky, and b) it is almost certainly going to be seen outside of the standard of care (since most doctors refuse to do it). and so if something goes wrong, it is a slam dunk malpractice case

          • Karen in SC

            Dr. Fred Duhart was a doctor who performed homebirths for years in the greater St. Louis area. He was revered by my LLL group. The nurse I used for my doula occasionally assisted. I never heard of any problems or if he had a high transfer rate.

            When he died, many NCB sites wrote about him including Rixa.

          • Karen in SC

            However, since I never knew him, I don’t know of his insurance coverage…

          • The Bofa on the Sofa

            Right. So there’s one example. And you have Dr. Biter. Then again, I said…

            “since real professionals, far and large, choose not to?”

            and random counterexamples don’t change that.

            If lots of doctors chose to do homebirths, women wouldn’t need CPMs. They are a consequence of the fact that responsible professionals by and large choose not to do homebirths. Therefore, pretty much the only ones available to do them are irresponsible hacks.

          • Karen in SC

            Not arguing with the point, just wanted to mention sort of prove it…with that one example. 🙂

          • Vyx

            There are many countries where homebirth is integrated into a larger care model, and is performed by highly trained professionals. It still seems to be a riskier decision, but clearly there are ways to allow women to be attended by professionals at homebirths.

          • Tim

            They are typically countries with a government run medical system though, which changes the dynamic for lawsuits/insurance I would think.

          • The Bofa on the Sofa

            I think so, too. I have been thinking about that. To get doctors to do hbs, you have to reduce the liability risks. However, I have to admit, I don’t want that. I think it is important that patients have full recourse in the case where medical providers screw up, and that includes making bad decisions. I

          • fiftyfifty1

            “However, I have to admit, I don’t want that. I think it is important that patients have full recourse in the case where medical providers screw up, and that includes making bad decisions”
            Yep, the big downside to limiting liability is that it would allow providers to do this game: “Oh, I suppose I should tell you that some people say it’s not as safe, but you don’t believe them do you? Go ahead and sign this liability waiver!”
            I would like to think that the vast majority of doctors and CNMs would never stoop as low as to do this. But the truth is that there are always going to be a handful of bad apples (woo driven or even just lazy). Patients deserve protection against these unethical types.

          • Vyx

            True, but to limit the options to either a hospital birth or a homebirth with an untrained lay person is a false dichotomy. It would certainly not be easy, or perhaps even worthwhile, to implement an alternative solution in the US, but there are certainly other models of care from which we could extrapolate just such an alternative scenario.

          • Tim

            The problem is that you can’t fairly limit the liability of the providers to their patients, or force insurers to take on massive risk. The way our system is setup doesn’t really lend itself to many highly qualified providers going into the homebirth arena. There are SOME MD’s and DO’s and CNM’s that choose to do it, but they are few and far between because it would be prohibitively expensive for them to carry malpractice insurance, and guaranteed to be ruinous to them if they did not.

          • Young CC Prof

            Actually, the Oregon data set had about 500 planned home births with CNMs. (About 200 ended in hospital transfer, as opposed to 10% of the 2,000 CPM births.) This suggests that some kind of semi-responsible home birthing system is possible.

            It would require a hospital willing to take transfers smoothly, and OBs and pediatricians willing to back up midwives, and it’s possible that in some states the legal climate WOULD make it economically unfeasible, but it’s not out of the question.

          • The Bofa on the Sofa

            This suggests that some kind of semi-responsible home birthing system is possible.

            But even your numbers indicate that is 80% cpms, so while _some_ is possible, that is a massive number of women who will be without providers. Even if the CNMs double their workload, still the majority of woman who want homebirths won’t be able to find a provider to do it.

            Quit with these silly “counter-examples” which do not in the least change the point: there aren’t near enough real professionals willing to do homebirths to meet the demand.

          • fiftyfifty1

            ” there aren’t near enough real professionals willing to do homebirths to meet the demand.”
            I expect demand will go way, way down once MANA is forced to release their numbers. Then again, CNMs willing to do homebirths may also decrease when the facts are known.
            In my opinion, the CPM credential has to be abolished, but home midwives don’t have to be. The fact that women choose to deliver at home with lay midwives is not what bothers me. What bothers me is that the CPM credential is a lie that gives women (and some state Medicaid plans!) the illusion that they have hired a medical professional.
            30-40 years ago a few fringe women (my mom was one of them) hired lay midwives. The demand was low, and the deal was clear: you have chosen to hire a lay person. I’m fine with that situation. It almost killed my sister, and I would never recommend it, but I don’t think we should outlaw it.

          • The Bofa on the Sofa

            I guess I don’t know what that means. Don’t outlaw what? Homebirth? Nonsensical concept (you can’t force anyone to leave home to give birth). Homebirth with a midwife? Of course not, if you can find a legitimate, responsible professional to attend, then of course. Homebirth with a lay midwife? You’ve already said that you think the CPM (lay midwife credential) needs to be abolished, so you are saying that it needs to be illegal for someone to pass themself off as a legit professional when they are not. So that is illegal.

            Who are you envisioning to be these legal “lay midwives”?

          • fiftyfifty1

            “Who are you envisioning to be these legal “lay midwives”?”
            Probably a lot of the same women who are CPMs now, but with demand lower a lot will be forced out of the hobby. But they will have to tell it like it is: they are lay people. They will not get insurance reimbursement. There will be limits as to what they can do: e.g. no Pitocin, no suturing, no AROM. Different states may make different rules. Some states may decide that they cannot accept payment at all (and that to do so would be practicing medicine without a license). Some may decide that the births should be viewed more as UCs with doula help, and so the person can be paid. Some states won’t even have it on the radar and won’t make rules either way. I don’t really care. But the CPM credential has got to go. And MANA has got to release their goddamn numbers.

            ETA: I’m not envisioning them as “legal lay midwives” but rather as “not-illegal lay midwives” or perhaps “decriminalized lay midwives”. Messy I know but there you have it…

          • The Bofa on the Sofa

            I guess, but I then again, I don’t see it as profound. Just as you can’t force someone to go the hospital, you can’t prevent people from attending and serving as a baby catcher. You can prevent them from calling themselves a healthcare provider, or carrying out medical procedures, and that includes making any cuts or sutures or anything. Effectively, they are a baby catching doula, right? And since you can pay a doula, you can pay them. But all of this pretty much goes without saying. How can you stop it? If the person does not pass themself off as a healthcare provider, does not practice any medicine, of course they can be there. Outlawing it is as nonsensical as outlawing homebirth in general.

            That’s why I am confused.

          • fiftyfifty1

            It actually doesn’t go without saying. It could/should be laid out. Should advertising your services be legal? And if so, should you be able to call yourself a midwife or should you have to use the term doula or some other term? Giving Pitocin is surely the practice of medicine, but is checking a cervix? Stripping membranes? McRoberts? Giving advice about when to transfer? Does the answer change if you have accepted money?
            It’s legal to give a friend or family member a massage. But is it legal to charge for that massage? Does accepting money for it turn you into “a massage therapist practicing without a license?”. If not, what does? I don’t know the answers to these questions, but I’ll bet somebody does. My guess is that the answer varies from state to state, but that in each state an answer exists. So if concrete answers can exist about massage therapy, why do you say it is nonsensical to think they could exist for homebirth?

          • FormerPhysicist

            I think she’s saying that you can homebirth and have a friend with you, or pay a support person, but they can’t pretend they have any training or credentials.

      • NCBer No More

        Rather than forcing professionals to attend HB, I think you have to force those attending HB to become professionals. There is an irreducible number of women who want HB no matter how well informed they are of the risks. Is it naive to think the CPM credential could be improved to fill this role one day, or must it be abolished as Dr. Amy says? This is an honest question.

        • The Bofa on the Sofa

          Rather than forcing professionals to attend HB, I think you have to force those attending HB to become professionals.

          The problem is that as soon as you “force those attending HB to become professionals,” meaning that they are held to professional standards and training, they tend to get out of the HB business because 1) they have learned through training how risky it is, and 2) the malpractice insurance costs are way too high.

          Doctors and CNMs, for the most part, don’t do homebirths. OTOH, that (and other out-of-hospital births) is all CPMs can do. It’s not a coincidence. The responsible professionals don’t do homebirths, because they treat it responsibly. CPMs do homebirths because they treat it like a game, and don’t take any responsibility for the results.

        • fiftyfifty1

          ” Is it naive to think the CPM credential could be improved to fill this role one day, or must it be abolished as Dr. Amy says?”
          It has to be abolished because the CPMs and their overseeing “professional” body have made it clear that they do not want and will oppose any serious standards.

    • Ob in OZ

      As the comments make clear, what competent professional would be willing to put their license in jeopardy for a few home births? My fees would be astonomical if I was to really cover mself for the potential litigation (consent would be worthless and just defending against completely reiculous claims is expensive). When I was in training the midwives were all going to practice in remote communities with poor access to obstetricians…until they worked at the hospital, saw all the things that can go wrong, and suddenly they want to stay at hospitals with full support from Obstetricians and pediatricians. It goes to one of the core points of this blog. Having a baby is dangerous and low risk is not no risk. If our patients want good outcomes as much as the professionals, then there is no case for an out of hospital delivery (this includes most birth centers). But the point of a prior post was that it is not just healthy mom, healthy baby. It is also the experience along the way. As long as patients don’t lose sight of the ultimate goal, then making hospitals family friendly, music, skin-to-skin, cut the cord, eat the palcenta (after it is out it is not my problem) is what hospitals have been doing for decades to try to appease what is really a small but vocal minority.

  • I wholeheartedly agree with you on this post – and it underlines the very important need for both patients and providers to understand what informed consent is and to endeavour to provide it and receive it. Women have the right to choose – why not make sure that right is supported by ensuring that women are protected from unscrupulous birth junkies and misinformation?

    • Lisa from NY

      Brainwashed women will ignore medical advice. Period.