The American College of Nurse Midwives prepares to throw ethics to the wind

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I’ve been wondering about the professional ethics of the American College of Nurse Midwives for years. Although they are well aware that American homebirth midwives, CPMs, LMs and DEMs are substandard practitioners, (even acknowledging it within their own publications), they have repeatedly allied with them. I’m not sure why they don’t see that it is harming their own reputation, but apparently they operate by the theory that “the enemy of my enemy is my friend.”

So their professional ethics have been suspect from the get go, appearing as it does that the ACNM values professional autonomy over the lives of babies and mothers. That impression of professionally unethical behavior was strengthened when the ACNM came out with a bald faced lie about the reliability of birth certificate data to support MANA in claiming that homebirth is safe when MANA showed quite clearly that it is not.

Now comes word that the ACNM is preparing to go even farther in unethical behavior. A new memo alerts CNMs that their organization “disagrees” with the American Academy of Pediatrics Committee of the Fetus and Newborn and the American College of Obstetricians and Gynecologists that waterbirth poses deadly risks to babies.

Are we really supposed to believe that a bunch of certified nurse midwives knows more about neonatal physiology than a group of neonatologists and perinatologists? Maybe ACNM believes it, but no one else will. Are we really supposed to believe that CNMs care more about whether babies live or die than the people who actually care for and save the lives of those babies? I doubt even the ACNM believes that. But what they apparently do believe is that waterbirth is their “turf” and just because a bunch of babies died from inhaling birth pool water contaminated with feces, or died of hemorrhage because their umbilical cords were torn off as they were lifted from the pool, is not reason enough for them to tell the truth about waterbirth.

The ACNM set out a memo to its members this morning:

ACNM believes this document does not accurately reflect the large and growing body of research that supports water birth as a reasonable choice for healthy women experiencing normal labor as well as birth.

What large and growing body of research? The ACNM doesn’t say.

Most water births occur under the care of a midwife and it has been a safe option for decades that provides comfort with good outcomes for the mom and her baby.

No one said otherwise. Most of the time giving birth in water, despite being non-physiologic and despite being dangerous, will end fine. But, of course, most of the time not buckling your infant into a car seat will end fine, too, yet we don’t say to mothers that if not buckling their infants into car seats improves the mother’s experience, she doesn’t need to use a car seat. Our babies are precious to us, and we want to mitigate risks of death, even when those risks are small.

However, this new ACOG/AAP opinion statement cautions about immersion in water during the second stage of labor. These cautions are similar to those in their prior publications, including warnings about a lack of data on the safety and benefits of water birth. The organizations refer to case studies of adverse outcomes, but case studies are not a reliable form of research, and should not be the foundation for their conclusion—that water births should only be considered as part of “experimental” clinical trials.

Case studies are generally the first warning sign that a medication or procedure is dangerous. For example, the companies that made a certain type of artificial hip presented a number of studies demonstrating the benefits of their new hip. The device was introduced into clinical practice based on those studies. It wasn’t until doctors began reporting unusually early failures of the device that both patients and physicians were alerted to the high failure rate of these devices.

The ACNM is either disingenuous or uneducated about the value of case studies in exposing unusual risks that occur unexpectedly when new medications, devices or practices are introduced.

Despite limitations, the best available research indicates that water birth is associated with perinatal outcomes similar to those expected in a low-risk population. In other words, healthy women and their babies generally stay healthy during and after normal labor and water birth. Therefore, water birth is a reasonable choice for healthy women to make in collaboration with their care provider, given the state of the science.

All you have to do is ignore the dead babies and you can keep recommending waterbirth!

The ACNM should be ashamed of themselves. They are placing their turf battles above the lives of babies who didn’t have to die. They are no different from Big Pharma who, when faced with case reports that a blockbuster drug has unexpectedly killed people it was supposed to benefit, insists that “their” safety data shows that the drug is safe and tthat no one needs to be warned about any risks.

Maybe things have changed since I practiced for years with dozens of CNMs. Those women cared just as much about babies as I did. They were highly educated, highly trained, and scientifically rigorous. Maybe I am naive, but I can’t imagine a single one caring more about her turf than about providing accurate information to mothers so they could make the choices that were right for them and their babies, not the choices that were advantageous for midwives.

The current leadership of the ACNM is apparently different:

Additional information will be forthcoming to members in the coming weeks to further support our collective efforts to maintain women’s access to water birth under appropriate conditions. These include:
• An official ACNM position statement on Hydrotherapy During Labor and Birth
• Articles to be published in an upcoming issue of JMWH
• ACNM’s official response to the ACOG/AAP committee

I can’t speak for others, but for me whatever the ACNM has to say is going to be ethically suspect. I don’t believe that they have even a tiny fraction of knowledge of neonatal physiology as neonatologists and perinatologists so their opinion is pretty worthless. And unlike neonatologists and perinatatologists who have no plausible reason to inflate the dangers of waterbirth, CNMs have an utterly self-serving reason to dismiss those risks; their desire to hold on to “turf.”

The ACNM commitment to “normal birth” and their cavalier willingness to dismiss babies who die at waterbirth reflects their preoccupation with processes that they can control and their demonizations of skills and procedures that are beyond their their education and training. But caring for women in childbirth is not supposed to be about process; it’s supposed to be about outcome, a healthy baby for a healthy mother.

The truth about waterbirth threatens CNMs. They’d rather suppress that truth and threaten babies lives.

  • Ash

    I wish this blog would go back to the old format…currently everything for me is on 1/3 of the page, and I previously had the black/white issue on comments fixed with Greasemonkey.

    • Amy Tuteur, MD

      A web designer is working on it at this very moment. That’s why there are new problems.

  • recovered NCB advocate

    Wow… a physician friend linked on FB to this blogger’s post on car seat safety, and I was ready to share… until I saw the title of her previous post, “Saying ‘Yes’ to a Home Birth.” http://www.candiedchaos.com/ 2014/ 02/ saying-yes-to-a-home-birth/ (I’m breaking the link on purpose.) Seems like a prime example of how women who are not committed ideologues can be led into this decision believing it’s, well, basically as safe as birth gets. Reading the post, you can see she’s not cavalier about safety in pregnancy and birth, either.

    • recovered NCB advocate

      Oops, I should have broken the main blog link, too. I’m not necessarily suggesting anyone from here go try to change her mind, or looking to antagonize anyone.

  • http://www.antigonos.blogspot.com/ Antigonos CNM

    I am pretty much staying out of this one, because I’m not practcing as a midwife in the US any more and I have very little sympathy with the attitude that there’s anything wrong with being “just” a midwife — something I’ve repeatedly heard from some of the CNMs who feel they have been overeducated for simple deliveries and look for additional responsibilty. That, and the sad fact that the whole nursing profession has been becoming more and more woo-oriented, seemingly unable to distinguish between pseudo-science and real science. IMHO, it’s no wonder the ACNM is also having a problem making the distinction if its members can’t. And I think a lot of the blame for that lies with the conflation of a lot of “padding” courses added in order to make a Master’s program (leading to a CNM) seem full of content. I remember At Your Cervix listing her courses and my teasing her, but it really was absurd, the amount of nonsense she had to plow through before she began the “hardcore” midwifery stuff–fully two years’ of “problem solving skills” and “communication” courses, along with learning how to set up and finance a birth center. BTW, AYC seems to be doing more office GYN these days than delivering babies, and I think she is finding this surprising.

  • Sue

    They appear to misunderstand the role of case reports.

    Individual case reports are generally of no value in distinguishing association vs causation.

    This is not the case, however, for directly observable phenomena.

    In a single case where a neonate inhales contaminated water from a waterbirth pool, there can be no doubt about causation.

    See the difference, ACNM?

    • Dr Kitty

      What about the single case report of the guy who ingested H. pylori and developed PUD?
      http://discovermagazine.com/2010/mar/07-dr-drank-broth-gave-ulcer-solved-medical-mystery#.Uy_grOcgGK0
      It lead to more research, but, by itself was quite compelling evidence.

      It was case reports that lead to the discovery of the link between Thalidomde and birth defects, case reports that lead to the discovery of a link between Rubella and birth defects..

      You DON’T need RCTs if you have enough evidence of harm from case studies.
      We know, for example, from case studies of rare situations where parachutes fail to deploy that such failure leads to deaths.
      As yet there have been no RCTs on parachute vs non parachute sky dives.
      http://www.bmj.com/content/327/7429/1459

      • Sue

        Yep – I’d say the parachute failure would qualify as ”directly observable phenomena”!

        The anti-vaxers always want to argue case reports, with no evidence of causation. If the case reports lead to good quality research (like the H pylori), then causation can be shown. (It’s instructive that the H pylori proponents didn’t just rely on their hunch and whine when everyone doubted them – they went about producing the evidence).

      • Medwife

        The few case reports of naegleria fowleri transmitted by tap water neti pot uses has me sworn off neti pots. (Granted this was New Orleans tap water, but still)

        • Young CC Prof

          Of course, if you want to rinse your sinuses, there are ways to do it while completely eliminating that very remote risk. Like buying the giant spray bottle of sterile saline for $5.

  • Sue

    Hmmm….wonder what their NICU nursing colleagues think…

  • VeritasLiberat

    OT but we were discussing Kate Middleton a while back. Those who hoped she had a waterbirth with midwives must be disappointed:

    Prince William Knights Kate Middleton’s Ob-Gyn

    http://magazine.foxnews.com/celebrity/prince-william-knights-kate-middleton%E2%80%99s-ob-gyn?intcmp=HPBucket

    • Trixie

      Well, when the entire point of your existence is to be a professional incubator, you don’t want to leave it to chance.

      • Zornorph

        That’s really harsh.

        • Trixie

          And accurate.

          • Certified Hamster Midwife

            Harsh! She is also allowed outside sometimes to wave at people and have flowers handed to her.

          • Trixie

            It is a bit harsh, I suppose she’s also responsible for having nice hair, and waving, and being attractive.

          • Certified Hamster Midwife

            But also being criticized for having hair that is too nice, or at least too long.

          • Trixie

            She can always cry in her piles of sapphires if the criticism gets to her.

          • MLE

            Has she been displaying an entitled attitude? I always thought of her role (and Diana’s, etc) as official do gooder. She still has a long career ahead of her.

          • Elizabeth A

            Yeah, I haven’t noticed her being particularly entitled at any point. She has a very public position, and seems pretty down to earth. I could not smile so reliably for ubiquitous cameras, and she always seems game for things like running around with a hockey stick while wearing heels.

          • Trixie

            Well, after they breed her, they’ve got to come up with something else for her to do. She’s a tourist attraction.

          • MLE

            I would agree, if this were some kind of arranged marriage to two countries’ mutual advantage instead of what appears to be a relationship that has stood the test of time. As for breeding, she is not exactly a spring chicken reproduction-wise, and while they BOTH probably felt pressure to produce an heir, many women her age feel pressure to get pregnant as well since the clock is ticking. She’s in a relationship with a man whom she appears to love, but her every move is representative of that family and the country at large. That is a lot of responsibility for a mere sock puppet. She doesn’t seem to be affected by any criticism or to be feeling sorry for herself in any way. I think the idea of a royal family is as ridiculous as the next person, but I’m not sure why she’s the particular object of your contempt.

          • Hannah

            Yeah. I don’t get the contempt, here. I am a Republican as an Australian and I still don’t get it.

            It’s not like she even has to be a breeding machine anymore. The heir doesn’t have to be a boy (had she had a girl) and modern obstetric improvements mean that she doesn’t need to have 8 heirs in order for 2 to reach adulthood (hurrah).

            My husband would not have married me if I didn’t want kids, preferably biological if it allowed, because he wanted kids and if that was missing in me I wouldn’t have been the right person for him (and vice versa). Doesn’t make me a breeding machine.

            I too think the whole idea of royalty is completely ridiculous, especially in a modern nation, but I don’t quite get this level of snark about her.

          • prolifefeminist

            Is it not possible for you to trash the existence of a monarchy without singling out and trashing a particular woman?

          • Comrade X

            Thank you, prolifefeminist. I am a republican (not in the US sense, in the sense of anti-monarchist) and a communist, and I find the personalizing of these issues both grossly offensive and utterly irrelevant.

            I know that some of you are just trying to parody what you believe to be the Royal Family’s attitudes towards wives/heirs. But language that dehumanizes women and compares them to livestock or objects (unless you’re being VERY OBVIOUSLY SATIRICAL) really turns my stomach.

          • prolifefeminist

            ^^^ yes, this!! Thank you, Comrade X. I truly detest language that dehumanizes anybody, especially a member of a group that has been and continues to be oppressed.

          • RebeccainCanada

            Agree this is such offensive language. Just because some only see her value/position as an incubator, ultimately suggests that women are incubators unless they do something “truly important” which is subjective beyond that. Again, you are defining women as vaginas unless they do something worthy enough? This is so dehumanizing and a disgusting elitist attitude. I think being “just a mother” is important. Being “just a mother” to someone with status is only valuable if you have a real career also? Maybe she married him because she loves him. Maybe she had a baby because she wanted to. Maybe mothers are worth something?

          • Trixie

            I’m saying that the point of her position is, at its core, transactional. Which is fine, she signed up for it.

          • RebeccainCanada

            Who says? Maybe that’s just your own projection? Who says they could have even conceived? Maybe she married him because she loved him despite the position.

            I didn’t sign up for my dh’s family, I married him for him despite his student status and despite his family.

          • Rebeccajnkmt

            Discuss is losing my posts. But I disagree.

            I married my dh because I loved him, despite his status as a working student, and despite his family. I accepted some of these things, but signed up for a marriage and reserve the tight to determine that marriage, between my dh and I. So does she.

            Some could say any marriage is transactional. I say it reduces people’s motives to a base and animalistic meaning. It’s very much dehumanizing.

          • Trixie

            Her husband is equally an object with no real purpose in life but to smile and waive and breed. I wasn’t singling her out based on gender.

          • prolifefeminist

            I didn’t say that she personally is oppressed, but she is a woman, and women worldwide are an oppressed class. You can say all you want that you didn’t single her out based on gender, but you did – you compared her to livestock being bred and said things like “when the entire point of your existence is to be a professional incubator.” Would you have said that about her husband? I think not.

            Also, who are you to say that either of them have “no real purpose in life”? Sure, the monarchy may have no other purpose for them, but then why not say that instead of declaring it yourself, as if you agree with it? Unless you also think that their only worth lies in their breeding ability.

          • Trixie

            Well, she’s the one who gets pregnant, and she was the subject of the OP link. So yeah, she’s an incubator for the royal blood line. Which she signed up for! Of her own free will! I’m saying that their only professional worth, the only reason anyone still bothers to keep them around and finance them, is to project a certain image and carry forth a supposedly noble ancient blood line.

          • prolifefeminist

            And I’m not arguing that that’s why the monarchy keeps them around – but can’t you trash that without singling out and trashing actual people, comparing them to livestock? Especially women, who are trashed enough already as it is?

            Anyway, who the hell knows – maybe she signed up for this life because she actually loves the guy. Who knows (or cares, really).

          • Elizabeth A

            Thanks from me too.

            I can agree that the whole idea of a royal family is crazy, and the attention paid to these people (which results entirely from an accident of birth) is mystifying. I am, nonetheless, unwilling to participate in the dehumanization of the individuals involved.

            Both William and Kate have been co-opted to perpetuate a system they did not create, and then are both beneficiaries and victims of that system. They get astounding amounts of privilege and gobs of inherited money, but they also get no private life to speak of.

          • SuperGDZ

            For a while she was getting thinner and thinner and her hair was getting bigger and bigger – she was like Cousin It in the Addams Family.

    • EllenL

      When the Queen’s granddaughter, Zara Phillips Tindall, gave birth to baby Mia on January 17, she had a planned epidural.

      From The Telegraph:

      The 32 year old told the magazine (Hello Magazine) that
      she had an epidural when she gave birth on an NHS ward. She had decided in advance that she wanted an epidural “rather than try and fight the pain.”

      http://www.telegraph.co.uk/news/uknews/theroyalfamily/10657810/Zara-and-Mike-Tindall-sell-pictures-of-baby-Mia-to-Hello.html

      • Dr Kitty

        This would be Zara Phillips, Olympic equestrian, married to former English Rugby player Mike Tindall. Neither of them are strangers to sporting injuries (hello, have you seen his nose?eight breaks and counting) and I imagine neither of them consider pain to be a moral good.

  • Trulyunbelievable2020

    OT: Cynthia Mosher of Mothering.com knows about as much about the law as Jan Tritten knows about the physiology of pregnancy. Here’s my latest post, which should be around for about the next five minutes:

    [CYNTHIA MOSHER'S QUOTE ABOUT DELETING A THREAD ABOUT GAVIN MICHAEL'S DEATH]
    “I think you are referring to the thread about Jan Tritten. That thread did not give the name of the infant. It was placed to make accusations against a midwife and others too. We do not host such accusations – at all. They are clearly a legal liability which I think everyone here can appreciate… It is a huge liability concern.”

    I don’t “appreciate” your “clear legal liability,” since there is none here. The law in the United States could not be clearer: an internet forum has no liability for libelous or defamatory statements made by third parties. Please see section 230 of the 1996 Communications Decency Act. Nor is there any threat that MDC could be forced to pay a judgement issued by a foreign court, since the SPEECH Act of 2010 prevents US courts from enforcing foreign libel judgements concerning statements that would not be libelous under United States law (so-called “libel tourism”). As long as the operators of the site are not themselves making defamatory or libelous statements, they have no liability.

    In any case, this is all irrelevant, since a truthful statement can never be treated as libel or defamation under American law. There is zero doubt that Jan Tritten and her enlightened colleagues don’t know how dangerous it is for there to be zero amniotic fluid. This was all documented on her publicly accessible Facebook page. Nor is there any real doubt that Christie Collins was the midwife responsible for this baby’s death. Are we seriously supposed to believe that she’s allowing such a serious false claim to stand unchallenged on multiple websites without uttering a peep?

    So this isn’t even remotely a legal issue, but an ethical one. And it couldn’t be clearer that you’re more concerned with protecting the reputations of incompetent and ignorant practitioners than you are with babies needlessly dying. You immediately delete references to the shocking ignorance and incompetence of supposedly respected midwives and yet you have no problem allowing posts to remain on the site and in the archives that present extraordinarily dangerous and inaccurate advice. How many posts are included in the archives that refer to breech as “a variation of normal?” How many posts tell women that putting garlic in their vagina will prevent the transmission of GBS?

    You have absolutely no problem allowing these posts to stand by pointing to your disclaimer that no “medical advice” is given here, despite the fact that it’s obvious to anyone with two working brain cells that this is precisely what goes on here.

    I really don’t know what I can say about a person who is more concerned about protecting the reputation of incompetent providers than she is about disseminating information that has and will continue to cause the deaths of babies. I can only hope that if you actually understood what you are doing here you’d be deeply ashamed.

    That’s all for now. Sorry for “trolling,” by which I mean presenting accurate statements.

    Namaste.

    • wookie130

      Love it. LOVE IT. I predict the reply will magically disappear within the hour, however.

      • Trulyunbelievable2020

        I think the mods must be sleeping. It’s been an interesting conversation. Pity that it will soon disappear. I’ll repost the other things that have been written just in case anyone’s interested:

        [TLDR: The people who run Mothering.com and the former Mothering Magazine are really, really, really stupid. But you already knew that.]

        - Another poster responds: “Stillappalled, just remember that Mothering, the paper magazine, endorsed HIV denialism. If you keep that fact in mind, some of the discussions and moderating decisions that go around on the forum become much less unexpected/disappointing.”

        - Someone else asks: “What issue, please? I’ve read everyone from about 2005 to when it folded & I don’t remember any such thing. I’m quite interested.”

        - Both the second poster and I pretty much simultaneously post a picture of an old Mothering cover with AIDS denialist Christine Maggiore and her lovely family. (She’s dead now by the way. So is her three year old daughter. Had nothing to do with AIDS though. Total coincidence.)

        - The other sympathetic poster writes this: “Interesting. Dr. Jay Gordon (very outspoken and critical of vaccines) was one of her daughter’s physicians and this is what he is quoted as saying about it :

        “Dr. Jay Gordon, a Santa Monica pediatrician who had treated Eliza Jane since she was a year old, said he should have demanded that she be tested for human immunodeficiency virus when, 11 days before she died, Maggiore brought her in with an apparent ear infection.

        “It’s possible that the whole situation could have been changed if one of the doctors involved – one of the three doctors involved – had intervened,” said Gordon, who himself acknowledges that HIV causes AIDS. “It’s hindsight, Monday-morning quarterbacking, whatever you want to call it. Do I think I’m blameless in this? No, I’m not blameless.””

        - My last post: “It’s really incredible how closely the articles mirror the current idiocy.

        An overriding concern for the “experience of childbirth?” Check. “If Dana had conceived her child just one month earlier, she might have had the birth experience she had always imagined” (i.e. she might have managed to give birth without doing anything whatsoever to avoid infecting her child with HIV).

        Approving reference to crackpot scientist and/or physician who believes something ridiculous? Check. See the multiple references to Peter Duesberg in this article: http://healtoronto.com/mothering1001c.html.

        A bizarre insistence on fetishizing breastfeeding above all else? Check. “The scientific literature varies on the possible risk of transmitting HIV during breastfeeding, from 5 percent to 29 percent. UNAIDS itself suggests that the risk of infection from breastfeeding is around 15 percent, which means that 85 percent of infants born to HIV-positive mothers are not infected through breastfeeding.” Oh, only 15% of them get HIV! Great! And remember, no one is really sure that HIV even causes AIDS in the first place, right?

        An insinuation that the fact that a given test has a less than 100% accuracy rate means that it’s reasonable to just ignore the test? Check. “Dana had Epstein-Barr virus, which is known to create false positives on certain HIV tests. She had remained healthy without medication, and she felt the HIV she supposedly carried might never actually make her sick.” (Note: It did make her sick. She died at 52. She “felt” wrong.)

        Ridiculous “No, we’re not giving horrendous medical advice but we clearly are” logic? Check. “The only way to avoid such Orwellian scenarios, many HIV-positive parents feel, is to go underground. They decline tests in 48 states where that is still allowable, look for the rare midwife knowledgeable about the reasons why a person would test HIV-positive but still be healthy, buy the AZT their doctors prescribe and flush it down the toilet, and stock formula and bottles in their cabinets while breastfeeding on he sly.” Christ, I just love it: “the rare midwife knowledgable enough…” Clearly a genius on the level of Lisa “Hands off the breech! Just let the baby die!” Barrett.

        Have these idiots learned anything? Anything at all?”

        • Jessica S.

          “The only way to avoid such Orwellian scenarios, many HIV-positive parents feel, is to go underground. They decline tests in 48 states where that is still allowable, look for the rare midwife knowledgeable about the reasons why a person would test HIV-positive but still be healthy, buy the AZT their doctors prescribe and flush it down the toilet, and stock formula and bottles in their cabinets while breastfeeding on he sly.” Sounds like a pretty Orwellian-like scenario they put themselves through, willingly, to convince themselves that harm is health.

          • Medwife

            Flushing ARVs down the toilet. Christ. Talk about a first world problem.

          • Young CC Prof

            Yes. Of course, certain authority figures in South Africa have also promoted AIDS denialism.

          • SuperGDZ

            Under the influence of the likes of Matthias Rath, David Rasnick, Tine van der Maas and Peter Duesberg, all foreigners with snake oil to sell.

        • ACN

          Gotta love this gem of a reply:

          “I knew Christine and her family. They were kind people. I knew that little girl. Once, she asked me to stay and have dinner with her while riding her tricycle through the kitchen. Christine loved her. Everyone did.
          I don’t necessarily agree with what Christine believed, but I knew her as a good person.

          You see, behind every username and magazine story there are ACTUAL PEOPLE. Who, regardless of your incessant need to argue and be right, are actually out there living and suffering and just being human.

          On behalf of the real people out there who aren’t only here to hear themselves speak and be “right”, I would like to ask some “members” here to please shut the hell up. People are trying to do the best they can in a cruel world and get a tiny bit of support where they can and you’re GETTING IN THE WAY.”

          The end.

          • Melissa

            “People are trying to do the best they can in a cruel world and get a tiny bit of support where they can and you’re GETTING IN THE WAY.”

            That about sums it up doesn’t it. We want an echo chamber supporting our decisions because it makes us feel better. We don’t want your facts here!

            The problem is that they are influencing others. If Christine had decided that she didn’t want to accept that her HIV status would lead to AIDS because she didn’t want to face her own mortality that would have been sad. But what made turned her from a pitiable figure into one that should be derided is when she started trying to convince other people to avoid getting treatment. The Maggiore family denial not only led to their own deaths but also killed other people who were so desperate to believe that their HIV diagnosis were meaningless.

    • Amazed

      Hats off to Stillappalled, or Trulyunbelievable2020.

      • RebeccainCanada

        Me too. Just read the wiki article on Maggiore. Ugh. Man, that’s so sad, frustrating, angering! I want to cry, I want to scream…!

        What is a mother’s love if it is going to end up killing you? How is that love? Oh Lord have mercy!

  • LMS1953

    Question: can moms have the typical electronic fetal/uterine monitoring when they are laboring and delivering in a birthing tub or does the CNM or OB nurse auscultate the FHTs every five minutes for 5 to 10 hours? If so, is that an evidence based cost effective use of resources?

    • Joyous76

      I developed ICP and had continuous monitoring in the tub and I can’t believe the NHS would be willing to spend that much on it.

    • Medwife

      They tend to use tele monitors.

  • LMS1953

    This is what really ticks me off:
    Progesterone treatment was first proposed for prevention of preterm birth way back in 1975. Coming off the heels of the DES and thalidomide tragedies, it was very hard to do research to get new medicines FDA approved for pregnancy intervention – indeed, in my lifetime, more men have walked on the moon than meds given FDA approval for obstetric indications. Now, add in the Bendectin affair circa 1983 and that squelched research even further. In the mid 90′s progesterone research cranked back up and the end result was the FDA approval of Makena (17 alpha hydroyxprogesterone caproate). I remembered it circa 1980 collecting dust on the residency clinic shelves in vials labelled “Delalutin” ostensibly to be given for lactation suppression.

    17-P (and other forms of progesterone supplementation) are the ONLY thing we can do (by evidenced based medicine) to decrease preterm delivery in the multigravid woman carrying a singleton pregnancy with a prior history of preterm delivery. This was becoming evident 15 years ago almost to the point that it was UNETHICAL not to unblind the studies because the benefit was so clear. The point is, 49% of US deliveries are on MEDICAID. Medicaid refused to cover a medicine (now being touted to save billions in NICU costs BECAUSE IT WAS EXPERIMENTAL.. So it got FDA approval and the cost skyrocketed from about $18 per dose to $1800 per dose.

    Truth be told, I think that sequence of events inspired ACOG and AAP to place the label of “experimental” in their position paper on waterbirth to put Medicaid and other third party payers in a bind. Typically, experimental procedures are not covered/reimbursed. Witness 17-P as a prime example. So how can they now cover waterbirth? Also, with cavalier hubris, some states have initiated a 39 week nazi provision such that their Medicaid office will not reimburse the hospital or provider if they detect that an “elective” delivery was done prior to 39w0d. So why don’t they also refuse to reimburse hospitals and providers for waterbirths which are 1) experimental 2) of no proven benefit and 3) known to have disastrous risks: aspiration pneumonia, hyponatremia (ie, drowning) and cord avulsion EVEN when used according to the package insert. Has the FDA approved the medical devise “birthing tub”? Has OSHA approved sterilization protocols after appropriately assessing the infectious potential of a puddle of sewage?

    The problem is that the political climate these days is to castrate all things “male” and to empower all things “female”. As such there is antipathy towards anything that could be construed as “disempowering” women or limiting in any way their sacrosanct reproductive autonomy even if their babies unnecessarily die because of it.

    • Medwife

      See, you’ll be going along, and I may not agree, but you’re reasonable… And then you go off into batshit land. Castration of all things male? What the fuck are you talking about?

      • Sue

        If LMS1953 means that scientific practice is seen as ”male” and reflecting the patriarchy, vs ”being with women” is somehow feminine, soft and loving, then I think I get the point.

        That stereotyping is definitely there amongst the radical-NCBers, ignoring all the smart, rational women who are quite happy with scientific rigor.

  • LMS1953

    http://www.npr.org/blogs/health/2013/11/20/246426132/popping-a-baby-out-like-a-cork-and-other-birth-innovations

    This is an interesting link to alternative birthing methods. Some look promising. In 1965 a patent was issued for Centrifugal Birth – which received a faux Nobel Prize for being so ludicrous. The Birthing Sleeve may prove valuable. But please notice the methodical pace of research before they are approved:

  • Rochester mama

    So I don’t pretend to know anything medical and my healthcare knowledge is limited to the utopia of Rochester MN, and Minnesota alone always ranks high in quality of healthcare in the US. But after doing some quick checking, ALL of the major hospitals in the Twin Cites and a few Mayo Clinic Healthcare System sites (not Mayo Clinic Rochester proper) offer water birth. I know a few women that have done water births in hospitals and loved it. Why can’t the data from all of those deliveries be used to determine if it is safe? How many hospital water births were there last year or the last five years and what were the results?
    Regions Health Partners is owned essentially by an HMO and Abbott Northwestern, home to a super expensive new high risk pregnancy facility both offer water birth to appropriately low risk moms. I have a hard time believing the evidence is so clear that water birth is bad if these hospitals have signed on to offer it.

    • Young CC Prof

      Many hospitals that offer “water birth” in fact require the mother to get out of the tub when ready to deliver. The hospital where I had my son worked that way.

      Of course, you make a good point. There might just be enough existing data to measure the risk.

      • Rochester mama

        Regions and Abbot actually say delivery in the water on their websites. Mayo Rochester uses the term labor in water to make clear they don’t have you deliver in water, so I was looking for that terminology.

    • LMS1953

      Minneapolis/St. Paul has a rather large Somali population. Somali women have one of the highest rates of female genital mutilation in the world and Somali women giving birth in their homeland have the highest rate of maternal death in the world. Is a history of female circumcision a contraindication to waterbirth? How do the Somali birth stats (preterm birth, C/S rates, maternal mortality and perinatal/neonatal/infant mortalities compare to the white utopia?

      • fiftyfifty1

        Huh? What has that got to do with what Rochester mama wrote?

        • LMS1953

          She said that ALL of the hospitals in the Twin Cities offer waterbirth. I guess I forgot to specify that I wanted to compare the birth stats of SOMALI IMMIGRANTS to the Twin Cities white utopia. The idea being that the birth culture of Somali women might have them more concerned about getting out of the experience alive rather than whether they get to birth in water.
          I am also concerned about allocation of precious medical resources. I will make the assumption that 1st and 2nd stage waterbirth pretty much needs one on one nursing. So here we have a woman vetted to be the lowest risk of a low risk cohort and allocating to her more personnel than a patient in the ICU or the 40 year old diabetic with pre-eclampsia having her cervix ripened with Cervidil down the hall.

          • LMS1953

            http://m.startribune.com/?id=132670583

            At last census, there were 32,000 Somalis in Minnesota who could be extrapolated to about 4500 to 5000 deliveries per year, no trivial number

          • Rochester mama

            I called Rochester a medical utopia because I grew up with highly individualized care from an instruction that prides it self on not only expertise in medicine and technology, but caring for the patient as a whole. Not because it was White. Rochester is a very diverse community.

      • Rochester mama

        Rochester too has a significant Somali population but I have no idea what their birth preferences are or complications might arise with birth for genital mutilation.

      • fiftyfifty1

        “Is a history of female circumcision a contraindication to waterbirth?”

        It would be a contraindication if a woman has an unmodified infibulation because you will need an episiotomy. Most Somali women in the United States choose not to be re-infibulated after their first, so an epis is not usually needed with subsequent births. Whether Somali women choose waterbirth is another matter. I would guess it is not popular in this group, as it doesn’t allow for modesty and because few Somali women know how to swim so don’t spend much time in the water so reports of “that wonderful weightless feeling that water gives” is probably not draw. But I don’t know that for sure.

        • lawyer jane

          Yikes. How do they give birth in Somalia if they have an “unmodified infibulation”? Is there a birth attendant that does the episiotomy then sews it back up?

          • fiftyfifty1

            Yes, someone to make the cut and either sew it back up or not.

          • Dr Kitty

            The UK has just prosecuted the first FGM case.
            Reading between the lines, it would appear the Dr is being charged for re-infibulating a woman at the time of episiotomy repair.

            In the UK re-infibulating a woman is a crime.
            In fact, the way that the law is worded, cosmetic labiaplasty of any kind is probably a crime, but nobody is interested in prosecuting surgeons doing “designer vaginas” for the rich and famous.

            http://www.theguardian.com/uk-news/2014/mar/21/fgm-female-genital-mutilation-men-charged

            My personal opinion is that either cutting normal genitalia to make it more like a cultural ideal of “normal” or “acceptable” is wrong, or it isn’t .
            I have deep reservations about cosmetic labiaplasty for that reason.

          • Jessica S.

            I couldn’t quite suss this out from the article: did the doctors do it at the patient’s request? Or was it against her will?

          • Dr Kitty

            Doesn’t matter under UK law.

          • Trixie

            Well, wouldn’t the difference be, one is an elective surgery paid for by a grown-up with their own money, and the other is inflicted on a child who cannot consent?

          • Dr Kitty

            No.
            The law, as written, makes “cutting or mutilation of the labia or clitoris or infibulation” a crime. Consent is irrelevant.

            The case currently before the courts involves an adult woman, and whether or not she wanted to be re-infibulated is not relevant.

            If FGM was performed on an adult woman with her consent, it would still be a crime. If the communities who practice FGM just delayed it to adulthood it would still be abhorrent. Labiaplasty removes sensitive, sexually responsive tissue so that the vulva approaches a cultural norm. So does FGM. Some of the labiaplasties offered remove almost all of the labia minora.

            Unless there is a functional problem with the vulva, it doesn’t need to be made “neater” or symmetrical. It would be better, culturally, to accept a wider variation of vulvas as being nice, than to impose a “standard shape” as the ideal which is to be obtained surgically if necessary.

          • Trixie

            What about gender reassignment surgery, then? What about people whose labia rub together and cause them pain?
            If an adult chooses to have elective plastic surgery, I guess I don’t see where it’s anyone else’s business, assuming they’re not asking anyone else to pay for it.

          • Dr Kitty

            I understand your point.
            SRS is not cosmetic, it is reconstructive. While I know many trans people do not feel SRS to be necessary for them, the aim of SRS is to make their physical anatomy match their gender.

            I have no issue with a necessary surgery which corrects a functional problem such as pain.

            I have an issue with a surgery which is in essence exactly the same as less severe type 2 FGM (which is what clitoral hood reduction and labiaplasty is) performed for purely cosmetic reasons on anatomically normal genitalia for no other reason than to meet an unrealistic cultural beauty ideal.

            If the issue with FGM is consent and unhygienic practices we would have no ethical issues with advising communities which practice it to delay until adulthood and have it done under general anaesthetic and aseptic conditions by a gynaecologist and with the woman’s consent. At present no-one is seriously advocating for that.

            I’m afraid I see it as a cultural double standard.
            “Your culture’s practices are unnecessary mutilation, while I’m having a cosmetic surgery to make me feel better about myself”.

            I am aware this is not a popular position and not shared by many people, but it is genuinely how I feel.IMO the only people who genuinely profit from cosmetic vulval surgeries are the surgeons.

            Sorry for the hijack.

          • Medwife

            I never heard of clitoral hood reduction. Wouldn’t there be a significant reduction of sensitivity? Sounds crazy to me but *shrug*

          • AlisonCummins
          • Dr Kitty
          • Comrade X

            And now I want a copy of the “Cunt Colouring Book”

          • The Bofa on the Sofa

            Who is the target market for that book? Is it for guys who want artistic porn? Or is it supposed to be for women?

          • AlisonCummins

            It’s for anyone who wants to normalize bodies and variety. It’s not porny at all.

            When I was in college in the 80s there was a program for peer counsellors that included watching a series of films of people having sex. It was produced by a church and while I never saw it, by all reports it was very boring. Old people having sex, young people having sex, straight/gay/lesbian sex, fat and thin people having sex, different races of people having sex, people masturbating. I think there were three hours of film in all so you had to sit there and watch other people having sex for three hours. It was pretty desensitizing, which was the point. As a peer counsellor you needed to be able to be unsurprised and objective when another student wanted to talk to you about sex.

            A friend of mine used images from that book to educate her eight year old son about women’s bodies.

          • AlisonCummins

            See also Julia Sweeny discussing technical aspects of sex with her primary school age daughter.
            http://www.ted.com/talks/julia_sweeney_has_the_talk

          • Comrade X

            Why would there even be a culturally acceptable vulva? My brain just does not comprehend this idea.

          • AlisonCummins

            Internet porn. Most of us didn’t used to know what other women’s vulvas looked like, and now we do. They look small, plump, hairless and tidy. Ours are not nearly as nice.

          • Dr Kitty

            This is the kind of thing I object to.

            http://www.theguardian.com/lifeandstyle/2011/oct/14/designer-vagina-surgery

            The “Barbie” look-which removes the entirety of the labia minora to give a “clamshell” appearance, and clitoral “unhooding” are identical to FGM.

          • AlisonCummins

            The entirety of the labia minora? I had no idea. And why clitoral unhooding? What is supposed to be the point of that?

        • Comrade X

          Is it legal for a health-care provider in the United States to re-infibulate a woman after childbirth? It is a criminal offence in the United Kingdom.

          • fiftyfifty1

            The choice to re-infibulate or not is up to the patient here. The vast majority choose not to re-infibulate. With the rare woman who does want to be sewn back up you need to make sure this is her free decision (not being pressured) and it’s important not to sew it so tight you get major problems like menstrual retention obviously. It’s rather shocking to me to hear that it’s a crime to do so in the UK.

          • Comrade X

            I’m rather shocked that it’s NOT a crime in the US. Wow.

            We’re about to get our first FGM prosecution here in the UK (after nearly 30 years of it being a crime). And guess who’s getting done? Yup, a doc who re-infibulated. So, having said that I find it shocking that it’s not a crime in the US, I have to also point out that our own craven worms have, having finally been pushed into not ignoring the whole thing altogether, opted for the lowest-hanging fruit, and also probably the least culpable. Still waiting for an ACTUAL mutilator to get their just desserts.

  • guest

    This is insanely hypocritical. Everg single time you post about the safety of hospital birth you use the mortality rates of certified nurse midwives to do so. You claim that full term babies almost never die in the hospital. You say that a neonatal death rate of 0.4/1000 is extremely low and appropriate for low risk birth. If CNMs provide water birth for their clients and have low mortality rates that YOU use to make your points, where are all these dead babies you speak of?

    • Mr.G

      Let me respond as a medical Director of an in-hospital birthing Center for over 10 years. There are very clear guidelines in hospitals for in-hospital birthing centers. Patients are screened very carefully. If there is a problem, labor & delivery as well as the cesarean section room are seconds away. At home they are far away. In hospitals, water labor is OK but second stage labor and water births are more often than not not OK. At home these lay midwives have no guidelines and are reckless.

      • Guest

        No, that’s not what she said. She said that babies die because of water birth. She said CNMs don’t care that these babies are dying. She thinks that water birth should not be an option in hospitals because they kill babies. If this is all true, why does she use the mortality rates of babies attended by CNMs to prove hospital birth is safe? In one instance she says babies almost never die in the hospital if they are full term and healthy. She uses CNM mortality rates because they are very low and yet she also claims that all these preventable deaths are happening in hospitals under the care of CNMs. Which one is it? It can’t be both.

        • Mer

          Most hospitals don’t allow water deliveries. The deaths from birth underwater that Dr. Amy talks about likely come from birth centers and homebirths. Plus it doesn’t just kill sometimes the babies get really really sick and near death but recover and survive. But it still isn’t ok that they were exposed to preventable morbidity just because the lived.

          • Guest

            No. Wrong again. The vast majority of CNMs practice in hospitals. CNMs allow water births and hospitals in almost every state, if not every state, allow water birth. The alleged deaths that Dr. Amy talks about are from water births attended by CNMs. She says that “the truth about water birth threaten CNMs”. That is because, according to her CNMs utilize water birth and according to her waterbirth kills babies. She is not talking about morbidity she is talking about death. So if waterbirth kills babies and CNMs use waterbirth often in their practice why is she using the mortality rates of babies attended by CNMs to prove hospital birth is safe?

          • Andrea

            You make a valid point guest!

          • guest

            Sorry, what is the point?

          • Trixie

            None of the hospitals in my area offer or allow water birth. Water birth is really not that widespread across the entire US population. If I wanted a water birth, I’d have to go to a CNM birth center or have a CNM home birth. Or I could alegally hire a CPM, I suppose.

          • Deena Chamlee

            hey there.
            Unfortunately the implementation of this type of birth was initiated widely, vastly, internationally without clinical trails. Data that was available in 1999 proved horrific outcomes. And I myself only read this review yesterday.
            Always remember: Nothing is as it seems, when living in other’s reality. Definitely my new motto for life.

          • Mer

            Quite simply because it is safer. That’s a great illustration of just how dangerous birth at home is. If a baby is put at risk in a hospital from water birth and dies from it despite high level care immediately available then doing the same thing at home is much more dangerous. If a CNM can lose a baby in a hospital despite all the care available there, how in the world can homebirth be safe except by pure luck? There are more babies dying from water birth in birth centers and at home than in hospitals, mostly because MOST hospitals do NOT allow birth to happen in a tub. Some do, but most do not, women can labor in water but not deliver in water.

          • R T

            I live in Southern California and there are no hospitals here that allow water birth. You can labor in water, but have to get out for the delivery. There are CNM’s with freestanding birth centers that offer water births, but a hospital that allows it is pretty rare in the US. If you can’t get a hospital water birth in SoCal, you know it’s really hard to get one in most of the country.

          • Young CC Prof

            MOST of the births attended by CNMs are not water birth. The vast majority, I believe. So, the fact that CNM results overall are very good doesn’t mean that their water birth results can’t be lousy.

          • Guest

            US states that offer waterbirth in hospitals:Alabama, Georgia, Florida, Ohio, Texas, Maine, Chicago, California, Colorado, Michigan, Washington, Oregon, New Mexico, Nevada, Vermont, Idaho, Montana, Utah, Minnesota, New Jersey, Massachusetts, Connecticut, Indiana, etc. Also, the recent study that demonstrated the safety of birth centers showed that 79 licensed, freestanding birth centers all lead by CNMs and offering waterbirth, had the low neonatal mortality rate of 0.4/1000. The exact same rate as low risk women giving birth in the hospital. So even if CNMs in the hospital didn’t offer birth in water (which they do) the mortality rates are the same in licensed birthing centers, where we know with certainty that babies are born in water. If waterbirth kills babies why are the neonatal mortality rates the same between licensed freestanding birth centers and CNM led hospital birth?

        • Elizabeth A

          She uses CNM mortality rates because they are very low and yet she also
          claims that all these preventable deaths are happening in hospitals
          under the care of CNMs. Which one is it? It can’t be both.

          It can be both. A low mortality rate can still include some preventable deaths.

          For low-risk women and their babies, hospital birth under the care of a CNM is the safest available option, but improvements could still be made to make it safer. Until the rates of morbidity and mortality are zero, we can always try to do better.

    • Medwife

      That’s the thing. I’d get huffy and defensive but my profession’s outcomes speak for themselves.

      • fiftyfifty1

        Hospital CNMs deliver low risk patients. Their death rates *ought* to be low. Just because overall outcomes for hospital CNMs are generally good (as they should be) doesn’t mean we should turn a blind eye when unsupported anti-science woo creeps in. I don’t think we should ban waterbirths. But for CNM leadership to oppose a call for further study is unethical.

    • Trixie

      Because most hospitals and CNMs don’t actually provide water births, and only allow labor in water under clear circumstances. Dr. Amy is distinguishing between the rank and file hospital CNMs that she has repeatedly stated that she respects, and ACNM leadership, which she thinks has gone off the deep end and is swimming around in woo.

      • Jessica S.

        This is what I was thinking, but you said it much better than I could have. So I’ll say “this!”. :)

    • Elizabeth A

      It appears that your argument here is that Dr. Tuteur has approved of the outcomes that include the neonatal death rate of .4/thousand, and therefore should not be complaining about neonatal deaths included in this number.

      The current neonatal death rate in hospitals is the result of a series of incremental improvements in treatments, technology and procedures, implemented over a considerable period of time, by professionals guided by both scientific consensus and obsessive review of practices. Every time a neonate dies unexpectedly in hospital, that hospital should be conducting a morbidity and mortality review and revising their practices and procedures to reduce risk. So one baby with pneumonia, one shoulder dystocia in a birth tub, one slip and fall accident in L&D, does (and should!) result in reluctance to allow waterbirth.

  • fiftyfifty1

    So let me see if I have this right. CNMs object when neonatologists refer to case reports of adverse outcomes because this is “not a reliable form of research”. But then they object to waterbirths being considered experimental. So basically they object to anecdotes, because “anecdotes are not data”….but then they also object to being required to collect data.

    Yep, that’s unethical.

    • araikwao

      Case studies are acceptable when they are used to “disprove” safe practices: “the evil OB told me I couldn’t have a vaginal delivery, but I proved him wrong with my HBA3C”. And therefore they are safe.

      • Young CC Prof

        Yes. A single example of someone surviving an activity suffices to prove it is safe, but a single example of a negative outcome proves nothing. That’s how risk assessment works, right?

  • fiftyfifty1

    I wonder if CNMs are justifying it to themselves by saying that they offer waterbirth in the hospital only so women don’t have a homebirth in order to get one? So until waterbirth is *proven* unsafe, it is safer to prevent a homebirth. …but no, that can’t be it, because the official CNM position is that homebirth is safe too.

  • Rochester mama

    Like it or not CNMs are the future of labor and delivery units in the US, especially for large group practices. Qualifying woman are more than safe with a CNM as the primary provider. You can charge the same (or nearly the same) for a CNM non surgical vaginal delivery as one done by an OB. And women whose insurance pays the most are demanding nicer surroundings, more personable care and pain relief options other than just an epidural. While it doesn’t make sense for every delivery suite to have a birthing tub, I can’t see any hospital undergoing a normal planned renovation of an L&D until not bothering to put in at least a few to say they offer the option. From the healthcare finance perspective I say figure out a way to make water birth as safe as possible in a hospital setting so woman don’t go elsewhere.

    • Aki Hinata

      If I were in risk management or hospital policy, I’d want to risk out as many moms from water birth as possible.

      • Rochester mama

        The facility I worked for did not allow delivery in water, but to me it is all about providing the right care, at the right place at the right time.
        As a lay person (not doctor or medical professional) I don’t understand allowing patients not over the age of 35 and without higher risk factors to get CVS testing, but not allowing a demonstrated low risk woman to give birth in water in a hospital if that is what she wants.

        • Elizabeth A

          To be very bluntly coat focused -

          If a woman has a miscarriage as a result of CVS, the facility’s costs are quite low. Aspirational pneumonia in a newborn requires far more equipment and expertise to treat, and in the event that such a pneumonia results in permanent brain damage, the hospital can safely anticipate that they will be sued.

          this is far from the only factor in that comparison of things hospitals are and are not willing to allow.

        • Melissa

          From a legal perspective: CVS is noptional test that the mother can ask for weighing all the options in a rational way without needing to make an immediate decision. If things go south there is very little chance of there being liability on the doctor of facility that allowed it to happen. They would say that the Mom knew the risks and that’s the end of story.

          On the other hand, cases involving things that happen while a woman in labor are much more likely to bring liability to the hospital. So, let’s say that the CNM gives the patient all of the warnings about the dangers of waterbirth and patient says that she still wants to do it. As far as most courts seem concerned, that decision is not final. The doctor has to alert her at any step along the way where he might have noticed a problem that she should get out of the water. There was a case where Mom did NOT want a C-section under any circumstance. Had said repeatedly she wanted vaginal birth. While the baby eventually had to be delivered via emergency c-section she sued, and successfully won, saying that she would have opted for a c-section earlier if the doctor had informed her of the danger involved. Not just the danger before, but as she was in labor (I suppose the court wanted him to say “oh, remember how I said that X could happen without a c-section. There is a sign that X is happening. Would you like a c-section with that information?”). I think something similar would happen in a waterbirth that ended up in tragedy. Labor is a developing situation and in order for there to be legal informed consent each new bit of information which might lead to a change in decision needs to be given to the mother.

          I don’t think that’s a realistic thing to expect hospitals to be able to do. But that’s the way the courts tend to see the issue. If people could just sign a waiver absolving the hospital of liability for waterbirth related injuries then it wouldn’t be a problem, but you generally can not waive the right to sue for negligent acts in a medical context.

          • Rochester mama

            Several respected hospitals in MN are offering water delivery. I provided a link above to the form they use. I’m simply pointing out that hospital water deliveries are happening, and are likely to increase in number. I personally would have felt more at ease with the risk of a water delivery than with the risks that come with a CVS test.

          • AmyP

            Why not do neither if both are risky?

          • Rochester mama

            I’ll be turning 35 before my next birth if I’m lucky enough to get pregnant. So I won’t be a candidate for water birth and wont be doing CVS either.

          • Young CC Prof

            You know, a lot of other medical tests given in pregnancy, such as ultrasound, blood pressure, glucose improve your chances of a good outcome.

            Most of the things that CVS diagnoses, however, aren’t modifiable. They’re chromosomal or genetic disorders. And since the test itself can cause a miscarriage, to an awful lot of people it’s just not worth it.

          • Guestll

            Except that in some cases, the baby and parents will benefit from the information learned from CVS, and the potential for benefit outweighs the risks. In my case, knowing that a son had hemophilia A prior to delivery would have meant being under the care of a perinatologist, and a planned C-section. It would also have meant having time to prepare for the reality of caring for a son with hemophilia A. To me, this was worth the 1 in 800 risk of miscarriage quoted to me by the peri who did my CVS.

            Additionally, having lost 4 babies, 2 of whom had confirmed trisomies, the knowledge that I was carrying a 46XX significantly reduced my anxiety during pregnancy.

            There is no benefit to the baby to being born in water.

          • Young CC Prof

            Oh, I’m not saying that it’s never worth it or that the test has no value, just that deciding NOT to do it is a very reasonable cost-benefit analysis for many people. Unlike, say, a glucose-tolerance test. Basically no risk, and gestational diabetes outcomes can be drastically improved through diagnosis and management.

    • http://thefresstyler.blogspot.com/ Hannah

      Based on stories and data out of the UK, Canada and Australia, it seems abundantly clear that ‘qualifying’ women and their babies aren’t safer in the care of CNMs/hospital midwives and are at the mercy of their increasing predisposition towards woo.

      Just this week I have read of 3 cases in which inadequate hospital midwife care led to the avoidable death of a baby. In addition, I have read two cases in online forums where women raised concerns at term, were sent home, and their babies subsequently died in the womb.

      I’d hate to see that become par for the course in US hospitals.

      • Rochester mama

        I’m currently at home raising my son, but I left a job in hospital finance and it’s my observation that the only way for large health systems to keep an OB unit in the black is for OBs to concentrate on high needs patients and CNMs to handle low risk care. When a patient changes from low risk to high needs the handoff needs to be fast and effective. There has to be mutual respect in the department between OBs and CNMs because the needs of the patient are more important than anyone ego.
        I worked in Medicare reimbursement mainly but a friend of mine was a business analyst in OB and we talked a lot. So that is what informed my opinion but I do not claim to talk for any organization, especially the Schmayo Clinic.

        • http://thefresstyler.blogspot.com/ Hannah

          Like I said, that would be fine, except that time and again midwives are pushing a dogmatic agenda that isn’t improving outcomes for babies.

          My own cousin nearly died along with her baby because of delayed intervention in midwife-led care in Australia. Another cousin nearly lost her baby when they let her labor go on without progression for two days. Another friend of mine was sent home from hospital with contractions close together, but no dilation, three times until they finally admitted her and bothered to monitor the baby and it turned out she was never going to dilate and needed a section. In each case, they were sent home repeatedly and patted on the head, being told they ‘weren’t in active labor, darling’. It’s disgusting.

          I have a scary number of stories like that from within my own circles and even a brief search of pregnancy and baby boards find stories like this come up again and again and again and there are Australian doctors, for example, supporting that this is a major issue.

        • Elizabeth A

          If an OB unit is running into the red, it would be ill-advised for them to install birthing tubs, which require more cleaning and maintenance then the showers standard in hospital rooms, increase utility costs for water and heating, and create slip-and-fall risks on the L&D unit. (I honestly suspect that some objection to delivery in the water in hospitals arises from janitorial concerns. Not all of it – there are also genuine safety issues. But if we’re talking about hospital management, we always have to consider janitorial issues. How long does it take to clean a tub that someone has just given birth in? How does that effect the l&d unit’s capacity over the course of a year?)

          There’s some argument that OB services have an important marketing function for a hospital, and therefore it is not strictly necessary for them to be independently profitable. My experience with hospitals is that the OB units are considerably nicer then many other parts of the hospital. Hospitals could save a lot of money by eliminating private post-partum rooms, but those are very nearly standard in large swathes of the U.S.

  • amazonmom

    I wish I was young and unencumbered enough to go to medical school. I’m afraid nursing has been lost to the woo when I read things like this.

  • disqus_FeN6LaMBls

    Totally OT – have any of you OBs ever told patients not to quit smoking because stress is worse for the fetus than the cigarettes? It seems pretty far-fetched to me, but these moms are insisting that it’s true

    http://community.babycenter.com/post/a48637312/pregnant_and_still_smoking

    • wookie130

      I’m not an OB, but I have seen this floating about Baby Center, and other forums. It’s ridiculous. I was a former smoker, and my OB was quite relieved that I quit cold turkey upon getting a positive pregnancy test.

      • Aki Hinata

        My grand mother was told this back in the 1930′s. I thought it was an abandoned practice.

        • wookie130

          Oh, I’m sure that it was standard medical advice for “back in the day.”

          And that was also in a day and age when pregnancy was treated like a much more fragile medical condition…it was better to stay off your feet, lift nothing, and stay stress-free, lest you cause a miscarriage.

          Fortunately, I do believe most medical practitioners today would be MUCH happier these days seeing women quick smoking cold turkey…

          • Haelmoon

            I tell all of my patients to quit. They do frequently ask about the stress to baby, but I reinforce that smoking is worse. However, not all smokers will be able to quit, I strongly support that they at least cut back (less than 10 a day seems to be better than not quitting) or switch to the nicotine patch – I would rather the fetus exposed to just nicotine than everything else in the cigarettes. I think the myth keeps making its rounds because some smokers are trying to justify not quitting. For the record, it is associated with a lower risk of pre-eclampsia, but I would not advocate smoking to reduce that risk.

        • realitycheque

          Not sure how true this is, but I heard that they used to recommend women smoke cigarettes and diet during pregnancy to prevent their babies from growing “too big”.

          • Mathi Bear

            Yes, my mom told me that that bit of advice was just going out of style when she got pregnant with me, so she quit smoking. The generation before mine apparently liked the idea that smoking led to lower birth weight babies.

          • araikwao

            Except now we know so many of the problems associated with low birth weight babies it seems extra-wrong.

          • Melissa

            When I worked with teen girls the “smoke so your baby stays small” advice was popular with the ones who were pregnant. Not from any official source, just the girls gossiping with each other. The “smoking causes low birth weight” warning was seen by them as a selling point.

      • realitycheque

        I also call BS. My pregnancy was unplanned, and I was a very heavy smoker when I found out. Despite this, my doctor told me that quitting still needed to happen, and when I asked her about the whole “stress on the baby is worse than cigarettes” thing, her eyes practically rolled out of her head. She suggested that – given how heavily I smoked at the time – I might consider having a (very) short period of cutting down before stopping completely, but that it was (obviously) extremely important to quit.

        I know several women who quit smoking during pregnancy, and only *one* person who claims that their doctor told them not to quit, attempt quitting or even bother cutting down. She wasn’t even that heavy a smoker. I later had her partner say to me that he had to lie to their OB about their smoking status when they went to the hospital, which only further supports the belief that they were lying. If their OB had been supportive of her smoking status, there would have been nothing to hide.

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

          I was told the same thing. Quitting by stepping down rapidly – which was easy, since hyperemeses made it miserable to smoke anyway. I stayed totally smoke free until several months after he weaned. Unfortunately I caved around the terrible two’s…

        • theadequatemother

          I get all sorts of cute patients who lie to me about their smoking status. Claiming they don’t smoke when you can smell it and you can see it on their fingers and nails. It’s amazing how commonly patients will lie. I am convinced that at least 20% of preops eat breakfast (and possibly lunch) and lie about it.

          • AmyP

            I would bet on it.

    • Trixie

      That was in my grandmother’s pregnancy book from 1954. Along with the advice to avoid all condiments.

      • Zornorph

        Avoiding condoms was how she got pregnant in the first place.

      • R T

        Was the advice to avoid condiments when eating out? I avoid public communal bottles of ketchup and mustard etc. I see them as festering bottles of disease!

        • Trixie

          No, all condiments during pregnancy and breastfeeding. Except maybe mayonnaise. Because the spiciness of ketchup is bad for your baby or something. Grandma says she ignored that one. Next time I’m over there I’ll have to get some pictures.
          I will say this for Grandma, she took vaccination very seriously and kept track of each of her kids’ shots in the back of that book.

          • Young CC Prof

            Didn’t they also say that you shouldn’t raise your arms overhead when pregnant? That one was also pretty weird.

          • Trixie

            Not that I recall. I’ll have to look. They did introduce solids at like 8 weeks. Carrots and rice cereal, but they called it pablum.
            My grandmother was fairly unusual for upper middle class women of the era, in that she breastfed all of her kids for at least 6 months. Which is pretty remarkable given the terrible breastfeeding advice in that book and also in her hospital discharge papers. (Nurse your newborn only once every 4 hours, for one).

    • realitycheque

      I think it’s just one of those internet rumours based on extremely outdated “information”. I can’t imagine a doctor telling a woman to not even TRY quitting, and I’ve only seen it shared as third-hand information in “mommy forums”.

      I think some women aren’t really interested in quitting, so when they see something like this they take it as a license to not even try, “Well, now I HAVE to keep smoking”. In reality, I’m sure that if they asked their doctors they (and their partner) would be encouraged to quit smoking and the doctor would probably even offer support services to help them do so.

    • http://thefresstyler.blogspot.com/ Hannah

      I have a family member who was told that by her OB. In the 80s. For her three subsequent children she was advised to quit, strongly.

    • Medwife

      I’ve had patients tell me they were told this by a doctor. Now it’s true you shouldn’t cold turkey from opiates while pregnant. Maybe they got cigarettes and heroin mixed up.

      Edited- the patient got mixed up, I mean.

      • fiftyfifty1

        “I’ve had patients tell me they were told this by a doctor.”

        So have I. And then I’ve read the chart (we have an integrated EMR) and the prenatal notes all document repeated advice to quit, prescriptions for smoking cessation aids, and other evidence that the patient is not telling the truth.

        • Young CC Prof

          Yeah, sometimes people hear what they want to hear, or just flat-out lie.

          And sometimes people do legitimately misunderstand, or not hear, or the doctor forgets to say everything out loud. I LOVE the fact that my allergist has his nurse put all patient instructions in writing, so I don’t get confused.

          However, I doubt that advice to quit smoking in pregnancy, accompanied by offers of multiple kinds of help, could be misunderstood.

          • KarenJJ

            Interesting because I’ve had a relative say they were told this by their doctor too (within the last 5 years).

          • GranolaTastesLikeFrootLoops

            My OB told me “Quit immediately. If you can’t, at least cut back to a couple a day.” when he saw smoking in my chart. I immediately quit smoking at BFP, but I can see how someone not wishing to do anything other than what they wanted to do would hear only “Cut back.” It’s the same response as taking your meds at 3 hours when the bottle says “Every 4 to 6 hours as needed.”

        • Medwife

          I have always found it extremely unlikely that they were actually told that by any doctor. People tend to hear what they want to hear.

    • Dr Kitty

      It’s rubbish.
      I offer nicotine replacement therapy at the first BFP appointment and tell them the sooner they stop the better.

      If the low birth weight and increased risk of miscarriage don’t seem convincing, I’ll remind them that newborns in nicotine withdrawal aren’t fun to care for, that the children of smokers have an increased risk of asthma, SIDS, ear infections and having to bury their parents early, and that smokers are much less likely to be around to see their grandchildren.

      While BF may have marginal benefits over FF for the majority, smoking is so clearly an inferior choice with major health risks that I’m not going to try and pretend I can support it.

  • Aki Hinata

    Thank you for this post, Dr. Amy. It helps articulate my growing discomfort with CNM’s.

  • Dr Kitty

    The only benefit of waterbirth is maternal “comfort”.
    As opposed to actual analgesia, such as provided by epidurals or IV opioids.

    ACNM’s position is that if everything is going swimmingly, so to speak, a waterbirth is fine, because adverse outcomes are rare.

    It boils down to “Women like this option. We like being able to provide it. Don’t harsh our buzz, we don’t want to hear your negativity”.

    • Comrade X

      In the UK you pretty much have to sacrifice a goat under a full moon when the stars are in perfect alignment to access a timely epidural (which represents almost total pain relief, and presents miniscule risks to mother and child). But hospitals are more than happy to allow the majority of women to give birth in water (largely ineffective as pain relief, growing evidence of risk to child).

      I am really starting to wonder about this (and not in a good way). Are epidurals crazy expensive or something? Or is this about some kind of Curse Of Eve bullshit, where it is frowned upon if women have it “too easy”?

      • Ash

        Oh, didn’t you know that pain is beneficial so that women can raise a newborn?

        http://www.theguardian.com/lifeandstyle/2009/jul/12/pregnancy-pain-natural-birth-yoga

        Also, anyone know why this OB/GYN practice has this electrode stimulator thingie? What does it do in clinical practice? (other than funny Youtube videos)

        • http://thefresstyler.blogspot.com/ Hannah

          Did the journalist even see Knocked Up? The lead character had the baby completely pain-free, all she got was something to ‘speed things up’.

          That guy should not be allowed to make decisions about womens’ care.

        • araikwao

          If it’s the pic I’ve seen before, it’s probably just a TENS (transcutaneous electrical nerve stimulation) machine – it can be set to stimulate muscle contractions, or used as (not especially effective) pain relief in labour (or other pain conditions) when different settings are dialed up. In that situation it works theoretically like sensory interference, so fewer pain signals reach the brain.

        • Young CC Prof

          And that professor of midwifery cites the obvious nonsense about epidurals causing malpositioned babies. The relationship between length of labor and epidural, there’s some evidence (and minimal plausibility) either way, that maybe epidurals lengthen labor, maybe longer labors cause requests for pain relief, and maybe it’s a little of both.

          But who in their right mind would think that an epidural given well after labor is established would CAUSE a baby to change position? Especially when causation in the other direction makes perfect sense?

      • Hannah

        Seriously?? Now I’m kinda scared… I’m moving to the UK soon (paperwork processing) on a marriage visa, with eventual plans to come back. But we might start a family while over there… and I have no tolerance for people telling me what I want or ignoring my wishes with regards to healthcare! Rats… ok time to hope my future high-risk status might get me a doctor more willing to listen…

      • http://thefresstyler.blogspot.com/ Hannah

        My money is on the Curse of Eve bullshit. It’s just dogma and it’s disgraceful.

        Plenty of women talking about it on Mumsnet:

        http://www.mumsnet.com/Talk/childbirth/1147361-Anyone-else-tricked-out-of-epidural/AllOnOnePage

      • araikwao

        Funny, I asked a British anaesthetist about epidural access issue this morning when I was following him around (med student), and he flatly stated it was not a problem at all and to be careful what I read on the internet!! I had no comeback.

    • http://safermidwiferyutah.wordpress.com/ Safer Midwifery Utah

      its kind of shitty to put comfort in quotes like that.

      • Dr Kitty

        Sorry, what I meant was that the “comfort” provided by water, in context, means “slightly less agonising pain”. It does not mean comfort, as widely understood by the majority of people, and certainly doesn’t mean “adequate pain relief” for the vast majority of women.

        I do not mean that maternal comfort isn’t important. It is.

        I’ve had my own run in with UK midwives acting outside their scope of practice this week.
        If a post partum patient with a UTI which is known to be resistant to all oral ABx is sent to the OB admissions unit by her GP, one would think it would be sensible to admit her for IVs. But no, a MW decided to repeat the urine culture and send her home without treatment, and without being seen by a Doctor.

        Because, apparently urosepsis is better than IV antibiotics and admission to hospital

        • Dr Kitty

          I should say that the senior midwife I spoke to when this came to light was extremely apologetic and arranged immediate admission, with the distinct impression that junior heads would be rolling… But I was seriously less than impressed.

        • fiftyfifty1

          “MW decided to repeat the urine culture”

          !!!!!!! How incredibly stupid!!!!!
          Can you imagine doing this with other tests? Chest pain …positive troponin…I think I’ll just repeat that test and see if I get a result I like better.

          • Dr Kitty

            I think it is because GPs are seen as some sort of “Dr lite” that MWs feel they can ignore.

            I manage >90% of UTIs in the community. If we can’t manage it, it is safe to assume it can’t be managed in the community.

            Yes, it is not ideal for a new mother to be admitted for IVs that are incompatible with breast feeding.
            But urosepsis is potentially life threatening…and still requires IV antibiotics, and a longer stay in hospital.