Homebirth is like driving without putting a seatbelt on your child

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Finally!

Finally, the dangers of homebirth are gaining attention in the wider scientific community and the lay press.

I’ve been making the homebirth-seatbelt comparison for years (see, for example, Unnecesseat belts from 2011) and now it’s been taking up by ethicists.

The paper Homebirth and the Future Child by OB-GYN Lachlan de Crespigny, and Oxford Philosophy Professor Julian Savulescu is deservedly getting widespread attention in the mainstream media.

From the paper:

Debate around homebirth typically focuses on the risk of maternal and perinatal mortality and morbidity – the primary focus is on deaths. There is little discussion on
the risk of long-term disability to the future child…

… [O]ne silent tragedy is the long-term disability that can result from homebirth. And it is this risk that we will argue weighs heavily against homebirth. In this paper, we will argue that both
professionals and pregnant women have an ethical obligation to minimise risk of long-term harm to the future child…

This is not merely a theoretical argument. I’ve written about several babies who suffered hypoxic brain injury at homebirth:

Conflicted: successful VBAC, brain damaged baby
Another homebirth, another brain injured baby, but the midwife was awesome
Sam: a victim of homebirth
But the baby’s heartrate was fine right before it dropped nearly dead into the homebirth midwife’s hands

Two recent studies, released since de Crespigny and Savulescu submitted their paper for publication, have shown that the risk is extraordinarily high.

The most important paper on homebirth published in 2013 showed that homebirth increases the risk of a 5 minute Apgar score of zero by nearly 1000%!

Grunebaum et al. found:

Home births (RR 10.55) and births in free-standing birth centers (RR 3.56) attended by midwives had a significantly higher risk of a 5-minute Apgar score of zero (p<.0001) than hospital births attended by physicians or midwives. Home births (RR 3.80) and births in free-standing birth centers attended by midwives (RR 1.88) had a significantly higher risk of neonatal seizures or serious neurologic dysfunction (p<.0001) than hospital births attended by physicians or midwives.

A poster entitled Home birth and risk of neonatal hypoxic ischemic encephalopathy, to be presented at the forthcoming February meeting of the Society of Maternal-Fetal Medicine also looks at this issue.

The authors explain:

Women who delivered at home had 16.9 times the odds of neonatal HIE compared to women who delivered in a hospital (p <0.01). The odds remained significant after controlling for maternal age, ethnicity, education level, primary payer and prepregnancy weight (aOR 18.7, 95% CI 2.02-172.47). After controlling for mode of delivery the odds of HIE increased for home birth compared to hospital birth (aOR 32.9, 95% CI 3.52-307.45).

In other words, homebirth increased the the odds of a baby needing cooling therapy for brain damage due to lack of oxygen by more than 18 fold.

Why is there an increased risk of brain injury at homebirth? de Crespigny and Savelescu point to multiple factors.

First:

Homebirth is expected to cause a delay in diagnosis, delivery and/or transfer following an acute intrapartum event with rapidly developing hypoxia, acidosis and asphyxia. Such a delay
will necessarily result in a prolonging of asphyxia. The best intrapartum fetal heart rate parameter for predicting newborn acidemia [ed. decreased blood pH due to low oxygen] is minimal or absent variability, with or without the presence of late decelerations. This is difficult to detect with intermittent auscultation alone, and even if diagnosed there will be the inevitable delay in expediting hospital delivery, which may be time critical…

Second:

[O]xygen, bag and mask ventilation, intubation, chest compressions and resuscitative medications, which cannot be optimally provided in a homebirth environment. It would be expected
that in some cases inadequate neonatal resuscitation will not only convert potential future normality to survival with morbidity, but may also convert potential normality or mild morbidity to survival with major morbidity.

The third factor is delay in accessing treatment for the brain injury:

Transfer of an infant who has suffered a severe asphyxial insult from home to hospital may delay the commencement of neuroprotective strategies, particularly therapeutic hypothermia. This will worsen outcome. The therapeutic window can be too short for infants requiring transfer to a tertiary referral centre.

What about women’s right to choose place of birth?

Homebirth is said to be about the ability of women to make a fundamental choice about their own bodies. Homebirth advocates often wish to keep birth free from medical interventions.
Homebirth decisions may also be influenced by what is fashionable or the latest cause célèbre.

The authors address a variety of legal and philosophical arguments and then conclude:

Having a homebirth may be like not putting your child’s car seat belt on. The risk of being injured in a single trip by not wearing a seat belt is extremely low. Still, we expect people to wear a seat belt to make the risks as low as possible, despite some inconvenience and diminution of driving pleasure. Most children will be unharmed. Some trips are very safe. And
wearing a seat belt will not remove all risk of injury or death. Indeed, wearing a seat belt in an accident will, on rare occasions, cause greater injury than not wearing a seat belt. But on
balance it is much safer with a seat belt…

Homebirth appears to be a risk factor for the future child, or at least so uncertain, that it should be discouraged, pending further research. Doctors and midwives often do not currently tell patients that there are predicatable avoidable risks of future child disability with homebirth. They should do so.

Amen!

  • LMS1953

    Ashley L >>LMS1953

    • a day ago

    actually, there is new bluetooth technology that will allow for mobile, remote fetal monitoring
    ^BUMP
    Birth in sub-Saharan Africa is a dangerous proposal. WHO has tried to introduce a “partogram” which is just a modified Friedman Curve to help discern when interventions are needed. Now, there are poor medical resources there. But they do have cell phone technology. Hence, if a relatively inexpensive blue tooth fetal heart monitor +/- tocometer could be mass produced (probably no more expensive than a good blue tooth head set), then the labor could be monitored just about anywhere in the world via the internet. Add in Skype and you would have a way to tell them when to crank up the Land Rover for Nairobi General. That would sure beat what they’ve got going there now.

  • Ashley L

    Guess we shall see this week, won’t we? http://www.mana.org/blog/25/mana-statistics-project-update. MANA will be releasing the data that you claim they have been hiding all of these years. Look, as an objective scientist, it is clear. until there are good, randomized controlled trials out there comparing planned home birth, planned birth center birth, and planned hospital birth, we are all going to continue to yell at one another. And there really won’t be any randomized trials b/c it is a matter of choice. We could also make the argument that deciding to formula feed your baby before he/she is born is like NOT putting your baby in a car seat. It can be argued that it is harmful. Do you see how these types of inflammatory vitriol are useless?

    • Box of Salt

      Ashley L ” it is clear. until there are good, randomized controlled trials out
      there comparing planned home birth, planned birth center birth, and
      planned hospital birth”

      You’re kidding, right? Do you understand how unethical that would be?

      It’s not just “a matter of choice.”

      • Ashley L.

        Yes, of course I understand how unethical that would be! My phrasing was poor. I apologize. What I meant was the RTC isn’t possible to truly compare outcomes (b/c women will choose where they want to give birth and so variables related to those types of women would not be controlled for), so different studies are going to point to different outcomes, and every study can be criticized.

        • AlisonCummins

          Every study may have weaknesses that can be understood, but that does not mean that every study is equally informative or reliable.

          Some studies are more carefully done with more data than others. You don’t get to say that the small, poorly-done studies are just as revealing as the large, well-done ones and that anyone can pick whatever result they like best because it’s just an opinion. It doesn’t work like that.

    • AlisonCummins

      There are different ways to get at an answer. There has never been a randomized, prospective, controlled study in humans on cigarette smoking, but we have still been able to determine that it causes lung cancer.

      Ignoring the data that we do have, that all point in the same direction, doesn’t make you look smart.

      • Ashley L.

        No, all the data do NOT point in the same direction. The point is that the data point in all sorts of directions!

        • AlisonCummins

          Oh do share.

          • Ashley L.

            Look, I’m coming at this discussion from reading the comments under this blog post. (http://www.scienceandsensibility.org/?p=1422&cpage=1#comments), which I thought were well thought out and a good discussion of the data and issues. I think we can all agree that the quality of research on planned home birth is varied, and proponents and opponents will find flaws with respective studies. And if they don’t find flaws, they will say the results cannot be extrapolated to the U.S (or to our current out-of-hospital birth options in the U.S.). I’m sure the same thing will happen with the MANA data..it will be interesting to see. But to use the headline-grabbing, blood pressure increasing language of home birthing is like driving with your child who is not in a seat belt isn’t productive.

          • AlisonCummins

            proponents and opponents will find flaws with respective studies

            The question isn’t about proponents or opponents, it’s about what’s true. All studies have limitations, that’s not the point. When you understand the limitations you know what inferences can be drawn.

            There are no studies that demonstrate that homebirth with a US homebirth midwife is less likely to kill or permanently disable either mother or baby than hospital birth under the care of an ob.

          • Ashley L.

            What he said (Nicholas Fogleson MD, in the discussion portion below another blog post): “The most important line in the whole piece is this ““Is home birth safe?” is a bogus question to which there is no answer.”

            I could not agree more. The whole concept of safety of childbirth, in any environment, is flawed. Bad things can happen in childbirth, just as they can happen crossing the street. The question is whether birth environment has a clinically important impact on outcomes in low risk pregnancies. This will always be hard to answer, as to the 99.9% that do fine the difference wasn’t significant, but if there is an attributable risk, the 0.1% that hits it will see that risk in special significance that cannot be described in mathematics.

            Wax has published a meta analysis which has some strengths and weaknesses. It does show an increased neonatal death rate for homebirth. Those that are against homebirth will taut it, those that support homebirth will attack it. This is nothing new. This type of post-hoc research commentary is part of the process of scientific discovery, and has gone on with every major paper that anyone ever cared about.

            The most important part of all of this is that both Wax and DeJonge showed that homebirth is largely safe. There may be a few more bad outcomes in the homebirth groups depending on how you look at the data, but when you consider the number of births we are looking at, the absolute number is so very few that the argument is a little ridiculous.”

          • AlisonCummins

            Your numbers are off. It’s not 99.9% that don’t die. From the Oregon numbers:

            Planned hospital birth: 99.94% don’t die.
            Planned home birth with a homebirth midwife: 99.44% don’t die.

            These numbers might look the same to you presented this way, so let’s look at them another way.

            Planned hospital birth: 1/1,667 die.
            Planned home birth with a homebirth midwife: 1/179 die.

            That’s a huge difference. Really? You like those odds? I don’t. One in every 179 is not “so very few” that I can feel good about it not happening to me.

          • AlisonCummins

            And it’s not just death. There’s HIE, or hypoxic neonatal encephalopathy. That is, brain damage from being suffocated. The following is a mish-mash of figures from different sources so it’s approximate, but it gives an impression.

            About 3.7 per thousand US babies are born with HIE. About 0.2 per thousand die (so are already counted in the neonatal death statistics) so that leaves 3.5 per thousand probably brain damaged.
            http://www.ncbi.nlm.nih.gov/pubmed/19084096

            The odds of HIE with home birth are about 18.7 times the odds of HIE with hospital birth

            so let’s look at the numbers again.

          • AlisonCummins

            And it’s not just death. There’s HIE, or hypoxic neonatal encephalopathy. That is, brain damage from being suffocated. The following is a mish-mash of figures from different sources so it’s approximate, but it gives an impression.

            About 3.7 per thousand US babies are born with HIE. About 0.2 per thousand die (so are already counted in the neonatal death statistics) so that leaves 3.5 per thousand probably brain damaged.
            http://www.ncbi.nlm.nih.gov/pu

            The odds of HIE with home birth are about 18.7 times the odds of HIE with hospital birth.

            http://www.skepticalob.com/2014/01/risk-of-anoxic-brain-injury-is-more-than-18-times-higher-at-homebirth.html

            Let’s look at what combining those two facts can tell us:

            Chance that your baby will NOT suffocate and suffer brain damage

            Born in hospital: 99.7%

            Born at home: 93.5%

            Those still look kind of similar so let’s turn them around the way we did with deaths.

            Chance that your baby WILL suffocate and suffer brain damage:

            Born in hospital: 1/286

            Born at home: 1/15.

            Really? 1/15 is so low as to be a little ridiculous to worry about?

          • AlisonCummins

            the headline-grabbing, blood pressure increasing language of home birthing is like driving with your child who is not in a seat belt isn’t productive

            Ah, but is it true? That’s the question.

          • Box of Salt

            Ashley L, please read this blogpost which also discusses more recent studies:

            http://whatifsandfears.blogspot.com/2014/01/home-birth-safety.html

          • Trixie

            Why isn’t it productive? They are both similar risk scenarios.

    • Young CC Prof

      The difference between home birth and formula feeding is that no first-world babies have died of formula feeding. (Yes, babies in the poorer parts of the world have died of being fed formula mixed too thin or made with non-sterile water, but that’s not generally an issue for readers of this site.)

      By contrast, there are quite a few examples of babies who died at home birth who almost certainly would have been fine if born in a hospital. And a randomized controlled trial is NOT the only convincing form of evidence. When randomization is impossible, impractical or unethical, carefully performed observational studies are a fine substitute.

      • Trixie

        Full-term babies, yes. Preemies have higher rates of NEC with formula. And, while extremely rare, there have been cases in the developed world of babies being sickened or dying from contaminated water used to mix formula, or in rare cases from powdered formula contaminated with cronobacter sakazakii, so I’m not sure you can say no baby has ever died from formula feeding. Not arguing against the decision to FF, just the blanket statement that formula has never killed anyone.

        • Young CC Prof

          Fair enough. Of course, there have probably been babies who died or were badly harmed from breastfeeding, due to supply issues or food allergies that weren’t diagnosed in time. So I suppose you have to look at the actual number and rate of problems to decide how dangerous something actually is.

          • Trixie

            Oh, certainly. For that matter, there are various genetic conditions for which either breastfeeding or conventional formula would be deadly or lead to permanent brain damage.

  • LMS1953

    Mandatory reading for 39 week Nazis:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902487/#!po=79.6703

    This is the seminal paper that discusses the risk of the mandatory 39w0d rule. In their study 14% of repeat C-sections went into labor in the 38th week. Another study from Israel showed 25%. In a post below, I said 40% – a bit overstated but not so much went you add in the overall 10%+ preterm birth rate (<37w0d)

    Of note to EVIDENCE BASED MEDICINE fans out there, the authors discuss exclusionary factors in the 39w0d studies that OVERESTIMATED the risk of iatrogenic prematurity and UNDERESTIMATED the risk of still birth in the 38th week and fetal/maternal morbidly/mortality arising from converting an elective C-section to one that is urgent/emergency.

    The point is that it is time to install some seat belts, car seats, airbags and anti-lock brakes to that 39w0d Edsel if we are truly concerned about safety. And not let the perfunctory dictates of a 39week Nazi or state legislature trump the experience and judgment of a board certified obstetrician and maternal autonomy following the informed consent process.

    • Young CC Prof

      That is a very interesting study! Definitely I believe the 39-week rule is being pushed way too hard, and pushed into inappropriate places, like a doctor’s decision-making process when actual complications exist. Hopefully there will be some push back soon, I think ACOG is where it would have to start.

      My cousin with the hypoplastic left heart baby is big into advocacy, (I suppose that’s how she stays sane) and I’d love to do the March of Dimes walk with her this spring, but I just don’t like their “healthy babies are worth the wait” campaign. If they added 3 words, I’d be so much happier with it. Instead of, “Avoid inductions before 39 weeks,” say, “Avoid inductions before 39 weeks unless medically indicated.”

      • LMS1953

        And “as long as you are emotionally prepared to withstand the small but real increased risk of a stillbirth in the 38th week that statistically outweighs the small benefit of waiting to the 39th week”. Though that is kinda hard to fit that on a glib poster or a sound bite on a public health commercial.

      • LMS1953

        CC, I think that it has been adjudged, on the ethical basis of maternal autonomy that a pregnant woman has the RIGHT to choose a primary C-section without a TOL. Why then, does she not also have the RIGHT to have her elective repeat C-section schedule in the 38th week after an appropriate informed consent discussion? The authors are quick to point out that a 38th week C-section should DEFINITELY be offered to older mothers and those with more than one prior C-section

        • Young CC Prof

          THAT is a medical indication. And medically necessary elective c-section is a different case from induction. Heck, one of the reasons I’m glad I got my section the day that I did is that I was effaced and had been having more intense contractions, and there’s a distinct possibility that I would have gone into natural labor that night, in the middle of a blizzard, with a breech baby.

          Of course, with early induction, unless the mother’s cervix is already pretty ripe, there’s a greater chance that it just won’t work! And 40 hours of attempted induction, no progress, then a c-section is not something that most mothers really want to go through.

          The point is, when and how to hasten a birth (by induction or section) should be a decision made between the doctor and the patient, informed by ALL the facts, both medical and personal. The 39-week rule isn’t always wrong, but it’s a blunt-force tool that isn’t always appropriate.

      • LMS1953

        In academic parlance, the dictum and ethics of primum non nocere (first do no harm) must be balanced with the ethical principle of beneficence – an intervention or willful withholding of intervention should not cause harm or oppose the welfare of a patient. The 39 week dictum certainly has the potential to oppose the welfare of the mom and her baby, especially if her autonomy is ignored

  • LMS1953

    Here is an idea for another “seatbelt” that would have applications for monitoring high risk pregnancies as well. Typically we do biweekly NSTs and give the patient a Fetal Kick Count Sheet should she perceive decreased fetal movement. Now imagine this (BTW, Cardiologists already have via a real time Holter monitor with internet telemetry) – a relatively inexpensive Doppler could be attached by the patient to her abdomen by an adhesive ring and Velcro mating to the Doppler. It would provide complete mobility – to counter the complaint of HBers that when you go to the hospital they will strap you down on your back and prevent you from walking around. The signal would be transmitted by Bluetooth to her smart phone which has the appropriate app installed and relayed by Internet to her provider in realtime. The strips could be archived electronically at both places for medico-legal documentation. Voila, 24/7 access to NST surveillance and intrapartum FHT monitoring.

    • Certified Hamster Midwife

      iGestate

      • LMS1953

        I❤️Baby

    • Susan

      I don’t know… somehow I think what would end up happening is a lot of women would end up hospitalized because even normal babies are going to have decels from sucking on the cord or grabbing the cord or whatever. Then, long hospital stays and hazards of immobility. I’ve thought about this and I think the medico-legal implications are why it won’t happen. Even the home uterine monitors, which I believe never included a FHR for medico/legal reasons, not that they couldn’t do it, have become passé as they way overdiagnosed problems.
      On the other hand, I have often thought that virtually NOTHING about fetal monitoring technology has changed in my career. Or at least very little when it comes to mom’s comfort. I just can’t imagine that the technology to make external monitoring smaller and more comfortable doesn’t exist. I’d love to be putting a very small similar to an ecg lead on for both the toco and sono…. that would work no matter what position she’s in and especially no matter what the patient weighs. That’s what I would be looking into if I was HP or GE or whatever….

      • LMS1953

        Actually, the uterine tocometer adds very little to the fetal surveillance. The mom and/or provider could easily palpate and mark the onset and end of a contraction and you would just have to tap a toggle button on the app to register it on the strip. Decelerations are classified as variable, early, late, V-shaped, U-shaped, etc and each has a specified intervention such as positioning, O2 administration, IV hydration, amnioinfusion, etc. Or in the topic at hand, prompt transfer to the hospital. Will there be false positives? Sure enough. But there will seldom be false negatives as fetal acidosis takes a while to develop. Given that there will always be home births, this sure beats the nonsense of “the heart tones were fine until the baby started to crown and somehow he/she just came out stillborn. It just couldn’t be helped. It would have happened at the hospital just as easily”.

        • Susan

          Somehow I doubt you have been doing this as long as I have or you would have got my point instead of giving me a condescending lecture on what I do and teach. I actually met a homebirth midwife at a fetal monitoring class who does use EFM at home. She had the monitor with her. My point, is even that from a medical/legal standpoint getting that information in a setting you have little you can do about it other than transfer has implications that I think make it impossible to market that way (whether it be for homebirth or antepartum fetal surveillance). The home uterine monitoring fell by the wayside for different reasons but the technology to monitor at home has been around for awhile but has never been adopted. I think that is the reason and that was my point.

          • LMS1953

            Susan, I have been doing this for 30 years – so If you have me beat, you win the brass ring. The home monitoring you refer to was about 15 years ago (well before smart phones and blue tooth and WiFi). It was foist upon us by home monitoring companies who wanted to make thousands giving SQ terbutaline infusions at home.IIRC they only monitored contractions, not FHTs and you would get calls when your son was coming up for his first Little League at bat and the home health nurse would say, “Your patient is now having contractions every 7.5 minutes and the cut off is every 8 minutes and the terbutaline is set at blah, blah , blah… What? He got a DOUBLE!! … You want me to DOUBLE the rate…are you sure, Doctor?”

            And all of that was a COMPLETE WASTE OF MONEY. It didn’t make a jack squat of difference. But boy were you ever labelled a Ludite if you didn’t jump in with both feet. Other than 17-P there is NOTHING we can do at this time to prevent preterm delivery. The best we can hope for is to delay delivery long enough for the Betamethasone to take effect and buy time to arrange transfer to a tertiary care unit and give prophylactic PCN for GBS.

            You talk about a home birth midwife with a portable monitor. Yeah, you might as well give me a bat to face Sandy Koufax. Most HBMW’s are NOT CNM’s. CNMs have the training and expertise (if not the inclination) to do episiotomies and vacuum extraction especially in the face of fetal distress.

            And as far as your “medical legal” concerns go – there is nothing there that tort reform won’t solve. But you are more than welcome to crawl back inside your well-aged box since you certainly show no inclination to have your synapses fire outside of it:

          • Susan

            Gee.. you aren’t listening. Glad you are as well aged as I am. Listen, you have an idea I am pro.homebirth because I had one. Its been a long time since then and it didn’t take long as a lowly labor nurse before I realized how I had risked my baby’s health. Usually, I find OBs who are young and new are the most likely to give an RN a condescending lecture on fetal monitoring. Forgive me but it rubbed me the wrong way. And yes I am so old that l was around for home uterine activity monitors. I entirely agree with your description of what a pointless pain they were. I still disagree on the feasibility of home EFM I think it would be a nightmare. Glad to hear you’ve got tort reform on the horizon though… Really though I am usually the nurse who is most likely to get the ob’s perspective where I work. So perhaps we should start over. We both have hard jobs that no one really gets until they have walked in our shoes.

          • Susan

            Also LMS1953 I apologize, I read your original post that got me ticked off and I really don’t think now I was reading it as intended. I think I deserved the snarky comments.

        • Ashley L.

          actually, there is new bluetooth technology that will allow for mobile, remote fetal monitoring.

    • Meerkat

      That would be awesome! I had to go to the emergency room for monitoring a couple of times because I didn’t feel kicks, and it was really nerve wracking. I would have loved a peace of mind that would come with this monitoring.

  • LMS1953

    Given that the impetus for homebirth will not go away, how do we put a seatbelt on it? Papers from the UK say it can be done safely with low risk women, with well trained providers in attendance and with a good referral and transportation mechanism in place. Assuming that is true, the following system is feasible:
    1) Any woman desiring homebirth must be evaluated and examined by at least a CNM and cleared. The results of this certification will be registered on the Obamacare site. If the woman violates the certification with an unauthorized homebirth, then it will be reported to the IRS as Obamacare fraud with the appropriate sanctions/fines/garnishment as to be proscribed by law. Should the baby or mother be injured by the unauthorized homebirth, then the parties involved will be subject to charges of child endangerment.
    2) The midwife categories of Direct Entry Midwife and Certified Professional Midwife shall be abolished since providers with such qualifications have not been shown to provide safe care nor licensed as such anywhere else in the developed world. That would leave CNMs under the supervision of obstetricians as the only (current) category that would be permitted to serve as providers. Current professional standards typically prohibit CNMs and OBs from functioning outside of hospitals or birthing centers – primarily due to safety concerns and prohibitive malpractice costs. Hence, tort reform shall be passed to limit liability while initial beta testing in an evidence based format shall establish safety.
    3) A smart phone app could easily be made whereby intrapartum monitoring could be unobstrusively attached to the “client” in labor with internet telemetry. (Probably a better use for Obamaphones than what they are used for now). These could be as easily reviewed in house as hospital labors are now. Additionally, the app could be easily programmed to “read the strip” and provide on site alerts and treatment algorithms. As part of beta testing, ambulance availability and home transportation protocols shall be established and reviewed for efficiency and safety. It would not be hard to customize a 4 wheel drive SUV that the CNM would travel in that would be equipped with a panoply of primary intervention tools such as a vacuum extractor, local and pudendal trays, ob hemorrhage kit (hemabate, Pitocin, cytotec, methergine, intrauterine balloon), suture material and instruments, appropriate lighting and O2 with adult and neonatal ventilation masks. The SUV would have a gurney that would easily slide out to quickly extract the client from the home birth environment and whisk her off to the hospital as an ad hoc ambulance should such dire circumstances arise.
    Well, that is my initial brainstorm. Heck, if all that were in place, I’d be more than glad to be a beta tester myself! Kinda sounds like fun.

    • Antigonos CNM

      In my time in the UK, the Flying Squad was completely equipped to actually do a C/S in the home, but in the Cambridge region at least, that had never happened.

      But the sheer size of the US is in itself an obstacle. Apparently there is no place in the UK where you are more than 8 miles from someone else. If a designated OB-emergency vehicle has to travel long distances or through heavy traffic to get to a patient in the US, it will arrive too late, no matter how well equipped it is.

      Bringing midwifery to the higher level of the CNM as being the only legal form of midwifery, and making it incumbent on all midwives to adhere to uniform standards of practice would be a huge step — but the transfer delay will always mean that homebirth is riskier than hospital birth.

      • LMS1953

        Antigonos, the varied geography of the US poses obstacles not only for home birth but for hospital birth as well. I have attended to many women who request a repeat C-section and it takes them an hour or more to get to the hospital. And with the 39 week 0 day rule so zealously enforced now, it is almost guaranteed that up to 40% will go into labor prior to their scheduled C-section. Indeed, there has been an uptick in complications (ie a DECREASE in safety) by iatrogenically converting elective repeat C-sections to urgent ones. But such is the calculus that we are now forced to deal with. Some women will continue to demand homebirth. The ethics of patient autonomy prevents us from prohibiting it. To paraphrase the Bible – “The homebirthers will always be with you”. My proposal was an attempt to add in a utilitarian ethic (mandatory use of seat belts and car seats is based on a utilitarian ethic imposed on autonomy) to assure the best outcome for those who prefer home birth.

        • Antigonos CNM

          You are right about geography; I even had a woman on a kibbutz in northern Israel who went to Haifa when she was 38 weeks, and stayed, at the kibbutz’s expense, in a hotel until she went into labor because of a particular rare complication she was at risk of. The closest regional hospital to where she lived could not have dealt with it.

      • LMS1953

        I re-read your post and I think you misread mine. The idea is that the CNM would travel directly to the client’s home in her SUV/OBmobile. There would be immediate access to tools that would PREVENT most of the complications that require emergency transfer to the hospital such as unrecognized fetal distress, prolonged second stage and obstetric hemorrhage. Moreover, a reliable transport vehicle will already be on site obviating the point B > A delay, letting you go directly from A>B.

        • Antigonos CNM

          The Flying Squad carried an OB, a pediatrician, an anesthesiologist and an OR [theatre] nurse. Where would our CNM stash those?

          • LMS1953

            Didn’t you just write that they were never needed? Perhaps that was a bit of overkill. Have any studies been done to show that such a Flying Squad was cost effective since it was never used? I would think that an emergency C-section in somebody’s house would have made the World News. I have never heard of one. However, here in the US, a mom will be the lead story on the evening news if she happens to deliver on the roadside on the way to the hospital or if her 3 year old dials 911 while she is precip-ing on the couch.

          • Antigonos CNM

            No, I wrote that the Cambridge area had never had a C/S on the kitchen table. In fact, the Flying Squad was called out not infrequently. In one of my homebirths as a student midwife, there was a sudden, unanticipated abruption that undoubtedly would have been a major catastrophe if we’d been on our own [even the slightest bleeding, apart from bloody show, required us to immediately summon the Squad].

            This was in the 70s. The world, pre-cellphone and internet, was a bit bigger back then and it took a bit more to get on the news :-)

  • stacey

    PERFECT

  • R T

    This analogy only works in recent times. When my mom home birthing no one used carseats, lol! She used to tuck is in a basic behind the passenger seat shoved up against the front of the back seat! My husband’s mom said they just carried their children in their arms. I can’t believe it took so long too figure out how necessary a car seat was! It seems so common sense now!

    • The Bofa on the Sofa

      One thing that I remember is that our parents didn’t allow us to lie on the floor in the backseat. I don’t remember why. Then again, our parents didn’t allow us to wear sock to bed, because Dad knew a guy in the army who did that and his feet feel off. To this day, I can’t sleep with socks on (while my younger guy sleeps with socks AND slippers)

      Seatbelt laws where I lived were put in place when I was in high school, soon after I got my license. Before that, we never used them. I remember one time my mom came to pick us up at the roller rink in my aunt’s car, and it had a beeper that went off if the seat belt wasn’t pulled, and my mom drove with one hand on the wheel and the other holding the seat belt pulled out so the stupid alarm would stop.

    • Trixie

      My parents had a Volvo in the late 70s, and I had a car seat that I think latched into it somehow. Actually, I believe it was a Volvo engineer who invented the first rear-facing child seat. I know my mom was in the minority in always having me buckled at the time.

    • Dr Kitty

      When I was six we drove to Connemara for a holiday (it was a seven hour drive each way). My five year old sister and I on booster seats in the back with my grandmother between us …and my 3 month old baby sister in a Moses basket behind the front seats on the floor, basket wedged in place with pillows.

      That was child car safety in the 1980s.

  • Amy Tuteur, MD
    • LadyLuck777

      If midwives are contributing this information themselves, how do they know it is accurate? They discuss a peer reviewed process, but unless every midwife was someone that can back up the data, how can the validity truly be measured? Am I being too cynical off the bat?

      • http://shameonbetterbirth.wordpress.com/ Shameon Betterbirth

        Not at all. When midwives regularly advise hospital transfers to tell the hospital a lie- you know, when it REALLY matters that the truth is told, why the hell would anyone trust them to tell the truth about anything? Theres no consequence if they lie, is there?

      • Young CC Prof

        I’m pretty sure there have been incidents of hospitals, under far greater scrutiny, trying to color their outcomes one way or another, so no, data massaging by independent practitioners with little or no supervision wouldn’t surprise me.

    • Antigonos CNM

      Pardon me if I am underwhelmed. I expect the data to be partial, and very slickly presented to put the best spin on it all [something like "90+% of homebirths are uncomplicated", not that a certain percentage, much higher than hospital births, result in death or morbidity]. After all, they have to actually have a guide to “understanding MANA stats” along with those stats. Wanna bet death statistics are missing again?

      • Young CC Prof

        But fewer c-sections! Isn’t that what really matters?

      • Squillo

        It’s the classic “write a paper to explain the paper” thing.

    • Ainsley Nicholson

      Looks like they are still not releasing the data…just some papers based on the data they’ve collected. Along with lots of guidance on how they want it to be interpreted.

      • Squillo

        Maybe, maybe not. The blog post says that one of the articles “describes the outcomes of planned home births with midwives between 2004 and 2009.” I should hope they’ll include the actual data they’ve used, which is of course, not the same as making the data they’ve collected available. Unless they’re using “describe” to mean something other than what I’m assuming it means.

    • theNormalDistribution

      “normal physiologic birth” what the fuck.

      • Certified Hamster Midwife

        That’s the branding that the more competent homebirth practice in my region uses. “Normal physiologic birth” without outside interventions is healthier for mothers and babies. Except for the two babies that died within the space of a year. Nature is a real bitch.

        • theNormalDistribution

          It reminds me of another odd phrase taught to me by a friend of mine who went camping with a group of very religious friends… Sitting around the campfire one night, someone actually said “It’s so ridiculous how people think they can prove evolution with human science“. LOLOLOLO – wait, what?

          • Certified Hamster Midwife

            Well, compared to the Vulcans, our science is pretty rudimentary.

          • http://kumquatwriter.wordpress.com/ Kumquatwriter

            How can we judge that when the Vulcan Science Academy is so unashamedly speciesist/racist that they think having a human parent is a disability!

          • Karen in SC

            And they don’t release the death rates of the Pon Farr ritual, either!

          • anion

            HA!

          • anion

            And highly illogical.

        • Susan

          Like that…branding. Yes, I was thinking that the saying “birth is as safe as life gets” the other day when I was feeling just how unsafe life is. It’s sort of like saying… face it, birth isn’t safe and neither is life…

    • LMS1953

      “The first is that it provides contributing midwives with a tool to track outcomes for her or his own practice. The MANA Stats system auto-calculates midwives’ practice outcomes instantly so they can keep close track of their own outcomes. Ideally, as a midwife sits down with a prospective client who’s asking questions, he or she can provide up-to-the-minute information about transport rates, neonatal mortality rates, or whatever data are relevant to the questions the client is asking. This is an important part of shared decision making.”

      PC is so pervasive at Oregon State University that, like a cursing sailor, she just can’t get out of the her/his he/she zeitgeist. Notice how she even switched the genders so as not to give off a scintilla of “sexism”. An ungrammatical “they/their” would not have even been noticed. But they simply cannot bring themselves (oops, I meant “he or she simply cannot bring herself or himself) to speak that way.

      So the reader is forced to imagine a male homebirth midwife, something as incongruent as a fur-lined teacup. I have rarely seen a male nurse work on a maternity unit. I cannot imagine there is a male homebirth midwife. Does anybody know of one?

      Oh yeah, the PC “client” was de rigueur too.

      • http://shameonbetterbirth.wordpress.com/ Shameon Betterbirth

        there are male home birth midwives. there are male doulas. And people who say “PC” don’t understand what exclusion does to people who aren’t represented.

        • LMS1953

          http://www.homebirth-only.com/AboutME/AboutParteroJerry.htm
          I did a google search for “male homebirth midwife” and this was the only one I could find. Jerry said the only other male in the program he attended had dropped out because no “clients” wanted to use him. He said he got his midwife card without having attended a single delivery. He finally found his niche in Tijuana, Mexico (“in the hospital you will have the same pain and they will cut you and you will be alone, so why not deliver at home?”) With that glib spiel, he has done over 500 deliveries including several breech, twins and “countless VBACS”. All that with a “midwife card”.

          • Certified Hamster Midwife

            Oddly, there are two lay midwives on “The Mindy Project” who act as foils to the main character, a female OB in Manhattan. It rings very false to me.

            Male CNMs exist, but what lay midwives are selling is very different.

          • http://shameonbetterbirth.wordpress.com/ Shameon Betterbirth

            Well, just because they do not adverstise online does not mean that they do not exist. I trained undera DONA approved doula training and I asked specifically “are there any dudes that are doulas”? and the president of the midwifery school of utah noted one name. I have also posted information about a utah midwives organization meeting to monitor legilative issues, and a man (who is a midwifery student) volunteered. Also, a different man appeared on a midwifery school instagram recently. I am not saying its common, but it does happen.

          • Guestll

            There’s a Canadian male RM in Ontario. As a student, he participated in my care. He was really good and for what it’s worth, he was far more gentle in stripping my membranes than the other RMs were.

        • http://kumquatwriter.wordpress.com/ Kumquatwriter

          I’m sorry, but we’re talking about a profession with “wife” in the title and almost literally no male practitioners. This is PC oversensitivity.

          • Irène Delse

            Or maybe those homebirth midwives are trying to get more men interested in what they do? Either as potential practitioners themselves or as midwife assistants. I know it’s easy to deride “PC-ness”, but it’s also a good business practice to be or at least sound like you are inclusive. Being an all-female profession or nearly so is certainly one thing that keep some people taking midwifery as a serious endeavour, including journalists, as judged from the reaction to Dr Amy’s lawsuit!

        • Anne

          My understanding of one of the evidence based benefits of a doula came from studies which looked at “a woman known to the labouring woman” but not involved in her medical care being present for the labour reduced Caesarean section.

          Until the studies have been done with males, the gender is important.

          Ref. http://www.nice.org.uk/nicemedia/pdf/CG013fullguideline.pdf p 41

      • Squillo

        “Ideally, as a midwife sits down with a prospective client who’s asking questions, he or she can provide up-to-the-minute information about transport rates, neonatal mortality rates, or whatever data are relevant to the questions the client is asking. This is an important part of shared decision making.

        How exactly is the decision-making “shared” if only one of the parties has access to the “benchmarking” data?

      • Susan

        Well, my daughter was born at home with a male CNM…so yes… !

    • LMS1953

      Missy: …..Midwives’ participation in the MANA Stats registry is voluntary, except in Oregon and Vermont. Midwives log clients into the system early in care before the outcome of care is known. The system then prompts midwives to complete records for all clients who are logged. Once the data is entered, they go through a rigorous review process to make sure the data are as accurate and reliable as possible.

      J: And why doesn’t MANA make those benchmarking numbers open to the public?

      M: It has always been our goal to publish them in a peer reviewed journal, to provide the public with the highest level of accountability.

      J: Explain why the peer review process is so important to you and to MANA.

      M: I think it is very important that research papers that come from the MANA Stats Project’s datasets go through the process of rigorous peer review required for publication in an academic journal.

      >>Well, Missy, when will MANA publish the 2012 stats from Oregon which show a deplorable 800% increase in perinatal mortality for planned home birth?. Presumably, since these numbers are mandated by MANA for Oregon. they won’t have to be vetted through many “peers” before they are acknowledged as correct. You kinda owe it to a public to whom you wish to provide “the highest level of accountability”.

    • fiftyfifty1

      “one of only two large datasets where normal physiologic birth can be studied”

      1. What’s the other large data set?
      2. These stats are voluntary self-report, no? Do you think there is any chance they have cleaned them up or omitted any data?

  • Deborah

    Are there any studies out there about whether or not variability is something that can be determined by intermittent auscultation? Do midwives ever talk about being able to hear it or not? I remember in my residency (before central monitoring, and in a smaller unit) there being a golden spot where you could sit and hear all the strips at once, and I remember jumping up to run to rooms for decelerations, but I really can’t remember being able to hear variability. (And I was there for hours and hours and hours . . . )

    • Amy Tuteur, MD

      You can’t hear variability because it depends on a moment by moment calculation of rate.

      • Deborah

        Yeah, but are there any studies that PROVE that? Because otherwise I bet there are loads of midwives who think they can hear it.

        • Antigonos CNM

          If they do, then they really don’t understand fetal monitoring [which is quite likely, btw].

    • attitude devant

      Wow. We had that golden spot too! Between tasks, I was always resting there instead of the call room.

    • Young CC Prof

      My hospital has a big board with all the strips in the nurse’s station. No sweet-spot hunting necessary, the staff can do their paperwork and watch 5 different fetal heartbeats at once.

      • LMS1953

        Indeed, the absence of variability is a very ominous sign and is typically caused by significant fetal acidosis. Some anecdata: I listened to the heart tones with a Doppler at the office visit of a “low risk” pregnancy. Just as I was lifting the Doppler off the abdomen, I heard a lub….dub, lub…dub deceleration. I advised her to go to L&D for prolonged monitoring. There was poor variability. I added in some pitocin to perform an Oxytocin Challenge Test. With the first few contractions, late decels appeared and I performed an emergency C-section (oh the dreaded cascade of intervention). We got a good baby with Apgars of 8/9, but a ABG cord pH of 7.15. The pedi said she was going to have to transfer the baby because his Hgb was 8.0 – about half of what it should be. She asked me to do a KB test to check for fetal cells in the maternal circulation. It came back extraordinarily high, indicative of a severe fetal-maternal bleed. Making rounds the next day, mom said, “Come here, I want to give you a hug” “Sure, I can always use a hug, what’s up?” “I just wanted to thank you for saving my baby’s life. The neonatologist said my baby probably would have bled to death had he been delivered 10 minutes later. What made you think something was wrong?” “Well, I have this pet birdie on my shoulder who keeps me in line.” Tears were soon coming down both of our cheeks.

        There is no “evidenced base management” algorithms for that. But experience is a good teacher and there is knowledge we can perceive outside of our typical plane of discourse. “Use the force, Luke”.

        • LynnetteHafkenIBCLC

          You are amazing. Yeah science!

        • Karen in SC

          Wow, I got chills reading that.

    • Antigonos CNM

      The only way to determine beat to beat variability is with EFM. Further, auscultation, even with a Doppler, is easily done in such a way as NOT to hear decelerations.

  • Carolina

    This is the type of the posts I love: an excellent, straightforward explanation of scientific studies with no snark or attacks. Wonderfully done.
    (I’m not the tone police. I sometimes love the sarcasm, but on a post like this, I think it would detract from the message.

    • AlisonCummins

      I never love the sarcasm when it’s directed against mothers. They aren’t in a position to know they are being lied to and there are many different reasons a woman might prefer the idea that she doesn’t need a stranger’s help to give birth. Being immature might be one of the reasons that homebirth appeals but we all have faults. Having a fault is not a reason to be hauled up and insulted by someone who happens to know better — especially since someone might be immature and also have a more sympathetic reason to prefer the idea of homebirth that isn’t necessarily obvious.

      I never love the sarcasm when it’s directed against homebirth professionals without any background explaining why they are wrong.

      If the background and references are there, even as links, so that we can see why someone claiming to be a professional is lying — yeah, then I have no problem with sarcasm.

      • Carolina

        I think that sums up my feelings on it too. If she’s mocking an absolutely ridiculous blog post (see, e.g., anything from Alpha Parent), that’s fine. Or doing one of her annotated explanations of why a person doesn’t understand how a HB death or injury happened. When she explains why a person is an incompetent idiot, I’m totally good with the name-calling. But when it’s a more generalized rant against AP parents (who aren’t at all a homogenous group) or something like that, it just doesn’t work for me.

  • Elle

    Given that intermittent monitoring was stated as one of the risks involved in homebirth, what does that say about intermittent monitoring in the hospital, assuming monitoring is done at roughly the same intervals? Just curious since my hospital (and many others I’m sure) allowed that.

    • Karen in SC

      I’m speculating that the intermittent monitoring at the hospital would still be EFM, taken at intervals and lasting long enough to show any problems. I had intermittent though I really can’t remember how long the nurse held the thing against my uterus each time.

      Contrast that with the hand held dopplers or whatever midwives use. Add in lack of training on how to interpret.

      • Trixie

        They let me unhook from the EFM for about 15-20 minutes at a time once they had established that the baby was tolerating labor well.

    • Dr Kitty

      BUT hospitals often do IA after 30 minutes of EFM first, to ensure baby tolerates labour well.
      AND hospitals have strict criteria for continuing IA, with the ability of moving to EFM if all is not well.
      At HB it is all IA, all the time- with no other options, and plenty of evidence to suggest the IA is not being done often enough, or at the right times, or well enough when it is done.
      Ideally you use a doppler for the FH while manually checking mum’s pulse at the same time (or at the very least using a pulse oximeter) to make sure you aren’t picking up maternal HR instead of foetal HR.

      • Medwife

        I have basically stopped ordering IA because nursing staff are determined to interpret it as “20 min of EFM, 40 min off”, which is an unacceptably long length of time without checking FHT in active labor. Telemetry makes me, nurses, and the vast majority of patients happy.

    • Guest

      I’m still confused as to why monitoring is considered an intervention. To me it shouldn’t be. An intervention should be something that actually changes the nature of what’s going on, like drugs or invasive procedures. Maybe the internal monitor could be considered an intervention because it’s, well, internal. But I’m a lay-person…so what do I know? :)

      • The Bofa on the Sofa

        Exactly. Monitoring is assessment, not intervention.

      • C T

        It’s a medical intervention because it is 1) done as a medical practice, and 2) it intervenes in labor because it requires a woman to give up some of her usual mobility. When a woman is laboring without pain relief (which is a reasonable option for many because women’s anatomy and the way they feel pain vary widely), it can be quite uncomfortable to be told to lie immobile for long periods of time. Moving around can definitely get/keep labor going strong, which is why in hospitals they often have women in early labor walk the halls, so one could argue that the immobility required by EFM results in a slower labor.
        I think remote monitoring needs to become more widely available then at present. We can live-tweet our labors on our phones, but too many women are still being tethered to EFM machines; time to move out of the 20th century, hospitals! When a woman knows she will be just as free to move around in the hospital as she would be at home, she has one less reason to opt for homebirth.

        • Guest

          That makes sense. I didn’t really want it during my labor, but I didn’t feel like it was an intervention. Had to get one because of my epidural. They didn’t give me the option to not have it.

          • C T

            In your case, it wasn’t, for it didn’t change anything. You were already immobile.

        • AlisonCummins

          Does “intervention” not have a medical meaning that distinguishes it from “assessment”? I really don’t think that the technical definition of “intervention” is “something that the patient notices or has to sit down for if they were not otherwise sitting”

          • C T

            From dictionary.com:
            in·ter·vene
            1. to come between disputing people, groups, etc.; intercede; mediate.
            2. to occur or be between two things.
            3. to occur or happen between other events or periods: Nothing important intervened between themeetings.
            4. (of things) to occur incidentally so as to modify or hinder: We enjoyed the picnic until a thunderstormintervened.
            5. to interfere with force or a threat of force: to intervene in the affairs of another country.
            Per the fourth definition, it’s an intervention if it modifies or hinders labor. It can be both an assessment and an intervention.

          • The Bofa on the Sofa

            Is a blood pressure measurement an intervention then? If the nurse says, “Hold on for a moment, I have to measure your BP” is that “modifying” labor?

          • C T

            There is a large time difference between the scenario you give and non-remote EFM requirements. Blood pressure measurement only takes around a minute, while the other is usually 20 minutes or more at a time, depending on when the nurse is available to help remove it. (Telemetry is a win/win for both busy L&D nurses and for laboring mothers who want to be able to move.) Twenty minutes of enforced immobility when you really want to walk, shift position, visit the bathroom, etc. is a lot different from just holding still for a minute. Walking frequently augments labor; the prevention of walking can alter what would otherwise be the natural progression of a woman’s labor.

            I honestly don’t see why you’re so strongly opposed to the idea that forced immobility is an intervention; perhaps you have a more negative view of the word intervention than it merits.

          • The Bofa on the Sofa

            I don’t see a length of time requirement in the definitions you listed, and, in particular, definition 4.

            Wouldn’t the appropriate answer be, “Yeah, but it’s just a short intervention”?

          • C T

            But it’s not an intervention if it didn’t modify anything. One minute of sitting still is highly unlikely to do anything to nearly any bodily process you can think of, so I wouldn’t classify it as an intervention under the standard definition of intervention.

            If you Google “medical intervention,” the definition of intervention can actually sometimes be far broader and would encompass measuring BP. See http://www.equalpartners.info/Chapter1/ch1_6Glossary.html:

            Medical intervention
            Any examination, treatment, or other act having preventive, diagnostic therapeutic or rehabilitative aims and which is carried out by a physician or other health care provider (Declaration on the Promotion of Rights of Patients in Europe, WHO, Amsterdam 1994).
            We’re basically just arguing semantics here.

          • AlisonCummins

            Right. Clarifying terms is important. Intervention is not another word for interference, which seems to be the way you’ve been using it.

            If you want to talk about “annoying things” then EFM was very annoying for you but not for everyone; blood pressure monitoring is not annoying for you but for some people the constriction of a blood pressure cuff is very upsetting. However, “annoying” or “interfering with me moving around” are not part of the definitions of intervention.

            Both EFM and blood pressure measurement are interventions under your definition above; neither are under the other definition I found. Neither definition includes time, sitting-down-ness or annoyingness as part of the definiton.

            So now you’ve learned something!

          • C T

            Condescending much? I’ve been specifically talking about it as an act that produces an effect on labor, not as mere interference.

          • AlisonCummins

            So now you’re saying that the medical definition of the word “intervention” has a time component? Something like “something that the patient notices or that requires the patient to sit down for at least 10 minutes if they were not otherwise sitting”?

            So unless it takes a certain amount of time, it’s not an intervention; and if the patient is already lying or sitting down it’s not an intervention.

            Somehow I think there must be a medical person here who can provide a more technical definition of the word.

          • AlisonCummins

            Here you go:
            http://www.medilexicon.com/medicaldictionary.php?t=45249
            Definitions:
            1. An action or ministration that produces an effect or is intended to alter the course of a pathologic process.

            Nope, no time element at all. Nothing in there about whether someone was already lying or sitting down or not.

            Taking someone’s blood pressure doesn’t produce an effect, it measures one. Ditto fetal monitoring. Neither are intended to alter the course of a pathologic process. They aren’t interventions.
            EFM might be restrictive and poorly tolerated by someone who needs to move, but it’s not an intervention.

          • C T

            Of course there is a time element involved when you’re talking about producing effects of any kind. Compress an intrapartum baby’s cord for 20 seconds, he’ll be fine; 20 minutes, and it’s a tragedy.
            All those nurses and doctors sending women to walk the halls are highly unlikely to be all under an unsupported mass delusion that movement or the lack thereof doesn’t affect labor at all.
            A diagnostic procedure requiring a longish period of immobility that can (not all women will respond the same) affect the course of labor is an intervention

        • guest

          Remote/telemetry monitoring would be great! Many providers are in favor of it. My unit recently looked at purchasing one unit–they cost $11,000 each! We have 17 LDRP rooms with postpartum overflow often going upstairs to peds. It’s not unusual to have 6-8 laboring women at one time (not including several outpatients in triage rooms that also need monitoring). My hospital does 1200-1300 deliveries/yr and serves a patient population that is >60% Medicaid. Unfortunately, our labor and delivery unit is a money-loser for the hospital but we’re a safety net. It’s unlikely the Affordable Care Act will change any of this. That’s just the way it is. We’ll be lucky if we can get even one remote unit, nevermind the 4 or 5 that would be appropriate

      • Elle

        From what I’ve seen of NCB, the idea is that using continuous monitoring prevents the mother from moving around, or at least makes it harder, and to them, giving birth on your back is pretty much the worst thing ever. :-P From what I’ve seen, hospitals can be very accommodating when it comes to making the monitors (and even the IV) more mobile, but that’s not good enough for many of them.

        • C T

          BTDT (4 natural births in hospitals), and it really isn’t good enough. When a woman can feel her body and wants to move, it’s sometimes quite horrible not being able to move. Just as a woman should be able to get an epidural on request, she should have the ability to move when she wants. Telemetry is available and permits both continuous monitoring and mobility. Get that in all the hospitals, and you’ll drastically weaken the strongest NCB arguments for homebirth (“the hospitals will tie you down and make you so uncomfortable that you’ll want drugs, and then the evil cascade starts”).
          I just attended a childbirth education class by a friend working on getting certified to be a childbirth educator. All the women there are planning on hospital births, and my friend basically told them repeatedly how they can/should resist various hospital procedures (she is prejudiced toward homebirth). If a woman tries natural childbirth in the hospital, is thwarted by having to remain immobile, and ends up with a scary birth story, she will be much more open to having a “healing homebirth.” The NCB movement isn’t going to go away, but maybe we can keep it in hospitals.

        • Antigonos CNM

          But you see, if EFM is used, you MIGHT just discover that you NEED to intervene, to save the baby! And that’s terrible! Ignorance is bliss. Or maybe it’s more “see no evil, hear no evil…”

  • guest

    OT – this petition in Hawaii: http://www.thepetitionsite.com/247/920/781/kill-bill-sb-no-2569-in-hawaii/
    Choice bit – the bill claims 2- to 3-fold increase in neonatal mortality for planned homebirth, but “(i)n fact is it well and widely known that international data supports the fact that planned home birth has similar if not better outcomes than planned hospital births. This is the bill that they are objecting to – legiscan.com/HI/text/SB2569/2014. It would establish a licensing system and create risk categories of things like breech and multiples that a licensed midwife couldn’t attend.
    I wish there could be a post devoted to this.

    • Houston Mom

      I read the bill you linked to. It sounds good. Would CPMs still be allowed to practice?

    • LMS1953

      Thanks for this post!
      Quote from the midwife site:
      ” There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system.” (http://www.bmj.com/content/346/bmj.f3263)

      In the US, are parturients appropriately vetted as “low risk”? Hardly. In fact, it seems to attract distinctly high risk women – breech, multiple prior uterine incisions, prolonged labor to name a few. Invariably the “variation of normal” card is played.

      Are the midwives who attend to them “well trained”? Hardly. You would be better served going to the young lady at the counter of your pet store. DEMs and CPMs in the US would not be allowed to practice anywhere else in the developed world.

      Is there a good referral system? Hardly. OBs on call are expected to promptly respond to botched intrapartum management without a hint of annoyance in the presence of patients and their midwives who typically abhor them and object to their “unnecessary” intervention often in life-threatening circumstances.

      Is there a good transportation system? Ever try to catch a cab at Times Square? Might be easy, might be hard, but it is hardly “reliable”. Now try it with an umbilical cord hanging between your legs or blood gushing out from an abruption. Moreover, many women live in rural areas miles from the closest hospital – a circumstance not typically found in the UK. Indeed, the Netherlands has crappy home birth stats despite satisfying the triad of the UK article. What is going on there?

      It seems the bill in Hawaii is merely trying to assure that triad is satisfied for home birth in Hawaii. So the midwives compare apples to pineapples and spice the dressing with claims of unconstitutionality and suppression of religious freedom and maternal autonomy. In any other circumstance they would be arrested for wanton child endangerment.

  • http://www.hfme.org/ Thy Miocena

    “Indeed, wearing a seat belt in an accident will, on rare occasions, cause greater injury than not wearing a seat belt.” Can that be applied to birth?

    • The Computer Ate My Nym

      Probably and likely in much the same way. For example, there really is a risk of infection and medication error in the hospital that might endanger a perfectly healthy labor and delivery. And analgesics do have risks. I know of one woman who had an epidural and had an unfortunate reaction (her BP went down and caused her to have hypoxic brain injury) during an otherwise normal delivery. She would likely have done ok at home.
      The risk of something like that happening is much lower than the risk of something bad happening at home, but people are particularly nervous about risks taken to prevent other risks (Dr Tuteur did a post on this a while back using the analogy of a smoke detector with a greater ability to detect fire-but a small risk of starting a fire) and so often rate the risks of being in the hospital much higher than the risks of being at home, even though the absolute risk of being at home is orders of magnitude higher.

  • http://www.hfme.org/ Thy Miocena

    Check on this petition. https://www.change.org/petitions/saskatoon-health-region-remove-ban-on-midwife-support-for-home-birth-after-caesarean-hbac

    “A public policy banning midwife support for HBAC puts a limit on
    women’s right to choose the circumstances in which they give birth, thus
    violating their basic human rights.”

    It sounds pretty reasonable to stop preventable deaths from homebirths actually. Why do homebirthers put in so much energy to advocate for something that kills women?! I believe all women have a human right to evidence based medicine, not to hurt themselves in evidently dangerous practices. Women should be prevented from harm, I don’t think those who seriously think homebirth is better are mentally in a very good place. It shows a scary lack of critical thinking. I don’t consider it paternalistic to tell a woman people who went to medical school know best.

    • Antigonos CNM

      A consistent theme in US midwifery is the desire to be allowed to do procedures which doctors are licensed to do and which European certified midwives do not do. Before I went to the UK in 1974, I remember reading angry articles by American midwives who could not see any reason why they could not be permitted to use outlet forceps. They chafed at the concept that they had a particular sphere of action, and doctors had theirs. So it does not surprise me that US midwives think that accepting such high risk patients as HBAC candidates is perfectly within their competence. The idea that caring for high risk women without being under OB supervision is NOT a midwife’s function seems to have completely eluded direct-entry US midwives.

      • Dr Kitty

        There is the “you broke it, you better be able to fix it” reason why MWs don’t do certain things and OBs do.

        If the solution to a complication requires operating, and you can’t operate, for example.

        If you’re not the one actually cleaning up the mess, you can get quite gung-ho about what you do.

    • Mel

      Personally, I’d rather attack the home-birth problem from the midwives than from the patients. A pregnant woman has the right to choose how she wants to give birth. She is free to choose any attendant she wants. Women will make choices I think are bat-shit crazy, but in the US, they are well within their rights.

      The midwife, on the other hand, is performing medical procedures without proper training, without peer or governmental oversight and doing it for money.

      If midwives want to run with the real medical professionals, then they need to act like professionals. Make a plan to phase out CPM/DEM initial certification within 2 years. Require all CPM/DEM’s to be certified in infant/child CPR annually. Have all CPM/DEM’s file plans to accepted into a RN program within 2 years with extension options of 2 1-year periods. Anyone who’s not in a RN program and making adequate progress towards graduation within 5 years has CPM/DEM credential stripped.

      We managed to pull something similar to this for teachers in Michigan between 2000-2005 to get everyone to highly certified status under NCLB. Of course, teachers care about teaching. I don’t know that many or most direct-entry midwives care enough about saving moms and babies to do this.

      • Young CC Prof

        Good plan! But they don’t need infant CPR, they specifically need neonatal resuscitation, which is rather different than CPR on a baby who has previously used his lungs successfully.

  • Squillo

    Don’t forget Cheng et al., 2013, ”
    Selected perinatal outcomes associated with planned home births in the United States,” which also found that planned homebirth had higher rates of Apgar < 4 and neonatal seizure. One of the co-investigators on that one was a well-known CNM.

    • http://shameonbetterbirth.wordpress.com/ Shameon Betterbirth

      What is astounding to me about these numbers is that homebirth midwives are trusted to accurately report these numbers when they should not be. They will literally sacrifice anything to the cause of midwifery and probably fudge their numbers and apgars all the freaking time, and it STILL looks horrible for them.

      • Antigonos CNM

        Homebirth midwives, since they aren’t under any legal requirement to keep complete records [or any records at all, really] in the US, would probably fudge or omit such extreme outcomes except that most of these cases wind up in hospitals and can’t be hidden. A baby who arrives dead, or needs NICU and/or ventilation is a statistic, even if the parents attempt to hide the fact that it was a midwife-only attended homebirth. The outcomes where the baby only begins to breathe after long enough to suffer some hypoxic damage, but does eventually pink up and so no one calls 911 are the outcomes which fall under the radar. And, until Johnny shows significant developmental delay, or can’t read in third grade, do the parents even begin to think that the circumstances of the birth might be relevant.

        It would be instructive to have long-term followup, but it would be impossible to arrange [this was done in the UK, btw. All babies born, whether at home or in hospital, during a particular week of a particular year --forget when, exactly-- were literally followed by the NHS until they were 18 years old. The results were very interesting] in the US.

        • OBPI Mama

          When I switched from my midwife to my doctor, I asked for my records from my birth with my first son… that way, the doc could see them and be watchful or whatever with my 2nd son… what did the midwife give me? 1 purple sheet (for a 30 hour labor) that said how long I labored, transition length, and the injury to the baby. With a little note at the bottom about how wonderful I had been during a tough labor and a smiley face. Yep. I am still upset about that as I would have liked to know the exact details of her ignorance.

          • OBPI Mama

            Forgot to add: Midwives can not be trusted to tell the whole story with the bad births.

          • anion

            Aw, you got a smiley face! Was she out of gold star stickers?

          • OBPI Mama

            I was a “good little NCB” who endured 30 hours of labor, 4-1/2 hours of pushing, severe tearing (had to go in to get stitched up), a broken tailbone, AND an injured baby and still sung the praises of my midwife… I should have gotten the gold star sticker, dern it all! Now I feel cheated, anion.

          • Certified Hamster Midwife

            I hope this helps.

          • OBPI Mama

            haha! That totally trump the smiley face! Homebirth Trauma Flashback solved. I still remember my OB’s face when I handed him that damn purple sheet of paper. I was still in the Homebirth Cult then (even though I was about to be a c/s mama), but now I can only imagine his thoughts as he read it…

          • anion

            So it’s a Healing Gold Star, then. :-)

  • LMS1953

    Most of the ethics concerning the choice of home birth centers on the primacy of autonomy. A woman has a right to choose. But with Obamacare, the ethics has shifted to the primacy of utilitarianism. There, it is the primacy of doing the most good for the most people. You want a home birth for performance art sake. NO YOU CANT (who would have thought we would have been FORCED to buy a product ?) No ma’am. We will spy on the conversations between you and your midwife and if we have reason to believe that you intend on a home birth we will kick your door down in the middle of the night and drag you kicking and screaming to jail where we have installed a delivery cubicle and you will be incarcerated until you deliver. We are not about to burden “the middle class” with an 18 fold increased chance of you delivering a defective child due to your stupidity and narcisisim. That is the ethics of the Brave New World we are entering. Grab a chair and get comfy, it is going to be a long ride.

  • LMS1953

    I guess nobody has read the Obamacare Law. On page 32,941 it specially says home birth is banned.

    OK, seriously, consider this: a couple of years ago Vermont mandated that their Medicaid pay providers (non-professional Certified “Professional” Midwives = CPMs) for home birth. They also mandated that BC/BS pay for that too. Fine, said BC/BS, we will, as long as they are on our provider list. And to do that, they have to have 1) a written transfer protocol and agreement with an obstetrician with hospital privileges and 2) malpractice coverage- B-b-b-but malpractice coverage is expensive and we can’t afford it. Well, Missy, join the club – it’s tough all over. Maybe your Libturd buddies could have supported tort reform instead of kissing trial attorney butt 24/7.

    Now, contrast that with the 39 week 0 day rule. Several states have instructed their Medicaid office to review OB charts and if an elective induction is found to have been done prior to 39 weeks 0 days they will recoup (ie, steal) the paultry payment and if such a pattern continues they will issue sanctions against the provider and the facility. Why such a draconian measure? Well, you see, babies born in the 38th week have a slightly increased risk of transfer to the NICU and the state has an interest in saving that expense. Mind you, the state does not figure in the emotional cost of the quadruple risk of still birth for babies who try to make it to 39 weeks and are NOT born in the 38th week. Oh well, says the state, one less mouth to feed.

    So here we have the state on the other hand doing its damnedest to facilitate home birth which has an 8 fold increase in neonatal mortality (again the one less mouth to feed argument may apply) AND an 18 fold increase in hypoxic newborn brain injury. ALL of those babies have to go to the NICU often for very extended stays. And then many have tens if not hundreds of thousands of dollars of cost of a lifetime of disability (lost earning potential, added medical expense, etc). I guess Obama and Sebellius can make the Affordable Health Care Act more affordable by denying such care to these unfortunates to get them to die young and wipe them off the slates completely – the burden of keeping them alive to age 18 to glean another Democrat vote deemed not “cost effective”. If you think I’m kidding, please recall the 12 year old girl with cystic fibrosis for whom Sebellius initially denied a lung transplant.

    Abject hypocrisy ….

    • http://shameonbetterbirth.wordpress.com/ Shameon Betterbirth

      I read a presentation from a home birth midwife here that said obamacare could ‘make or break’ them. I am glad they weren’t organized enough to convince the federal government that they deserved reimbursement for their services. Now that there are some common sense standards on insurance cost will no longer be a factor in if midwives can prey on the less fortunate.

      • The Bofa on the Sofa

        I can imagine that the ACA would cause a problem. If everyone has healthcare insurance, that means there won’t be those who choose HB because it’s cheaper, since their hospital birth will be covered by their insurance.

        • Guest

          In some states OOH birth is covered by insurance. My birth center birth was covered by BCBS at 80%, so I paid about $1000 out of pocket. But I agree, I think in most states it’s not covered by insurance.

          I wonder what portion of women are choosing to pay for OOH birth in countries with universal health care.

          Btw, WHY are insurance companies covering OOH birth? They have the stats to know it’s not safe and a profit motive to boot.

          • The Bofa on the Sofa

            I know that SOME insurance companies will cover it, but as noted, most won’t. And we absolutely hear about people choosing a HB because it is cheaper.

            LMS’s comment above about the insurance company being willing to cover a HB if the provider is in network, which means that she satisfies the network provider requirement is pretty much what I would expect. In particular, they aren’t going to take a chance unless the provider has their own malpractice insurance, so that they can recoup the costs due to malpractice. Otherwise, the health insurance would have to pay for it.

            I would expect nothing less.

          • Guest

            In Canada where we have Universal Health care, the midwives are covered whether you have a hospital birth or a home birth. So we don’t pay anything out of pocket if we choose a home birth. In fact, you can’t get a private midwife in my province (not sure about the others). It would be like practicing medicine without a licence.

          • The Bofa on the Sofa

            What do the mws have in terms of liability insurance?

          • AlisonCummins

            The context for liability insurance is different in Canada because everyone gets the same level of health care and services independently of what caused them to need them in the first place. For specifics:

            http://www.loc.gov/law/help/medical-malpractice-liability/canada.php

            One other feature of Canadian law that tends to discourage parties from suing physicians for malpractice is that the Supreme Court has set out guidelines that effectively cap awards for pain and suffering in all but exceptional cases. In a trilogy of decisions released in 1978, the Supreme Court established a limit of Can$100,000 on general damages for non-pecuniary losses such as pain and suffering, loss of amenities and enjoyment of life, and loss of life expectancy. The Supreme Court did state that there may be extraordinary circumstances in which this amount could be exceeded, and courts have allowed the figure to be indexed for inflation so that the current suggested upper limit on awards for non-pecuniary losses is close to $300,000. Nevertheless, the flexible cap on non-pecuniary losses is a major disincentive to persons considering whether they should sue a physician for malpractice and for lawyers to specialize in or seek out malpractice cases.

            The Supreme Court of Canada has also limited the types of cases in which punitive damages may be awarded, although it has allowed as much as Can$1 million in punitive damages in an extraordinary case.

            This specifically covers physicians, but I expect that liablility insurance for midwives is similar and would not be unimaginably high.

    • http://www.hfme.org/ Thy Miocena

      That was a smart move to ban it. Women is the US deserve better.

      • Young CC Prof

        LMS1953 is being sarcastic (or possibly just paranoid.) There is no law against home birth, and I very much doubt the Affordable Care Act mentions it at all.

    • rh1985

      I hate that stupid 39 week rule. On my due date club there’s a woman whose doctor wants to induce her now (38w0d), but because of that rule, he had to admit her to the hospital until it gets bad enough to justify a 38 week induction. Which I think is ridiculous. At least he had he admitted so the baby can be delivered right away if things go really wrong but I think it is so absurd to not allow a 38 week baby to be delivered for medical reasons because it’s not enough of an “emergency.”

  • Bombshellrisa

    OT: my baby boy was born last Wednesday!! He was a little early at 35w5d but he is doing well and home with us. 5 lbs 13 ounces, 19 inches long.

    • Box of Salt

      Congratulations to your whole family!

    • Meerkat

      Congratulations!

    • amazonmom

      Congrats!

    • Young CC Prof

      Congratulations! Glad he is thriving despite his early arrival!

    • http://whatifsandfears.blogspot.com/2012/12/the-business-of-being-misled.html Doula Dani

      Congratulations!!

    • theadequatemother

      Congrats! That’s almost the same wt as my full term 1st born.

      • mollyb

        Mine too! 5 lbs 14 oz full term. Little peanuts!

      • Young CC Prof

        Bigger than my 37-weeker (4 pounds 15)!

    • Mishimoo

      Congratulations! Good to hear that he’s doing well despite showing up early!

    • Josephine

      Hooray! Congratulations!

    • Sorin

      Congrats! I had a 4lbs 8oz 35 weeker who is now a strapping 7 month old. According to the doc, he’s doing “developmentally awesome,” so know that being born early doesn’t necessarily mean any kinds of delays. Enjoy that little guy!

    • Sue

      Welcome to mini Bombshell!

      • Antigonos CNM

        Is a mini Bombshell a Squib?

    • Siri

      Congratulations!! Did the birth go well? Have you named your little mannie? Xx

      • Bombshellrisa

        I got to the hospital after my water broke but I didn’t think I was having contractions ( so much for “mama knowledge”!) and found out I was dilated to nine. Things were short and sweet. The nurse and doctor (hospitalist) were the only people in the room besides my husband (the team came in right after the birth). It was peaceful and everything was fine with my son. When they put him on my belly and I saw him, what a moment! He looks exactly like my husband, something the entire team of doctors and nurses commented on. It did take me four days to settle on a name. We had to observe him first.
        He is such a sweet baby. I am so blessed.

    • Antigonos CNM

      Mazal tov!

    • anion

      Congratulations, wonderful news!!

    • Dr Kity

      Congratulations! I hope the little pickle is behaving himself and that you’re able to get some sleep.

    • Ainsley Nicholson

      Congrats!

    • http://Www.awaitingjuno.blogspot.com/ Mrs. W

      Congratulations!

    • fiftyfifty1

      Thrilled for you! Congrats!

  • anion

    And these same women who are willing to bet the lives and health of their babies against such enormous odds, then refuse to allow those children to be vaccinated because of the “risk of autism” (I know there is no risk and that theory is utter bunk, I’m just discussing their thinking on the subject).

    • Elle

      Many of them are, at least the ones I know.

  • mostlyclueless

    Thanks for the thoughtful summary. This seems a very apt analogy to me; I wonder if it has been responded to by the NCB crowd?

    • fiftyfifty1

      Yes, their main response is that we shouldn’t pick on homebirth because every activity has some level of risk that can’t be mitigated and if we spend too much time dwelling on risk we will end up leading pathetic lives where we decide never to have children at all and refuse to ride in cars at all. Basically that since life is not 100% safe we should throw up our hands and resolve to do whatever we please without worrying about safety. The motto they use to try to sum up this poor logic is “Birth is as safe as life gets”.

      • Young CC Prof

        Treating a trip to the park like a disaster waiting to happen is unnecessary and possibly evidence of a mental health issue. Treating birth like a disaster waiting to happen… fairly reasonable.

        Like I always say, there are some risks that you genuinely can’t do anything about. There are others which are remote and can be mitigated only at great cost. But some disasters actually can be prevented fairly easily, and there’s no reason not to try.

      • Captain Obvious

        Did Justin Beiber say that?

      • Lisa Murakami

        Not every choice merits a Kumbayah. There’s a reason there are laws about seatbelts.

  • Trixie

    I’ve spent a lot of time on car seat forums, and you wouldn’t believe how many of them think home birth and not vaccinating are great ideas. But they’ll shame people for boostering a 40 lb 5 year old instead of keeping him harnessed even though there’s no evidence that one is safer than the other.

    • rh1985

      Yeah, unfortunately some take it too far. Like considering new cars to keep four year olds rear facing.

      • Trixie

        Which, if you’re going to be wacky about something, assuming you can afford it, is certainly less harmful than these same people’s decisions to HBAC or put their kids on weird restrictive diets for imaginary yeast infections.

      • Siri

        You must be next now, surely? (Yes I know it’s OT but we’re talking about the next new baby on this forum!!). Ooohh, exciting!

        • Vyx

          I hit 31 weeks today. Things are certainly moving along.

        • rh1985

          February 27 due date. Hoping for a little earlier though…..

      • R T

        I don’t think that’s taking it too far. In Sweden it would be weird not to try to rear face until 4. It is safer! We have the money to take in to consideration how long a particular vehicle would support refacing so its an important criteria! Even if we didn’t have the money I would try to find it! If I can rear face my son until 4 years of age I would be thrilled. He’s really tall though so probably will have to turn him before 4. Unless they built a taller carseat in the US before then. They may since extended rearfacing is beginning to catch on here!

        • AlisonCummins

          Right, so your son is rear-facing until his fourth birthday. But rh1985 is talking about people buying larger cars so that they can have their children continue to be rear-facing after their fourth birthdays.

          • Certified Hamster Midwife

            How big a car do you need to keep your kid rear-facing after they turn 16?

            …I’m asking for a friend. Whose kid just turned 16.

      • Certified Hamster Midwife

        By current standards I would have been in a booster seat until I was in my teens. I’m all for safety, but what the hell.

        • Trixie

          Once you hit puberty though, your bones, especially your hips, are better able to take crash forces with just a seatbelt, even if you’re technically still too short to ride without a booster. There’s actually a new product on the market for this purpose, called the Dorel Incognito. It has a low profile and blends with the car interior, so it doesn’t look like a booster, but still positions the lap portion of the belt properly.

    • R T

      To be fair, the odds of dying or being injuried in a car crash are much higher than being killed or injuried during a homebirth or killed or injuried from not vaccinating in the US. Car crashes are the leading cause of death for children of any age in the US. 260,000 children die in car crashes and 10 million are injuried worldwide.

      • The Bofa on the Sofa

        If you did anywhere NEAR as many homebirths in a year as you spend driving, it wouldn’t even be close.

        The risk of car crash is not in the risk, it is in the prevalence of driving.

      • Young CC Prof

        See my math on today’s post. Home birth is worse than driving your kid around for his/her entire childhood. With or without a seatbelt.

      • Trixie

        The odds of dying from not vaccinating are only so low because almost everyone vaccinates. As far as dying in a home birth, that’s true mostly because there are so few home births across the population.

    • Certified Hamster Midwife

      There are car seat forums?

      That’s it, I’m having myself sterilized.

      • Trixie

        Almost everyone who uses a car seat is doing it wrong. It’s good to have places on the internet to go and ask questions about what seat to buy, how to get 3 seats across your back seat, etc.

  • Lisa

    THE CHILD IS FORWARD FACING! REAR FACING IS 5X SAFER!!!!

  • http://shameonbetterbirth.wordpress.com/ Shameon Betterbirth

    is anyone else getting audio ads when they open this website?

    • Antigonos CNM

      I’m not.